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

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

Objective

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

Methods

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

Results

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

Conclusions

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

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

Objective

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

Methods

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

Result

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

Conclusions

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

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

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Survival Impacts of Mitochondrial Status in Esophageal Squamous Cell Carcinoma Patients

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Correlation Between Histopathological Response of Esophageal Squamous Cell Carcinoma to Neoadjuvant DCF Therapy and the Clinical Efficacy of Palliative Chemotherapy for Recurrence

BACKGROUND

Docetaxel-cisplatin-5-fluorouracil (DCF) is a new standard neoadjuvant therapy for locally advanced esophageal squamous cell carcinoma (ESCC) in Japan. However, some patients experience recurrence and require further systemic platinum-containing chemotherapy. It is unclear whether such regimens are appropriate after a poor histopathological response to neoadjuvant DCF.

METHODS

Data were retrospectively collected on patients with recurrence of ESCC treated with palliative chemotherapy after neoadjuvant DCF at our institution between February 2014 and June 2022. We defined patients with a grade 0-1 histopathological response as insufficient responders (IRs) and those with grade 2-3 as good responders (GRs). The correlation between the histopathological response and the response to palliative chemotherapy was investigated.

RESULTS

Thirty-two patients (median age 63.5 years, range 46-76) were included. Performance status was 0 in 12 (37.5%), 1 in 16 (50.0%), and 2 in 4 (12.5%). Histopathological response grades 0/1/2/3 were 3.1%/68.7%/21.9%/6.3%, respectively. Platinum-containing chemotherapy was administered to 13 patients (56.5%) in the IR group and 9 (100%) in the GR group. The overall response rate was 34.8%, and median progression-free survival was 2.431 months in the IR group and 44.4% and 4.041 months, respectively, in the GR group. Multivariate analysis identified a chemotherapy-free interval of < 6 months as an independent prognostic factor (HR 4.096, 95% CI 1.116-15.037) but not the histopathological response (HR 1.137, 95% CI 0.309-4.177).

CONCLUSIONS

Histopathological response to neoadjuvant DCF therapy did not affect the efficacy of first-line chemotherapy for recurrent ESCC.

Comprehensive pathological evaluation of risk factors for metastasis after endoscopic resection of superficial esophageal squamous cell carcinoma

BACKGROUND

Esophageal cancer is a major cause of cancer mortality worldwide. Endoscopic resection (ER) is a curative treatment for esophageal squamous cell carcinoma (ESCC). Predicting risk of metastasis is crucial for post-ER management. In this study, we aimed to identify predictors of metastasis by examining endoscopically resected specimens.

METHODS

The cohort of this retrospective multicenter study comprised 422 patients who had undergone ER for ESCC from 1994 to 2017. Inclusion required a histological diagnosis of pT1a-muscularis mucosa or pT1b-submucosa (SM) cancer. Central pathological review comprehensively evaluated depth of invasion, lymphovascular invasion (LVI), droplet infiltration (DI), infiltrative growth pattern, histological differentiation, intraductal and intraglandular involvement, solitary nest, resected margin, and other factors. Logistic regression was used to identify predictors of metastasis.

RESULTS

Metastases were identified in 103 patients. Univariate analysis identified LVI, depth of invasion, and DI as significant predictive factors. Multivariate analysis identified LVI, depth of invasion pT1b-SM2 (odds ratio 2.72) and indeterminate (positive vertical margin) (odds ratio 3.63) compared with the reference category of pT1b-SM1 as independent predictors of metastasis. Conversely, there were no significant associations between metastasis and lesion size, differentiation, cytological atypia, or infiltration pattern. Subgroup analysis showed that both the number and layer of LVI were associated with metastasis risk. In addition, four or more foci of DI was an independent predictor of LVI.

CONCLUSIONS

LVI and depth of invasion were significant predictors of metastasis in ESCC. Detailed pathological evaluation and standardized criteria are essential for accurately assessing risk of metastasis and guiding post-ER treatment strategies.

A review of deep learning methods for gastrointestinal diseases classification applied in computer-aided diagnosis system

Recent advancements in deep learning have significantly improved the intelligent classification of gastrointestinal (GI) diseases, particularly in aiding clinical diagnosis. This paper seeks to review a computer-aided diagnosis (CAD) system for GI diseases, aligning with the actual clinical diagnostic process. It offers a comprehensive survey of deep learning (DL) techniques tailored for classifying GI diseases, addressing challenges inherent in complex scenes, clinical constraints, and technical obstacles encountered in GI imaging. Firstly, the esophagus, stomach, small intestine, and large intestine were located to determine the organs where the lesions were located. Secondly, location detection and classification of a single disease are performed on the premise that the organ's location corresponding to the image is known. Finally, comprehensive classification for multiple diseases is carried out. The results of single and multi-classification are compared to achieve more accurate classification outcomes, and a more effective computer-aided diagnosis system for gastrointestinal diseases was further constructed.

Endoscopic Submucosal Dissection for Recurrent Esophageal Squamous Cell Carcinoma Post-Radiation

BACKGROUND

The feasibility and outcomes of salvage endoscopic submucosal dissection (ESD) and ESD for metachronous esophageal squamous cell cancer (ESCC) inside the irradiated field are not clear.

AIMS

To explore the viability of ESD for ESCC in areas previously exposed to radiation, identify elements hindering successful ESD, assess prognosis, and elucidate considerations for follow-up.

METHODS

Patients with ESCC who underwent salvage ESD or ESD for metachronous ESCC within the previously irradiated field at Kanagawa Cancer Center between January 1, 2013, and December 31, 2023, were retrospectively investigated to evaluate patient and lesion characteristics and short- and long-term outcomes.

RESULTS

Thirty patients with 41 lesions were analyzed. The median age was 73 (52-88), and 93.3% were men. The middle thorax was the primary location, with flat lesions constituting 73.2%. In salvage ESD cases, the en bloc dissection rate was 91.3%, without adverse events. Conversely, the en bloc dissection rate in metachronous ESD was 100%, and aspiration pneumonitis and post-procedure stricture occurred in 12.5% and 12.5%, respectively. No lesion removed by salvage ESD recurred. During a median follow-up period of 685 (range 24-3061) days, 10 patients (52.6%) developed other organ malignancies, three died from pneumonia, and one died from pharyngeal cancer. The 5-year overall survival rate was 74.9%. No patient died of esophageal cancer.

CONCLUSIONS

Salvage and metachronous ESD are feasible and can achieve high en bloc resection rates and good local control. Screening for other organ malignancies after salvage ESD is indispensable. Preventing aspiration may also improve the prognosis.

Efficacy and safety of PD-1 inhibitors as second-line treatment for advanced squamous esophageal cancer: a systematic review and network meta-analysis with a focus on PD-L1 expression levels

Background

PD-1 inhibitors have shown promising efficacy in enhancing OS and AEs as second-line therapies for patients with advanced esophageal squamous cell carcinoma (ESCC). However, there remains no clear consensus on which PD-1 inhibitor provides the best balance between efficacy and safety. To address this key issue in the second-line treatment of ESCC, we conducted a network meta-analysis (NMA) with a focus on OS benefits, particularly in patients with different levels of PD-L1 expression.

Methods

A systematic search of relevant literature was conducted in Web of Science, Embase, PubMed, and Cochrane Library, covering publications from the inception of these database to June 2024. The evaluated endpoints included OS, progression-free survival (PFS), objective response rate (ORR), AEs, and Grade ≥ 3 adverse events (Grade ≥ 3 AEs). A systematic review and Bayesian network meta-analysis were performed to assess the efficacy and safety of various immunotherapy regimens in patients with advanced ESCC. To ensure transparency, novelty, and reliability, this study was prospectively registered in the systematic review registry (CRD42024540581).

