Adjuvant radiotherapy after modified Ivor-Lewis esophagectomy: can it prevent lymph node recurrence of the mid-thoracic esophageal carcinoma?

A approach of gastric conduit via the anterior of pulmonary hilum route during minimally invasive McKeown esophagectomy

BACKGROUND

The gastric conduit is the most commonly used replacement organ for reconstruction after minimally invasive McKeown esophagectomy. Although the optimal route of gastric conduit remains controversial, the posterior mediastinal route is physiologically preferable but is not without disadvantages. Here, we report the safety and efficacy of a method of gastric conduit reconstruction via the anterior of the pulmonary hilum route.

METHODS

We have used the anterior of the pulmonary hilum route since 2021. This procedure involves pulling the gastric conduit up through a substernal tunnel between the right thoracic cavity and the abdominal cavity and passing it into the neck via the anterior of the pulmonary hilum route. In this retrospective study, we compared the clinical outcomes between 20 patients who underwent this procedure and 20 patients who underwent the posterior mediastinal route from 2021 to 2022.

RESULTS

No mortality was reported in either group. No significant differences were observed between the two groups in duration of surgery, blood loss, incidence of postoperative complications, and postoperative hospital stay. As a result of the anterior of the pulmonary hilum route, the primary tumor bed and lymph node drainage area were effectively bypassed, which facilitates postoperative adjuvant radiotherapy or chemoradiotherapy. The distance of the gastric conduit accompanying the airway was significantly shorter in the anterior of the pulmonary hilum route group.

CONCLUSIONS

Our method is considered to be a safe and useful technique for the reconstruction of gastric conduit.

Radical esophagectomy for stage II and III thoracic esophageal squamous cell carcinoma followed by adjuvant radiotherapy with or without chemotherapy: Which is more beneficial?

Background

This retrospective study compared the efficacy and side effect profile between postoperative adjuvant radiotherapy and chemoradiotherapy in stage II or stage III thoracic esophageal squamous cell carcinoma (TESCC) patients who underwent curative (R0) esophagectomy.

Methods

A total of 272 TESCC patients who underwent radical esophagectomy from 2007 to 2016 were included in this retrospective analysis. All cases were pathologically confirmed with stage II or III disease and 148 patients received postoperative chemoradiotherapy (CRT), while the remaining 124 patients received postoperative radiotherapy (RT) alone.

Results

In CRT and RT groups, the three‐year overall survival rates were 51.3 versus 31.5% (P < 0.01) and the median overall survival (OS) was 39 months (95% CI, 31.6 to 46.3 months) and 30 months (95% CI, 21.0 to 38.9 months), respectively (P = 0.213). Three‐year disease‐free survival rates (DFS) were 30.5% versus 15.9% (P = 0.008), while the median DFS times were 26 months (95% CI, 17.7 to 34.3 months) and 19 months (95% CI, 16.4 to 21.6 months), respectively (P = 0.156). Univariate and multivariate analyses showed AJCC (American Joint Committee on Cancer seventh edition) stage and N stage were independent prognostic factors for overall survival, while the N stage was an independent prognostic factor for disease‐free survival.

Conclusions

Postoperative chemoradiotherapy led to one‐ and three‐year overall survival benefits along with an obvious increase in treatment side effects for stage II to III TESCC patients, with no further improvement in five‐year survival. However, the chemoradiotherapy benefits mainly favor stage III,number of resected lymph nodes less than 15, younger (less than 60 years old) and smoking patients.

Comparison of the effect of postoperative radiotherapy with surgery alone for esophagus squamous cell carcinoma patients: A meta-analysis

BACKGROUND

This meta-analysis was conducted to evaluate the effect of postoperative radiotherapy for patients having esophagus squamous cell carcinoma after radical surgery.

METHODS

A comprehensive research was performed in Pubmed, Embase and Cochrane Library electronic databases from inception until December 10, 2017. We collected all published full articles about comparison of surgery plus postoperative radiotherapy with surgery alone.