Results

Five randomized controlled trials (RCTs), encompassing 2,078 patients and six treatment regimens, were included in this study. Among advanced ESCC patients not selected based on PD-L1 expression, Sintilimab demonstrated the greatest OS benefit (HR = 0.70, 95% CI: 0.50-0.98). Camrelizumab showed the most favorable improvement in PFS compared to chemotherapy (HR = 0.64, 95% CI: 0.47-0.87) and also achieved the best ORR benefit (OR = 3.72, 95% CI: 1.98-6.99). In terms of safety, Nivolumab (OR = 0.10, 95% CI: 0.05-0.19) and Tislelizumab (OR = 0.18, 95% CI: 0.10-0.33) exhibited significant safety advantages over chemotherapy concerning AEs. Moreover, Nivolumab (OR = 0.13, 95% CI: 0.08-0.20) was associated with a markedly lower risk of Grade ≥ 3 AEs compared to chemotherapy. Subgroup analysis based on PD-L1 expression revealed that Tislelizumab (HR = 0.53, 95% CI: 0.37-0.76) offered the greatest OS benefit for patients with PD-L1 ≥ 10%, while Camrelizumab (HR = 0.71, 95% CI: 0.57-0.89) was the most likely regimen to provide an OS advantage for patients with PD-L1 < 10%.

Conclusion

Compared to chemotherapy, PD-1 inhibitors may provide improved survival outcomes for patients with advanced ESCC. Among patients not selected based on PD-L1 expression, Sintilimab is most likely to deliver the best survival benefit. For patients with PD-L1 expression ≥ 10%, Tislelizumab is expected to offer the greatest efficacy, while Camrelizumab appears to be the most effective for those with PD-L1 < 10%.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024540581.

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

BACKGROUND

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

CASE PRESENTATION

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

CONCLUSIONS

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

Treatment strategy involving docetaxel plus cisplatin and 5-fluorouracil followed by conversion surgery for locally advanced unresectable/borderline resectable esophageal squamous cell carcinoma

Definitive chemoradiotherapy (dCRT) is the standard treatment for unresectable (T4) esophageal squamous cell carcinoma (ESCC), but the prognosis is poor. Borderline resectable (T3br) ESCC has been discussed, but its clinical features and appropriate treatment are unclear. The effects of docetaxel plus cisplatin and 5-fluorouracil (DCF) therapy and subsequent surgery for potentially unresectable ESCC remain controversial. This was a single-center retrospective cohort study. Patients with T3 or deeper ESCC lesions between January 2017 and June 2020 were examined. We identified T3br/T4 ESCC patients who initially received DCF therapy or dCRT, and analyzed the long-term outcomes of these patients. Seventy-four patients with T3br/T4 ESCC were identified. Forty-four patients initially received DCF therapy, while thirty initially received dCRT. The 3-year overall survival of T3br/T4 patients in the DCF group was better than that in the dCRT group (62.9% vs. 34.1%, P = 0.001). In the T3br cohort, 95.8% of patients underwent surgery after DCF therapy, with an R0 resection rate of 78.3%. In the T4 group, 40% of patients underwent surgery after DCF, with a 75.0% R0 resection rate. No cases of reoperation or in-hospital death occurred. For both subgroups, T3br and T4, the prognosis tended to be better in the DCF group than in the dCRT group. This study explored real-world data from T3br/T4 ESCC patients who initially received DCF and subsequent surgery and revealed that DCF is a promising treatment strategy.

Predictive factors for failure of neoadjuvant docetaxel, cisplatin, and 5-fluorouracil therapy in esophageal squamous cell carcinoma

Recently, neoadjuvant chemotherapy comprising docetaxel, cisplatin, and 5-fluorouracil showed promising efficacy for esophageal squamous cell carcinoma. However, some patients do not achieve curative resection despite neoadjuvant chemotherapy using these drugs. This study aimed to clarify the pretherapeutic characteristics of these patients. We included 113 patients who underwent neoadjuvant chemotherapy with docetaxel, cisplatin, and 5-fluorouracil for potentially resectable esophageal squamous cell carcinoma and compared the clinical characteristics between patients who achieved curative resection (curative group) and those who failed to achieve curative resection after planned neoadjuvant chemotherapy (noncurative group). Moreover, we determined the factors predicting noncurative outcomes. Ninety-one (81%) and 22 patients (19%) were in the curative and noncurative groups, respectively. The noncurative group had significantly more tumors located in the upper third of the esophagus, larger-sized tumors, and borderline resectable tumors than the curative group (P = 0.003, 0.049, and <0.001, respectively). Moreover, the noncurative group had significantly higher serum squamous cell carcinoma antigen concentrations than the curative group (P = 0.008). Multivariable analysis identified tumor location in the upper third of the esophagus (odds ratio 7.31, P = 0.002), tumor size ≥50 mm (odds ratio 4.71, P = 0.037), and borderline resectable tumors (odds ratio 6.65, P = 0.003) as independent predictors for noncurative outcomes. Tumor location in the upper third of the esophagus, larger-sized tumors, and borderline resectable tumors might be significant predictors for noncurative outcomes in patients who received neoadjuvant chemotherapy with docetaxel, cisplatin, and 5-fluorouracil.

Is prophylactic lymph node dissection efficacious in salvage esophagectomy after definitive chemoradiotherapy?

BACKGROUND

Salvage esophagectomy for esophageal cancer after definitive chemoradiotherapy (dCRT) is a high-risk surgery, and radical lymph node dissection (RLND) can cause severe complications. However, the significance of RLND in salvage surgery remains unclear.

METHODS

This study included 55 patients who underwent curative-intent salvage esophagectomy after dCRT for esophageal squamous cell carcinoma. We evaluated the prognostic impact of lymph node dissection of each station using efficacy indexes (EIs) and compared the outcomes between RLND and limited lymph node dissection (LLND).

RESULTS

Nine (16.4%) patients underwent RLND and 46 (83.6%) underwent LLND. Patients who underwent RLND had greater operative blood loss and a greater number of resected lymph nodes compared to patients who underwent LLND (P = 0.053 and 0.002, respectively). However, the incidence of postoperative complications was not significantly different between the groups. The EIs of the cervical and mediastinal lymph nodes were zero because no patients with involved nodes at these stations remained alive at 5 years. In contrast, perigastric lymph nodes had relatively high EIs. Overall and cancer-specific survival did not differ significantly between patients who underwent RLND and those who underwent LLND (P = 0.475 and 0.808, respectively).

CONCLUSIONS

The EIs of the cervical and mediastinal lymph nodes were zero, and RLND did not improve survival. Depending on tumor status, LLND may be sufficient for salvage esophagectomy.

Modified reconstruction procedure in subtotal esophagectomy with retrosternal gastric pull up to reduce anastomotic leakage: a propensity score-matched analysis

One risk factor for anastomotic leakage (AL) after esophagectomy with retrosternal gastric reconstruction is excessive compression of the gastric tube at the thoracic inlet. In this study, we evaluated the effect of our modified procedure to reduce AL by placing the esophagogastric anastomosis below the thoracic inlet. Between January 2008 and December 2022, 174 consecutive patients underwent subtotal esophagectomy with retrosternal gastric pull up, followed by circular stapler anastomosis in our hospitals. After January 2016, the gastric tube was pulled down to place the anastomosis below the suprasternal notch. Postoperative CT then measured the level of esophagogastric anastomosis (LEA). Comparing cases before and after revision (conventional group, n = 65 vs. test group, n = 109), AL was significantly reduced from 11 (16.9%) to 3 (2.8%) cases (P = 0.002). After propensity score matching, AL was observed in 14% (8/57) and 0% (0/57) cases in the conventional and test groups, respectively (P = 0.006). Smaller circular stapler size (P < 0.001), less intraoperative blood loss (P < 0.001), and lower LEA (P < 0.001) were observed in the test group than in the conventional group. Multivariate analysis revealed that anastomotic procedure (OR [95%CI], 0.01[0.00-0.46], P = 0.008), and body mass index (OR [95%CI], 6.92[1.10-135.01], P = 0.038) were the independent risk factors for the development of AL. Our modified procedure to avoid compression of the gastric tube at the thoracic inlet is suggested to noninvasively reduce the risk of AL in the subtotal esophagectomy with retrosternal reconstruction.

Survival outcomes of robot-assisted transmediastinal esophagectomy in patients with esophageal squamous cell carcinoma

We developed a robot-assisted transmediastinal esophagectomy (RATME) to reduce the surgical invasiveness of open transthoracic esophagectomy (oTTE). However, the long-term survival outcomes of patients who undergo RATME remain unclear. Patients who underwent RATME for esophageal squamous cell carcinoma (ESCC) between January 2012 and April 2020 were enrolled. Overall survival (OS), relapse-free survival (RFS), and ESCC cause-specific survival (CSS) were analyzed according to clinical stage. Survivals were compared between patients who underwent the RATME and oTTE using propensity score matching analysis. One hundred and twenty-seven patients who underwent RATME were included in the analysis. The 3- and 5-year OS rates were 96.2 and 92.1% for cStage I RATME group, 84.8 and 82.3% for cStage II, and 61.8 and 61.8% for cStage III, respectively. The 3- and 5-year RFS rates were 94.3 and 84.3% for cStageI, 71.7 and 69.3% for cStage II, and 5 48.2 and 48.2% for cStage III, respectively. Survival analysis using 74 paired patients showed that the RATME group had better OS and RFS than the oTTE group (p = 0.0028 and p = 0.016, respectively), but equivalent CSS (p = 0.078). The OS of the RATME group stratified by clinical stage was equivalent to that of the comprehensive registry data from Japan, and showed better OS and RFS than the oTTE group, indicating that RATME radicality is guaranteed with regard to long-term survival.

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

BACKGROUND AND PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Modification of the lesser curvature incision line enhanced gastric conduit perfusion as determined by indocyanine green fluorescence imaging and decreased the incidence of anastomotic leakage following esophagectomy

AIM

This study aimed to investigate the effectiveness of a modified incision line on the lesser curvature for gastric conduit formation during esophagectomy in enhancing the perfusion of gastric conduit as determined by indocyanine green fluorescence imaging and reducing the incidence of anastomotic leakage.

METHODS

A total of 272 patients who underwent esophagectomy at our institute between 2014 and 2022 were enrolled in this study. These patients were divided based on two different types of cutlines on the lesser curvature: conventional group (n = 141) following the traditional cutline and modified group (n = 131) adopting a modified cutline. Gastric conduit perfusion was assessed by ICG fluorescence imaging, and clinical outcomes after esophagectomy were evaluated.

RESULTS

The distance from the pylorus to the cutline was significantly longer in the modified group compared with the conventional group (median: 9.0 cm vs. 5.0 cm, p < 0.001). The blood flow speed in the gastric conduit wall was significantly higher in the modified group than that in the conventional group (median: 2.81 cm/s vs. 2.54 cm/s, p = 0.001). Furthermore, anastomotic leakage was significantly lower (p = 0.024) and hospital stay was significantly shorter (p < 0.001) in the modified group compared with the conventional group. Multivariate analysis identified blood flow speed in the gastric conduit wall as the only variable significantly associated with anastomotic leakage.

CONCLUSIONS

ICG fluorescence imaging is a feasible, reliable method for the assessment of gastric conduit perfusion. Modified lesser curvature cutline could enhance gastric conduit perfusion, promote blood circulation around the anastomotic site, and reduce the risk of anastomotic leakage after esophagectomy.

Outcomes of endoscopic submucosal dissection versus esophagectomy for poorly differentiated superficial esophageal squamous cell carcinoma: A 10-year cohort study

BACKGROUNDS

The efficacy of endoscopic submucosal dissection (ESD) to treat poorly differentiated superficial esophageal squamous cell carcinoma (SESCC) is unclear.

AIMS

To exploring the efficacy and prognosis of ESD treatment poorly differentiated SESCC compared with esophagectomy.

METHODS

A retrospective cohort study was conducted, the data of poorly differentiated SESCC patients who received ESD or esophagectomy from Jan 2011 to Jan 2021 were analyzed. Overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), and procedure-related variables were compared between ESD and esophagectomy group.

RESULTS

95 patients underwent ESD, while 86 underwent esophagectomy. No significant differences were found between the two groups in OS (P = 0.587), DSS (P = 0.172), and RFS (P = 0.111). Oncologic outcomes were also similar between the two groups in propensity score-matched analysis. For T1a ESCC, the rates of R0 resection, LVI or nodal metastasis and additional therapy were similar between ESD and esophagectomy groups. But for T1b ESCC, the rates of positive resection margin and additional therapy were significantly higher in ESD group than those in esophagectomy group.

CONCLUSIONS

ESD is a minimally invasive procedure that has comparable oncologic outcomes with esophagectomy for treatment poorly differentiated T1a ESCC. However, ESD is not suitable for poorly differentiated T1b ESCC, additional surgery or radiochemotherapy should be required.

Prognostic impact of preoperative osteosarcopenia on esophageal cancer surgery outcomes: a retrospective analysis

BACKGROUND

Osteosarcopenia, recognized as a consequence of aging, has garnered attention as a prognostic marker in recent years; however, its clinical significance in esophageal cancer remains uncertain. This study aimed to investigate the impact of osteosarcopenia on esophageal cancer surgery outcomes.

METHODS

This retrospective study included patients with advanced esophageal cancer who underwent surgical resection between 2018 and 2021. Skeletal muscle index at the L3 vertebral level and bone density at the Th11 vertebral level were measured on preoperative computed tomography scans. Based on the findings, we divided patients into sarcopenia, osteopenia, and osteosarcopenia groups, and analyzed the relationship between osteosarcopenia and clinicopathological factors, including prognosis.

RESULTS

Of the 124 patients included, 59 (48%) were diagnosed with osteosarcopenia. Among all, 46 (37%) patients experienced postoperative recurrence, and a significant correlation was observed between osteosarcopenia and recurrence (p < 0.05). Overall survival and relapse-free survival were significantly shorter in the osteosarcopenia group than in the non-osteosarcopenia group (p < 0.05 for both). In a subgroup analysis, overall survival and relapse-free survival were significantly shorter in the osteosarcopenia group than in the non-osteosarcopenia group, or in the sarcopenia and osteopenia alone groups (all p < 0.05).

CONCLUSIONS

The presence of preoperative osteosarcopenia was found to affect the prognosis following esophageal cancer surgery.

Phase II Trial of Adjuvant S-1 Following Neoadjuvant Chemotherapy and Surgery in Patients with Locally Advanced Esophageal Squamous Cell Carcinoma: The PIECE Trial

BACKGROUND

Neoadjuvant chemotherapy followed by surgery (NAC-S) is the standard therapy for locally advanced esophageal squamous cell carcinoma (ESCC) in Japan.