RESULTS

Four randomized-controlled trials (RCTs) with 1050 participants and 8 non-randomized-controlled trials with 3248 participants were included and evaluated separately. The risk ratio rate and its 95% confidence interval (CI) were calculated. Both RCTs and non-randomized-controlled trials (NRCTs) groups showed a significant increase in 3-year overall survival (OS) rate (RRRCT = 0.89, 95% CI: 0.80-0.99; RRNRCT = 0.82, 95% CI: 0.76-0.88) and decrease locoregional recurrence rate (RRRCT = 0.53, 95% CI: 0.43-0.66; RRNRCT = 0.47, 95% CI: 0.32-0.69) after postoperative radiotherapy compared with surgery alone. The 5-year OS rate in the group of NRCTs was markedly enhanced (RR = 0.87, 95% CI: 0.82-0.92), while that of the RCTs group was not enhanced in a significant way (RR = 0.84, 95% CI: 0.70-1.02). Subgroup analysis based on pathological lymph node status revealed that postoperative radiotherapy could improve OS regardless of pathological lymph node status (pathological lymph node positive patients: RR5-year os-RCT = 0.81, 95% CI: 0.70-0.93; RR5-year os-NRCT = 0.87, 95% CI: 0.80-0.94; Pathological lymph node negative patients: RR3-year os-RCT = 0.76, 95% CI: 0.59-0.96; RR3-year os-NRCT = 0.52, 95% CI: 0.30-0.89). No effect on distant recurrence rate was detected. Adverse effects induced by postoperative radiotherapy were comparatively modest and tolerable.

CONCLUSION

Polled results yielded that postoperative radiotherapy was promising in improving OS and reducing the locoregional recurrence rate. More large-scale up-to-date RCTs are needed to further validate the use of postoperative radiotherapy in modern practice.

CEP55 promotes the proliferation, migration and invasion of esophageal squamous cell carcinoma via the PI3K/Akt pathway

Background

Centrosomal protein 55 (CEP55) is an important prognostic biomarker that plays an essential role in the proliferation, migration and invasion of multiple tumors. We aimed to investigate the prognostic value of CEP55 in pN0 esophageal squamous cell carcinoma (ESCC) and explore its biological function in ESCC cells.

Methods

We used immunohistochemistry and Western blot analysis to detect the expression of CEP55 in ESCC. Furthermore, both in vitro and in vivo assays were used to determine the effect of CEP55 on malignant behavior in ESCC cells.

Results

As expected, we found that CEP55 was overexpressed in ESCC. Univariate and multivariate analyses demonstrated that patients with CEP55 overexpression had a poor prognosis. Additionally, the abilities of proliferation, migration and invasion of cells, as well as the epithelial–mesenchymal transition markers, were all altered with the changed CEP55 expression levels in ESCC cells. Further study elucidated that CEP55 facilitated ESCC via the PI3K/Akt pathway. Blockade of this pathway markedly attenuated CEP55-mediated proliferation, migration, invasion and epithelial–mesenchymal transition of ESCC cells.

Conclusion

Oncogenic CEP55 correlates with a poor prognosis by regulating tumor cell proliferation, migration and invasion via the PI3K/Akt pathway. It can serve as a promising prognostic biomarker and therapeutic target of pN0 ESCC after Ivor-Lewis esophagectomy.

Adjuvant radiotherapy for positive lymph nodes of oesophageal squamous cell carcinoma: Can it earn promising benefits at long-term follow-up?

PURPOSE

The value of adjuvant radiotherapy for patients with positive lymph nodes after curative resection of oesophageal squamous cell carcinoma is controversial. This study aims to investigate its long-term benefits in a specific cohort.

PATIENTS AND METHODS

The charts between 1990 and 2003 from patients with positive lymph nodes were retrospectively reviewed. Those subjects were divided into adjuvant radiotherapy and surgery alone groups, with two subgroups defined by radiation dose (cutoff value: 50Gy). Overall survival, disease-free survival and locoregional recurrence-free survival were compared between two groups, with predictive factors of overall survival analysed meanwhile.

RESULTS

In sum, 175 matched patients with 1:2 ratios for group balance were enrolled for final analysis. During the follow-up (median: 37.0 months), 143 (81.7%) deaths were recorded, with 70.6% of deaths from cancer progression. The median overall survival time (19.5, 4 to 172 months) was not significantly different between the two groups (18.9 vs. 20.0 months, P=0.179). However, the disease-free survival time was significantly shorter in the adjuvant radiotherapy group than that in the control group (median, 11.5 vs. 14.9 months; P=0.001), with the locoregional recurrence-free survival time impressively prolonged (median: 18.3 vs. 16.5 months; P=0.022). Age (P=0.030), number (P=0.005) and ratio (P=0.002) of positive lymph nodes were associated with overall survival, but radiation dose was not (P=0.204).