OBJECTIVE

The aim of this phase II trial was to assess the efficacy and safety of the addition of adjuvant S-1 after R0 resection in ESCC patients who received NAC-S.

PATIENTS AND METHODS

Key eligibility criteria included clinical stage IB-III (without T4 disease) ESCC, age 20-75 years, and an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. Patients received adjuvant therapy with four cycles of S-1 (80 mg/m2/day) administered orally for 4 weeks of 6-week cycles. The primary endpoint was 3 year relapse-free survival (RFS). If the lower confidence limit for 3 year RFS was >50%, we judged that the primary endpoint of this study was met.

RESULTS

A total of 52 patients were enrolled between January 2016 and January 2019. Two patients were excluded from analysis; five patients were determined to have R1 or R2 resection, and seven patients did not receive adjuvant S-1. The 3-year RFS and overall survival rates in the intention-to-treat population were 72.3% (90% confidence interval [CI] 59.9-81.5) and 85.0% (90% CI 73.9-91.6), indicating that the primary endpoint was met. Grade ≥3 adverse events with an incidence ≥10% included neutropenia (13.2%), anorexia (13.2%), and diarrhea (10.5%). There were no treatment-related deaths.

CONCLUSION

Adjuvant S-1 after NAC-S showed promising efficacy with a manageable safety profile for patients with resectable ESCC and warrants further evaluation in larger studies.

Effect of sprayable, highly adhesive hydrophobized gelatin microparticles on esophageal stenosis after endoscopic submucosal dissection: an experimental study in a swine model

BACKGROUND

Esophageal mucosal resection for superficial esophageal cancer can lead to postoperative esophageal stricture, with current preventive measures being insufficient. Sprayable wound dressings containing hydrophobized microparticles exhibit strong adhesion. This study aimed to investigate the preventive effects of hydrophobized microparticles on esophageal stenosis following endoscopic submucosal dissection.

METHODS

Circumferential esophageal endoscopic submucosal dissection was performed on miniature swine (n = 6). Swine were categorized into two groups: those sprayed with hydrophobized microparticles (sprayed group) and those not sprayed (non-sprayed group). Hydrophobized microparticles were sprayed onto the sprayed group on Days 0, 3, and 7 of endoscopic submucosal dissection. The non-sprayed group underwent endoscopy on the same days. Esophageal stricture rate, submucosal inflammatory cell infiltration, submucosal fibrosis, and thickening of the muscular layer were compared between the groups on Day 14 of endoscopic submucosal dissection.

RESULTS

Spraying of hydrophobized microparticles was easily performed using an existing endoscopic spraying device. The esophageal stricture rate was significantly lower in the sprayed group than in the non-sprayed group (76.1% versus 90.6%, p < 0.05). The sprayed group showed suppression of inflammatory cell infiltration in the submucosal layer (p < 0.01) and thickening of the muscular layer (p < 0.01).

CONCLUSIONS

Sprayable tissue-adhesive hydrophobized microparticles reduce the stricture rate after esophageal ESD by inhibiting inflammatory cell infiltration, submucosal fibrosis, and thickening of the muscular layer. The use of hydrophobized microparticles for preventing post-endoscopic submucosal dissection esophageal stenosis offers a promising avenue for clinical applications in endoscopic procedures, potentially improving patient outcomes.

The totally mechanical Collard technique for cervical esophagogastric anastomosis reduces anastomotic stricture compared with triangular anastomosis in minimally invasive esophagectomy with gastric conduit reconstruction through the retrosternal route: a propensity score-matched study

BACKGROUND

Cervical esophagogastric anastomosis is conventionally performed using the McKeown esophagectomy. However, an optimal anastomotic technique has not yet been established. This study aimed to compare the clinical outcomes of triangular anastomosis (TA) and totally mechanical Collard anastomosis (TMCA) for cervical esophagogastric anastomosis during minimally invasive esophagectomy with gastric conduit reconstruction through the retrosternal route.

METHODS

In this matched- cohort study, 117 patients who underwent minimally invasive esophagectomy between 2019 and 2024 were divided into TA and TMCA groups. The TA technique was performed between September 2019 and December 2021, and the TMCA technique was performed between January 2022 and January 2024. We then compared the surgical outcomes and postoperative complications (pneumonia, recurrent laryngeal nerve palsy, anastomotic leakage, and stricture) between the two groups.

RESULTS

Propensity score matching revealed that 40 patients were included in both the TA and TMCA groups. The rates of pneumonia, recurrent laryngeal nerve palsy, and anastomotic leakage were not significantly different between the two groups. However, the rate of anastomotic stricture was lower in the TMCA than in the TA group (2.5% vs. 27.5%, respectively, P = 0.003).

CONCLUSIONS

Compared with the TA technique, the TMCA technique reduced the rate of anastomotic stricture when performing cervical esophagogastric anastomosis during minimally invasive esophagectomy with gastric conduit reconstruction through the retrosternal route.

The usefulness of presepsin in the early detection of anastomotic leakage after esophagectomy

Background

Anastomotic leakage is a severe complication of esophagectomy, therefore early detection is crucial. Presepsin is a biomarker for early diagnosis of infectious complications. This study assessed presepsin as a biomarker for anastomotic leakage after esophagectomy, compared to C-reactive protein (CRP), white blood cells (WBCs), and neutrophils (Neuts).

Materials and methods

This study enrolled 27 patients between October 2019 and December 2020. Levels of presepsin, CRP, WBCs, and Neuts were measured preoperatively and on postoperative days (PODs) 1, 3, 5, and 7.

Results

Five patients had anastomotic leakage. Their presepsin levels on POD 7 were significantly higher and tended to be higher on POD 5 (p = 0.04 and p = 0.06, respectively) compared to those without leakage. The area under the curve values for presepsin were highest on PODs 5 and 7 (0.89 and 0.83). Optimal cut-off values for presepsin were 400 pg/mL (sensitivity 100 %; specificity 81.9 %) on POD 5 and similar on POD 7.

Conclusions

Presepsin levels on PODs 5 and 7 effectively detect anastomotic leakage after esophagectomy, making it a valuable, simple, non-invasive early detection test.

The Global Immune-Nutrition-Information Index (GINI) Is an Independent Prognostic Factor for Esophageal Cancer Patients Who Receive Curative Treatment

Background/Aim

The aim of the present study was to evaluate the clinical impact of the Global Immune-Nutrition-Information Index (GINI) in patients with esophageal cancer (EC) who received curative treatment and to clarify the potential of the GINI as a prognostic factor.

Patients and Methods

Patients who underwent curative resection for EC at Yokohama City University between 2000 and 2020 were consecutively chosen based on their medical records. The GINI was defined as follows: GINI=[C-reactive protein×platelet×monocyte×neutrophil]/[albumin×lymphocyte].

Results

This study included 180 patients. Among them, 67 were categorized into the GINI-low group and 113 were categorized into the GINI-high group, with a cutoff value of 5000. The 3- and 5- year overall survival (OS) rates were 75.6% and 64.9%, respectively, in the GINI-low group and 55.3% and 48.1% in the GINI-high group (p=0.005). According to a multivariate analysis for OS, the GINI was identified as an independent prognostic factor [hazard ratio=2.106, 95% confidence interval=1.252-3.544, p=0.005]. Similar results were observed for RFS. In addition, the GINI affects preoperative tube feeding and the induction rate of neoadjuvant chemotherapy (NAC).

Conclusion

The GINI is a promising biomarker for the treatment and management of EC.

Comparative analysis of manual vs. mechanical suturing techniques in esophagectomy: A propensity score‑matched study of long‑term outcomes

Esophageal cancer, particularly esophageal squamous cell carcinoma (ESCC), is a major health concern worldwide, particularly in China. Surgical resection is still considered the primary curative treatment for this disease. However, the effect of different surgical methods-traditional hand-sewn anastomosis and modern mechanical anastomosis-remains controversial. A retrospective study was thus performed to elucidate how these two techniques affected the clinical prognosis of patients. Data were retrospectively collected from the comprehensive Esophageal Cancer Case Management Database of Sichuan Cancer Hospital and Institute (Chengdu, China), covering the period from 2010 to 2017. The cohort consisted of patients who underwent esophagectomy for ESCC, divided into two groups based on the suturing technique used: Manual suturing (MS) and mechanical suturing (MeS). A total of four causal inference methods for retrospective studies, namely inverse probability of treatment weighting, standardized mortality ratio weighting, overlap weighting and propensity score matching analysis, were used to minimize potential selection bias. The primary outcome evaluated was overall survival (OS), allowing for a direct comparison of the long-term efficacy of the two suturing methods. In a retrospective analysis of 2,510 patients undergoing esophagectomy, significant differences in OS were observed between the MeS group and the MS group (hazard ratio: 0.84; 95% confidence interval: 0.75-0.95; P=0.004). However, after matching or weighting based on causal inference analyses, no significant differences in survival outcomes between groups were obtained. The equivalence in outcomes suggests that either suturing method may be equally viable in clinical practice, offering flexibility in surgical decision-making without compromising OS.

A rare case of retroperitoneal recurrence as squamous cell carcinoma 10 years after nephroureterectomy

Introduction

Local recurrence for upper tract urothelial carcinoma typically occurs within 2 years post-surgery. We report a rare case of retroperitoneal recurrence as squamous cell carcinoma 10 years after nephroureterectomy.

Case presentation

A 67-year-old female was referred to our urology department for a left ureteral tumor. The surgical specimen of the laparoscopic left nephroureterectomy revealed urothelial carcinoma at the pT3 stage. Ten years post-nephroureterectomy, magnetic resonance cholangiopancreatography revealed a mass lesion in the left retroperitoneum, a computed tomography-guided biopsy revealed squamous cell carcinoma. Despite suspected distant metastases of other organ tumors, examinations such as digestive endoscopy and bronchoscopy did not reveal any tumor lesions. The patient was diagnosed with recurrent invasive urothelial carcinoma as a pathological feature of squamous cell carcinoma.

Conclusion

The decision-making process for treating malignant tumors, such as in cases with recurrence as squamous cell carcinoma, can be challenging.

Evaluating the discrepancies between evidence-based and community standard practices in the endoscopic diagnosis of esophageal squamous cell carcinoma: a survey study

BACKGROUND

The practice of endoscopic diagnosis of esophageal squamous cell carcinoma (ESCC) often diverges from evidence-based standards due to various factors, including inadequate dissemination of evidence or a mismatch between evidence and real-world contexts. This survey aimed to identify discrepancies between evidence-based standard practices and community standard practices for ESCC among endoscopists.

METHODS

An online survey targeting endoscopists who perform upper gastrointestinal endoscopy at least weekly was conducted to collect data on clinical practices related to ESCC diagnosis. The survey, comprising 20 questions, was disseminated through multiple professional networks. Descriptive statistical analysis and logistic regression were performed to analyze the data.

RESULTS

Data from 819 endoscopists were included in the analyses. Notably, a significant proportion employed narrow-band imaging/blue-laser imaging over iodine staining, and preferences varied based on risk assessment for ESCC. In total, 64.0% of endoscopists primarily used iodine solution at a concentration of 1% or less, while 96.5% of endoscopists performed an observation of the oral cavity and the pharynx when conducting upper gastrointestinal endoscopies on individuals at high risk of ESCC. The surveillance interval for metachronous multiple ESCCs was most commonly every 6 months, followed by every 12 months. In addition, most physicians conducted surveillance of metastatic recurrence at 6-month intervals.

CONCLUSIONS

This survey highlights significant gaps between evidence-based and community standard practices in the endoscopic diagnosis of ESCC. These findings underscore the need for enhanced dissemination of evidence-based guidelines and consideration of real-world clinical contexts to bridge these gaps and optimize patient care.

Safety and Efficacy of Conversion Therapy After Systemic Chemotherapy in Advanced Esophageal Cancer with Distant Metastases: A Multicenter Retrospective Observational Study

BACKGROUND

Patients with esophageal squamous cell carcinoma (ESCC) with distant metastasis were treated with systemic chemotherapy. Recent advances in multimodal treatments have made conversion therapy a viable option for patients with incurable ESCC.

OBJECTIVE

We aimed to assess the safety and efficacy of conversion therapy for ESCC with distant metastases.

METHODS

Conversion therapy was defined as surgery or chemoradiotherapy (CRT) used to cure tumors that were previously considered incurable because of distant metastasis. We conducted a retrospective review of patients who underwent ESCC conversion therapy and assessed the treatment outcomes, including adverse events and survival rates.

RESULTS

A total of 147 patients from 22 institutions were included. Systemic chemotherapy was initially administered to all patients. The most common M1 factor was the para-aortic lymph node, accounting for 55% of cases. Following the initial treatment, 116 patients underwent surgery, with 31 receiving CRT as conversion therapy. Postoperative complications in surgery patients included pneumonia (16%), anastomotic leakage (7%), and recurrent laryngeal nerve palsy (6%). During CRT, 18% of patients developed grade 3 or higher non-hematological toxicities. The 5-year overall survival (OS) rate was 31.7%. Pathological responders had significantly longer OS than non-responders (hazard ratio 0.493, p = 0.012). The distribution of distant metastasis, regimen type, clinical response, and conversion therapy modality did not have a significant impact on OS.

CONCLUSIONS

Conversion therapy can be safely performed for ESCC with distant metastasis and has a favorable prognosis.

Evaluation of urinary vanin-1 for the early prediction of cisplatin-induced acute kidney injury during neoadjuvant chemotherapy for esophageal cancer

PURPOSE

Cisplatin (CDDP) induces acute kidney injury (AKI) as a side effect during neoadjuvant chemotherapy (NAC). Urinary vanin-1 excretion may increase during CDDP treatment. We investigated whether urinary vanin-1 is an early biomarker for CDDP-induced AKI.

METHODS

Thirty patients were administered 80 mg/m2 CDDP on day 1 as NAC for esophageal cancer. Blood and urine samples were collected on days 1, 2, 3, 4, and 6 after CDDP administration. Serum creatinine (sCr) and urinary vanin-1 levels were measured. Creatinine clearance (cCr) and estimated glomerular filtration rate (eGFR) were calculated from sCr. Based on the change in sCr after CDDP administration, the AKI and non-AKI groups were defined using the Kidney Disease Improving Global Outcomes classification. Changes in sCr, cCr, eGFR, and urinary vanin-1 levels were compared between the two groups.

RESULTS

A gradual increase in sCr and a decrease in eGFR were observed over time post-CDDP administration, with differences between the two groups becoming significant by day 4. However, urinary vanin-1 levels increased on day 3 after CDDP administration, and the difference between the two groups was significant on day 3. Receiver operating characteristic curves of urinary vanin-1 on day 3 revealed that a cut-off value of 3.17 ng urinary vanin-1/mg urinary creatinine yielded an area under the curve, sensitivity, and specificity of 0.83 (P < 0.05), 75.0%, and 22.7%, respectively. The non-AKI incidence below the cut-off value of urinary vanin-1 of 3.17 ng/mg uCr was 89.5%.