CONCLUSION

Adjuvant radiotherapy with low- or high-dose did not improve survival compared with surgery alone. However, radiotherapy was effective to control locoregional recurrence, and could be applied as salvage therapy when recurrence event occurred.

Survival Benefit of Neoadjuvant Treatment in Clinical T3N0M0 Esophageal Cancer: Results From a Retrospective Multicenter European Study

BACKGROUND

Based on current guidelines, clinical T3N0M0 esophageal tumors may or may not receive neoadjuvant treatment, according to their perception as locally advanced (cT3) or early-stage tumors (stage II). The study aim was to assess the impact of neoadjuvant treatment upon survival for cT3N0M0 esophageal cancer patients, with subgroup analyses by histological type (squamous cell carcinoma vs adenocarcinoma) and type of neoadjuvant treatment (chemotherapy vs radiochemotherapy).

METHODS

Data from patients operated on for esophageal cancer in 30 European centers were collected. Among the 382 of 2944 patients with clinical T3N0M0 stage at initial diagnosis (13.0%), we compared those treated with primary surgery (S, n = 193) versus with neoadjuvant treatment plus surgery (NS, n = 189).

RESULTS

The S and NS groups were similar regarding their demographic and surgical characteristics. In-hospital postoperative morbidity and mortality rates were comparable between groups. Patients were found to be pN+ in 64.2% versus 42.9% in the S and NS groups respectively (P < 0.001), pN2/N3 in 35.2% versus 21.2% (P < 0.001), stage 0 in 0% versus 16.4% (P < 0.001), and R0 in 81.3% versus 89.4% of cases (P = 0.026). Median overall and disease-free survivals were significantly better in the NS group, 38.4 versus 27.9 months (P = 0.007) and 31.6 versus 27.5 months (P = 0.040), respectively, and this difference remained for both histological types. Radiotherapy did not offer a benefit compared with chemotherapy alone (P = 0.687). In multivariable analysis, neoadjuvant treatment was an independent favorable prognostic factor (HR 0.76, 95% CI 0.58-0.99, P = 0.044).

CONCLUSION

Neoadjuvant treatment offers a significant survival benefit for clinical T3N0M0 esophageal cancer.

Overexpression of IFITM3 predicts poor prognosis in stage IIA esophageal squamous cell carcinoma after Ivor Lewis esophagectomy

Background

Recent research has shown that IFITM3 plays an important role in the tumorigenesis of many malignancies. We investigated the clinicopathological variables and prognostic value of IFITM3 in stage IIA esophageal squamous cell carcinoma (ESCC) patients.

Methods

Immunohistochemistry and Western blot analysis were used to examine IFITM3 expression in tumor specimens. The relationships between IFITM3 expression and clinicopathological variables, as well as the five‐year survival and recurrence status of patients, were analyzed.

Results

IFITM3 was aberrantly expressed in tumor tissue. Statistical analysis showed a close correlation of IFITM3 expression with T tumor status (P = 0.004). Additionally, IFITM3 overexpression, advanced T status, poor degree of differentiation, and large tumor size were not only associated with poor survival but were high lymphatic metastatic recurrence predictors in ESCC patients (P < 0.05).

Conclusion

Our data indicated that IFITM3 overexpression may predict poor prognosis in stage IIA ESCC patients after Ivor Lewis esophagectomy.

Adjuvant Therapy for a Microscopically Incomplete Resection Margin after an Esophagectomy for Esophageal Squamous Cell Carcinoma

Purpose: To investigate the prognosis of esophageal squamous cell carcinoma with a microscopically incomplete (R1) resection margin following an esophagectomy, as well as the impact of adjuvant treatment on survival. Methods: Data obtained from 124 patients with R1-resected ESCC were reviewed. The impact of clinicopathological factors and adjuvant treatment on the overall survival, locoregional recurrence, and distant recurrence were explored. Results: For a median follow-up time of 16.8 months, the median overall survival of 124 patients was 25.6 months. The 1, 3, and 5-year overall survival rates were 75.6%±4.0%, 35.9%±5.1%, and 23.2%±5.0%, respectively. Adjuvant therapy was administered in 78 patients. In the univariate analyses, patients with a pN0 stage (log rank, p=0.028) and adjuvant chemotherapy (log rank, p=0.032) exhibited more favorable overall survival. In the multivariate analyses, the pN stage (HR=2.192, p=0.004) and adjuvant chemotherapy (HR=0.032, p=0.004) were independent prognostic factors for overall survival. Locoregional recurrence was the main failure pattern after R1 resection. The pN stage (HR=2.567, p=0.009) and adjuvant radiotherapy (HR=0.278, p=0.000) were independent prognostic factors for locoregional recurrence. Conclusion: In R1-resected esophageal squamous cell carcinoma, adjuvant radiotherapy reduced locoregional recurrence; however, it did not improve overall survival. Adjuvant chemotherapy demonstrated benefits for overall survival. The pN stage was an independent prognostic factor for locoregional recurrence and overall survival.

Optimal Adjuvant Treatment for Curatively Resected Thoracic Esophageal Squamous Cell Carcinoma: A Radiotherapy Perspective

Purpose

The purpose of this study was to evaluate the benefits of adjuvant treatment for curatively resected thoracic esophageal squamous cell carcinoma (ESCC) and determine the optimal adjuvant treatments.

Materials and Methods

One hundred ninety-five patients who underwent a curative resection for thoracic ESCC between 1994 and 2014 were reviewed retrospectively. Postoperatively, the patients received no adjuvant treatment (no-adjuvant group, n=68), adjuvant chemotherapy (AC group, n=62), radiotherapy (RT group, n=41), or chemoradiotherapy (CRT group, n=24). Chemotherapy comprised cisplatin and 5-fluorouracil administration every 3 weeks. The median RT dose was 45.0 Gy (range, 34.8 to 59.4 Gy). The overall survival (OS), disease-free survival (DFS), locoregional recurrence (LRR), and distant metastasis (DM) rates were estimated.

Results

At a median follow-up duration of 42.2 months (range, 6.3 to 215.2 months), the 5-year OS and DFS were 37.6% and 31.4%, respectively. After adjusting for other clinicopathologic variables, the AC and CRT groups had a significantly better OS and DFS compared to the no-adjuvant group (p < 0.05). The LRR rate was significantly lower in the RT and CRT groups than in the no-adjuvant group (p < 0.05), whereas no significant difference was observed in the AC group. In the no-adjuvant and AC groups, 25% of patients received high-dose salvage RT due to LRR. The DM rates were similar. The anastomotic stenosis and leakage were similar in the treatment groups.

Conclusion

Adjuvant treatment might prolong survival after an ESCC resection, and RT contributes to a reduction of the LRR. Overall, the risks and benefits should be weighed properly when selecting the optimal adjuvant treatment.

Overexpression of Ku80 suggests poor prognosis of locally advanced esophageal squamous cell carcinoma patients

BACKGROUND

Recent studies have shown that Ku80 expression was implicated in development and progression of malignant tumors. In the present study, we analyzed for the first time the expression of Ku80 in locally advanced esophageal squamous cell carcinoma (ESCC) and its correlation with clinicopathologic features and patient survival.

METHODS

The expression profile of Ku80 was analyzed in 126 cases of locally advanced ESCC and 79 cases of normal subjects as control using immunohistochemistry and Western blot. The associations of Ku80 expression with clinicopathological features were estimated by χ (2) test. We further performed univariate and multivariate analyses to identify prognostic factors for overall survival (OS) of patients.

RESULTS

Immunohistochemistry and Western blot analyses both showed the Ku80 protein expression was significantly higher in ESCC than normal esophageal mucosa and corresponding healthy esophageal mucosa. Statistical analysis suggested a significant correlation of Ku80 overexpression with the tumor size (p = 0.037), differentiation degree (p = 0.018), depth of invasion (p = 0.020), lymph node metastasis (p = 0.045), clinicopathological staging (p = 0.001), and tumor recurrence (p = 0.011) in locally advanced ESCC patients. Moreover, overexpression of Ku80 was associated with reduced OS of patients after surgery (p = 0.001). Multivariate analysis with a Cox proportional hazards model further suggested that Ku80 expression was an independent prognostic indicator for patients' OS (p = 0.029).