CONCLUSION

Urinary vanin-1 is a superior minimally invasive biomarker for the early prediction of CDDP-induced AKI.

Long-term outcomes of intrathoracic versus cervical anastomosis after esophagectomy: A large-scale propensity score matching analysis

BACKGROUND

Esophageal squamous cell carcinoma is a prevalent and aggressive gastrointestinal tumor, particularly in East Asia. However, there is a lack of consensus on the long-term survival outcomes of intrathoracic anastomosis and cervical anastomosis following esophagectomy. This study aims to provide a comprehensive summary of the long-term survival outcomes of these 2 anastomosis techniques.

METHODS

We employed data drawn from the Sichuan Cancer Hospital and Institute Esophageal Cancer Case Management Database from January 2010 to December 2017. Patients were stratified into 2 distinct groups according to the anatomical location of anastomosis following esophagectomy: those who underwent intrathoracic anastomosis (IA) (IA group) and those who underwent cervical anastomosis (CA) (CA group). To account for potential confounding factors and baseline imbalances between the 2 groups, propensity score matching was employed.

RESULTS

The CA group exhibited longer overall survival compared with the IA group, with a median overall survival of 49.10 months versus 35.87 months (hazard ratio, 1.118; 95% CI, 1.118-1.412; P < .001). Additionally, survival rates at 1, 3, and 5 years were higher in the CA group (87%, 59%, and 48%, respectively) compared with the IA group (86%, 50%, and 39%, respectively). The significance persisted even after propensity score matching (hazard ratio, 1.164; 95% CI, 1.013-1.336; P < .001), inverse probability of treatment weighting, and overlap weighting were applied. The survival difference between CA and IA was attributed to varying extents of lymph node dissection, particularly in the upper mediastinal zone (P < .001).

CONCLUSIONS

Our study suggests that there could be the potential survival advantage of CA over IA in patients undergoing esophagectomy for esophageal squamous cell carcinoma.

Evaluation of N-NOSE as a surveillance tool for recurrence in gastric and esophageal cancers: a prospective cohort study

OBJECTIVE

Early detection of recurrent gastric and esophageal cancers remains a critical challenge. Innovative and non-invasive cancer screening technologies, such as N-NOSE, can improve early detection. N-NOSE is a urine-based scent test that leverages the olfactory abilities of the nematode C. elegans. For the first time, this prospective study evaluates the efficacy of the N-NOSE chemotaxis index as a novel biomarker for postoperative surveillance and recurrence in patients with upper gastrointestinal cancers.

METHODS

A two-year prospective cohort study was conducted at The University of Tokyo Hospital, involving 40 patients with gastric and esophageal cancers. Urine samples were collected pre- and postoperatively and analysed using the N-NOSE technique.

RESULTS

In cases of recurrence with vascular invasion, the chemotaxis index at 100-fold urine dilution was significantly elevated compared to the non-recurrence group.

CONCLUSION

This study suggests the potential of N-NOSE as an effective follow-up tool for patients with upper gastrointestinal cancer, particularly those with vascular invasion. While N-NOSE has been validated to distinguish between cancer and non-cancer, and its performance compared to traditional markers has been proven, it has not been studied for recurrence. Our data highlights, for the first time, the capability of N-NOSE in the surveillance of cancer recurrence.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Robot-assisted minimally invasive esophagectomy for esophageal cancer in the left lateral decubitus position

BACKGROUND

The use of robot-assisted minimally invasive esophagectomy (RAMIE) in the prone position for esophageal cancer has been currently increasing worldwide. In future, as surgical-assisted robots become more widespread, it is estimated that only two methods of transthoracic approach will remain: RAMIE and open thoracotomy for thoracic esophageal cancer. RAMIE in the left lateral decubitus position (RAMIE-LLDP) has the same field of view as open thoracotomy, is safe in emergency situations, and provides education on open thoracotomy.

METHODS

Between September 2020 and April 2024, RAMIE-LLDP was performed in 64 consecutive patients with esophageal cancer. RAMIE-LLDP was performed with the operating table rotated and tilted 45° to the ventral side under artificial pneumothorax. The hand-control setting of the surgical-assist robot system was reversed left to right when the Patient Cart was rolled from the same direction as the RAMIE in the prone position.

RESULTS

The mean total surgery and console times during the thoracic procedure were 254-min overall and 225 min in the last 24 cases and 195-min overall and 178- min in the last 24 cases, respectively. The mean amount of blood loss was 203.4 g overall and 28.3 g in the last 24 cases. Postoperative recurrent laryngeal nerve palsy with Clavien-Dindo classification (CD) was ≥ 2 in six patients (9.4%). Postoperative pneumonia with CD ≥ 2 was observed in 11 patients (17.2%). Conversion to open thoracotomy was observed in three patients (4.7%). In all three patients, an immediate conversion to thoracotomy without patients' position change was actually possible and no serious complications were noted. No mortality occurred within 30 days postoperatively.

CONCLUSION

RAMIE-LLDP which facilitates emergency thoracotomy has perioperative results comparable to those of conventional thoracoscopic esophagectomy and is educational for open surgery. RAMIE-LLDP is the safest and most optimal surgery for esophageal cancer.

Risk and pathologic factors of recurrence after endoscopic resection for superficial esophageal squamous cell carcinoma: a systematic review and meta-analysis

BACKGROUND AND AIMS

The risk and pathologic factors of recurrence after endoscopic resection (ER) for superficial esophageal squamous cell carcinoma (ESCC) are inconsistent across studies. We evaluated this in a systematic review and meta-analysis.

METHODS

The data of recurrence in such patients were extracted from all studies. Risk ratios (RRs) were combined using random-effects meta-analysis to assess pooled recurrence rate and pathologic risk factors. Relapse-free survival was combined using the Kaplan-Meier method to estimate the relationship between various pathologic factors and recurrence time.

RESULTS

We identified 26 studies, with a total of 5100 patients and 321 with recurrences (pooled rate, 6.2%). The risk of recurrence was significantly higher in positive vertical margin (RR, 4.51; 95% confidence interval [CI], 2.16-9.44), positive horizontal margin (RR, 2.54; 95% CI, 1.57-4.13), lymphovascular invasion (LVI) (RR, 2.33; 95% CI, 1.75-3.11; P < .001), lymphatic invasion (LI) (RR, 2.24; 95% CI, 1.24-4.06), and tumor invading submucosa of ≤200 μm (SM1) (RR, 1.71; 95% CI, 1.32-2.21, compared to muscularis mucosa). Patients with LI (hazard ratio, 2.47; 95% CI, 1.24-4.90; P = .02) and LVI (HR, 2.36; 95% CI, 2.22-4.59; P = .0006) tended to have earlier recurrence after ER.

CONCLUSIONS

The recurrence rate of superficial esophageal squamous cell carcinoma after ER is acceptable. Patients with positive margins, LVI, LI, and SM1 need to pay significant attention to the risk of recurrence. LI and VI should be evaluated separately. (PROSPERO CRD42023406309.).

Optimizing Organ-Preservation Strategies Through Chemotherapy-Based Selection in Esophageal Squamous Cell Carcinoma: Results From the CROC Multi-Institutional Phase 2 Clinical Trial

PURPOSE

This study aimed to assess the viability of definitive chemoradiotherapy (dCRT) as an organ-preservation strategy for remarkable responders who were downstaged to stage IA after receiving induction chemotherapy for resectable esophageal squamous cell carcinoma (ESCC).

METHODS AND MATERIALS

Chemotherapy-naïve patients with resectable ESCC (stage IB-III, Union for International Cancer Control, International Cancer Control seventh edition) were eligible for the study. All patients received 3 cycles of docetaxel, cisplatin, and 5-FU (DCF) therapy (docetaxel 75 mg/m2 on day 1, cisplatin 75 mg/m2 on day 1, and 5-fluorouracil [5-FU] 750 mg/m2 on days 1-5, repeated every 3 weeks). Remarkable response was defined as a reduction in the tumor to T1, metastatic lymph nodes <1 cm on the short axis, and downstaging to stage IA after 3 cycles of DCF therapy. Remarkable responders then underwent dCRT, which included 2 courses of cisplatin 75 mg/m2 and 5-FU 1000 mg/m2 on days 1 to 4, repeated every 4 weeks, along with 50.4 Gy of concurrent radiation therapy. The primary endpoint was 1-year progression-free survival in remarkable responders following DCF therapy and subsequent dCRT. Secondary endpoints included 3-year overall survival (OS) and esophagectomy-free survival.

RESULTS

Of the 92 patients registered, 90 were analyzed. A remarkable response to 3 courses of DCF therapy was observed in 58.4% of patients. Among these responders, 89.8% achieved a complete response after dCRT. During the median follow-up period of 33 months (range, 1-85 months), the 1-year progression-free survival was 89.8% (95% confidence interval [CI], 77.2%-95.6%, primary endpoint), and the 3-year OS was 83.7%. The 3-year OS and esophagectomy-free survival rates in the analysis group were 74.1% and 45.3%, respectively. An 18F-fluorodeoxyglucose-positron emission tomography response after 2 courses of DCF therapy was significantly associated with OS (P = .0049).

CONCLUSIONS

In patients with resectable ESCC, dCRT for remarkable responders downstaging to stage IA after induction chemotherapy with 3 courses of DCF therapy is a feasible treatment option and provides an optimizing organ-preservation strategy of chemotherapy-based selection.

Long-term outcomes of endoscopic resection of superficial esophageal squamous cell carcinoma in late-elderly patients

BACKGROUND AND AIM

As the population ages, the number of elderly patients with superficial esophageal squamous cell carcinoma (ESCC) is increasing. We aimed to clarify the indications for endoscopic resection (ER) in late-elderly patients with ESCC in terms of life expectancy.

METHODS

Patients aged ≥75 years who underwent ER for ESCC at our institution from January 2005 to December 2018 were enrolled. Clinical data, including the Eastern Cooperative Oncology Group performance status, American Society of Anesthesiologists physical status (ASA-PS), Charlson comorbidity index, and prognostic nutritional index (PNI), were collected at the time of ER. The main outcome measure was overall survival (OS).

RESULTS

Two hundred eight consecutive patients were enrolled. The patients' median age was 78 years (range, 75-89 years). The 5-year follow-up rate was 88.5% (median follow-up period, 6.6 years). The 5-year OS rate was 79.2% (95% confidence interval [CI], 72.2-84.8), and 5-year net survival standardized for age, sex, and calendar year was 1.04 (95% CI, 0.98-1.09). In the multivariate analysis, an ASA-PS of 3 (hazard ratio, 2.45; 95% CI, 1.16-5.17) and PNI of <44.0 (hazard ratio, 2.73; 95% CI, 1.38-5.40) were independent prognostic factors. When neither of these factors was met, the 5-year OS rate was 87.8% (95% CI, 80.0-92.9), and 5-year net survival was 1.08 (95% CI, 1.02-1.14).

CONCLUSIONS

ER for ESCC in late-elderly patients may improve life expectancy. ER is recommended in patients with a good ASA-PS and PNI.

Comparison of the treatment outcomes of different neoadjuvant chemoradiotherapy regimens for resectable locally advanced esophageal cancer

BACKGROUND

Neoadjuvant chemoradiotherapy (nCRT) followed by radical esophagectomy is the standard treatment for locally advanced esophageal squamous cell cancer (LA-ESCC). However, various nCRT regimens have been used, and their comparative efficacy and safety remain unclear.

METHODS

Patients with histologically confirmed LA-ESCC who underwent nCRT followed by radical esophagectomy between January 2016 and February 2022 were enrolled in this study. Of note, 3 different nCRT regimens were retrospectively compared: conventional radiotherapy (RT) + cisplatin/5-fluorouracil (FP) (Conv-FP), hypofractionated RT + FP (Hypo-FP), and regimens from the ChemoRadiotherapy for Oesophageal cancer followed by Surgery Study (CROSS) trial (CROSS). The overall survival (OS), pathologic complete response (pCR), toxicity, and treatment compliance rates were analyzed.

RESULTS

Among the 600 patients, 225 received Conv-FP, 255 received Hypo-FP, and 120 received the CROSS regimen. The OS rates at 1 year were 78.7%, 83.9%, and 88.1% in the Conv-FP, Hypo-FP, and CROSS groups, respectively (P < .001). The pCR rates were 30.6%, 33.9%, and 35.0%, respectively (P = .653). The overall incidence of grade 3 toxicities was 10.2%. Hematologic and nonhematologic toxicities of grade ≥ 3 were observed in 8.4% and 11.4%, 0% and 7.6%, and 5.5% and 0.8% in the Conv-FP, Hypo-FP, and CROSS groups, respectively (P = .002 and P = .030). Weight loss of > 5% was observed in 44.0%, 51.4%, and 32.5% in the Conv-FP, Hypo-FP, and CROSS groups, respectively (P < .001). In the multivariate analysis, clinical T stage (P = .004), N stage (P = .012), FP chemotherapy regimen (P = .013), surgical resection (P < .001), hematologic toxicity (P = .001), and weight loss (P = .004) were significantly associated with poor OS.

CONCLUSION

The choice of nCRT regimen did not significantly affect the pCR rates in patients with LA-ESCC. However, the CROSS regimen demonstrated better OS and lower toxicity, suggesting that it may be the optimal treatment option among the groups.

Emergency esophagectomy for esophageal perforation following balloon dilation due to stenosis post-endoscopic submucosal dissection for esophageal cancer: a case report

Introduction and importance

Esophageal perforation from endoscopic dilation is rare (0.53-0.6% incidence) but serious, with mortality rates of 12.5-20%. Optimal treatment is debated and depends on the medical facility's capabilities, the patient's symptoms, the extent of perforation, and the severity of associated lesions. Treatment options include medical management (fasting, antibiotics), esophageal stenting, surgical closure, or emergency esophagectomy. Early diagnosis and treatment are crucial to reduce mortality and hospital stay.

Case presentation

A 49-year-old male with lower third esophageal cancer (stage cT1aN0M0) underwent endoscopic submucosal dissection (ESD) and developed esophageal stenosis. Dilation attempts led to esophageal perforation, necessitating emergency esophagectomy with gastric conduit reconstruction. The patient improved and was discharged on day 10 post-operation without complications.

Clinical discussion

Managing esophageal perforation post-endoscopic dilation is complex. This case highlights the importance of rapid recognition and intervention. Esophageal dilation, while effective for stenosis, carries a perforation risk. Treatment decisions must be tailored to individual patients, considering perforation severity, patient's health, and facility resources. Here, severe perforation and clinical condition warranted emergency esophagectomy. The successful outcome underscores the efficacy of this surgical intervention when performed timely at specialized centers.

Conclusion

Emergency esophagectomy with gastric conduit reconstruction for treating esophageal perforation due to stenosis post-endoscopic submucosal dissection for esophageal cancer is considered a safe procedure and can be performed at an experienced esophageal surgery center.

Prognostic impact of dysphagia scores in patients with advanced resectable esophageal cancer who underwent radical esophagectomy after preoperative treatment

BACKGROUND

Dysphagia caused by tumor strictures is a major symptom in patients with advanced esophageal cancer. However, the prognostic effect of dysphagia in resectable cases is insufficiently investigated. This study aimed to investigate the prognostic value of dysphagia scores in resectable advanced esophageal cancer who underwent radical esophagectomy after preoperative treatment.

METHODS

This retrospective study enrolled 302 consecutive patients with advanced resectable esophageal cancer who received preoperative treatment. The preoperative dysphagia score was used to assess the relationship between tumor stricture and clinical outcomes.

RESULTS

Almost half of the patients had dysphagia scores of 2 to 4 (n = 152 [50.3%]). Lower body mass index, circumferential tumors, and noncurative resection were significantly more common as dysphagia scores worsened. Patients with dysphagia had significantly more advanced ypT stage and worse histopathologic response than those without dysphagia. The 5-year disease-free survival and overall survival (OS) rates for dysphagia scores of 0 to 1, 2 to 3, and 4 were 52.9%, 35.3%, and 26.7% and 60.7%, 40.4%, and 26.7%, respectively. Multivariate analysis identified dysphagia score as an independent factor of OS, similar to surgical curability and ypN stage. The postoperative recurrence rate was significantly higher among patients with dysphagia scores of 2 to 3 (56%) and 4 (67%) than among those with dysphagia scores of 0 to 1 (36%) (P < .001 and P = .037, respectively). Furthermore, distant recurrence in dysphagia scores of 2 to 3 and 4 was higher than in dysphagia scores of 0 to 1 (26%, 46%, and 42%, respectively).

CONCLUSION

The dysphagia score before initial treatment is associated with postoperative survival in patients with resectable advanced esophageal cancer.

Inflammatory Burden Index Is an Independent Prognostic Factor for Esophageal Cancer Patients Who Receive Curative Treatment

BACKGROUND/AIM

We hypothesized that the inflammatory burden index (IBI) is a promising biomarker for esophageal cancer (EC) treatment and management. To confirm our hypothesis, we evaluated the prognostic impact of IBI in patients with EC who received curative treatment.

PATIENTS AND METHODS

We conducted a retrospective review of medical records and collected data from consecutive patients with EC who underwent curative resection at Yokohama City University between 2005 and 2020. The IBI score was calculated as the C-reactive protein level multiplied by the neutrophil-to-lymphocyte ratio.

RESULTS

In total, 180 patients with EC were included in this study. The 3- and 5-year overall survival (OS) rates were 72.9% and 63.4%, respectively, in the IBI-low group, and 38.2% and 32.5% in the IBI-high group (p<0.001). In the multivariate analysis, IBI was identified as a significant prognostic factor for OS [hazard ratio (HR)=2.372; 95% confidence interval CI=1.478-3.806, p<0.001]. In addition, the 3- and 5-year recurrence-free survival (RFS) rates were 52.9% and 47.8%, respectively, in the IBI-low group, and 22.9% and 17.2% in the IBI-high group (p<0.001). In the multivariate analysis, IBI was identified as a significant prognostic factor for RFS (HR=2.484; 95%CI=1.373-4.494, p<0.001). When comparing the recurrence patterns between the IBI-high and IBI-low groups, there were significant differences in lymph node recurrence (46.0% vs. 26.2%, p=0.010) and hematological recurrence (52.0% vs. 18.5%, p<0.001).

CONCLUSION

IBI affects both the short- and long-term oncological outcomes. Thus, IBI may be a promising prognostic factor for the treatment and management of EC.

Essential updates 2022/2023: Recent advances in perioperative management of esophagectomy to improve operative outcomes

In the era of minimally invasive surgery, esophagectomy remains a highly invasive procedure with a high rate of postoperative complications. Preoperative risk assessment is essential for planning esophagectomy in patients with esophageal cancer, and it is crucial to implement evidence-based perioperative management to mitigate these risks. Perioperative support from multidisciplinary teams has recently been reported to improve the perioperative nutritional status and long-term survival of patients undergoing esophagectomy. Intraoperative management of anesthesia and fluid therapy also significantly affects short-term outcomes after esophagectomy. In this narrative review, we outline the recent updates in the perioperative management of esophagectomy, focusing on preoperative risk assessment, intraoperative management, and perioperative support by multidisciplinary teams to improve operative outcomes.

Current status and prospects of diagnosis and treatment for esophageal cancer with supraclavicular lymph node metastasis

Patients with supraclavicular lymph node (SLN) metastasis from esophageal cancer encounter significant variations in treatment approaches due to differences in pathological subtypes and the lack of a unified regional staging system between East Asian and Western countries. The Tiger study aims to develop an internationally recognized staging system and to delineate the extent of regional lymph node dissection. In the context of esophageal squamous cell carcinoma (SCC) with SLN metastasis, the treatment paradigms from East Asia offer valuable insights. The Japan Esophageal Society (JES) 12th edition staging system guides a tailored comprehensive treatment strategy, emphasizing either radiotherapy and chemotherapy or surgical intervention. In contrast, esophageal adenocarcinoma (AC) predominates in Western countries, where the 8th edition of the American Joint Committee on Cancer (AJCC) staging system classifies SLN metastasis as a distant metastasis, advocating for systemic therapy as the primary treatment modality. Nonetheless, compelling evidence suggests that a multidisciplinary treatment approach, incorporating either radiotherapy and chemotherapy or surgery as the initial treatment, can yield superior outcomes for these patients compared to chemotherapy alone.

Prediction of post-ESD esophageal stricture by a nomogram and risk factor analysis of ineffective oral steroids prophylaxis

BACKGROUND AND AIMS

Several risk models for esophageal stricture after endoscopic submucosal dissection have been developed. However, some of them did not include the use of steroids in the risk analysis. Glucocorticoid sensitivity mediated by glucocorticoid receptor expression has not been discussed in this condition.

METHODS

Clinical and endoscopic characteristics were included in the logistic regression model to establish a nomogram for stenosis prediction. The score for each risk factor was estimated. Risk factors of ineffective oral steroid prophylaxis were analyzed and glucocorticoid receptor expressions were detected by immunohistochemistry.

RESULTS

Three hundred fourteen patients of endoscopic submucosal dissection for esophageal superficial neoplasms were included to develop the nomogram. The circumferential range(≤ 3/4, 3/4-1 or the whole circumference), longitudinal diameter reached 4 cm (yes or not) and lesion location (the cervical and upper thoracic part, the middle thoracic part or the lower thoracic part) consisted of the nomogram. Patients have a high risk of esophageal stricture if they have a total point greater than 36. In the simplified risk score model, the corresponding cutoff score was 1. 92 patients with oral steroid prophylaxis were separately analyzed and the circumferential mucosal defect involving 7/8 or more was an independent risk factor of ineffective prevention (OR 12.2, 95%CI 5.27-28.11). The expression of glucocorticoid receptor β was higher in the stricture group (p = 0.042 for AOD; p = 0.016 for the scoring system).

CONCLUSIONS

We established a nomogram for esophageal stricture prediction. Depending on the characteristics of lesions, it is possible to estimate the risk of stricture under routine post-ESD treatments (no steroids or oral steroids). Alternative treatments should be considered if the risk is extremely high, especially for patients with mucosal defects involving 7/8 or more of circumference in which oral steroid treatment tends to be ineffective. The higher glucocorticoid receptor β may indicate potential glucocorticoid resistance.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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