CONCLUSIONS

Ku80 was a predictor of tumor's progression and prognosis of locally advanced ESCC patients. All of these results indicate that assessment of Ku80 level could improve stratification of locally advanced ESCC patients.

The impact of adjuvant radiotherapy on radically resected T3 esophageal squamous cell carcinoma

PURPOSE

The role of adjuvant radiotherapy in patients with esophageal squamous cell carcinoma (ESCC) remains controversial. This retrospective study was designed to analyze the impact of adjuvant radiotherapy in patients with T3 stage ESCC after radical resection.

METHODS

Data of a single-center cohort of 692 patients with T3 stage ESCC who underwent radical resection, with or without adjuvant radiotherapy, were reviewed. Univariate and multivariate analyses were performed to compare overall survival (OS) and locoregional recurrence-free survival (LRFS).

RESULTS

Two hundred and forty-six patients received adjuvant radiotherapy (S + R group), and 446 patients underwent surgery alone (S group). The median survival time and 5-year OS rate were 40.0 months and 40.9 % for the entire population, 50.0 months and 45.6 % for the S + R group and 38.0 months and 38.3 % for the S group (P = 0.114 for S + R group vs. S group). The 5-year LRFS rate for the S + R group was significantly higher than that for S group (50.8 vs. 35.9 %, P < 0.001). In subgroup analyses, adjuvant radiotherapy was found to improve the 5-year OS in the subgroups of tumor length >5 cm, pN0 and pN1 categories, pTNM stage IIa, IIb and IIIa (P < 0.005).

CONCLUSIONS

Adjuvant radiotherapy is effective in local control of radically resected T3 stage ESCC and may improve the overall survival in certain subgroups, such as the patients with tumor length >5 cm, pN0 and pN1 categories, pTNM stage IIa, IIb and IIIa. Further studies are required to confirm our results.

Overexpression of IFITM3 predicts the high risk of lymphatic metastatic recurrence in pN0 esophageal squamous cell carcinoma after Ivor-Lewis esophagectomy

Background. Recent studies have shown that the aberrant expression of IFITM3 is implicated in the lymph node metastasis of many malignancies. Our research aimed to investigate the expression of IFITM3 in pathological N0 (pN0) esophageal squamous cell carcinoma (ESCC) and its relationship with lymph node metastatic recurrence. Methods. Immunohistochemistry (IHC) was used to examine the expression profile of IFITM3 in 104 pairs of samples. Each pair consisted of ESCC tissue and its adjacent normal mucosa (ANM). This aberrant expression was verified by reverse transcription-polymerase chain reaction (RT-PCR) with 20 tumor specimens with strong immunostaining and their mucosal tissues. In addition, 20 samples of low expression tissues and their ANMs were evaluated. Moreover, the correlations between the IFITM3 expression level and the clinicopathological variables, recurrence risk and overall survival (OS) of patients were analyzed. Results. Both IHC and RT-PCR demonstrated that the IFITM3 expression level was significantly higher in tumor tissue than in ANM. Statistical analysis showed a significant correlation of IFITM3 expression with the T status of esophageal cancer (p = 0.015). In addition, IFITM3 overexpression was demonstrated to be not only an important risk factor of lymphatic metastatic recurrence but a significant prognostic factor in pN0 ESCC (p < 0.005). Conclusions. Even pN0 ESCC patients will still experience lymphatic metastatic recurrence. The IFITM3 gene could be a predictor of lymphatic metastatic recurrence in pN0 ESCC after Ivor-Lewis esophagectomy.

Postoperative Radiotherapy Improves Survival in Stage pT2N0M0 Esophageal Squamous Cell Carcinoma with High Risk of Poor Prognosis

PURPOSE

Clinically, some patients with stage pT2N0M0 esophageal squamous cell carcinoma (ESCC) might have poor survival outcomes after Ivor-Lewis esophagectomy. We explored whether adjuvant radiotherapy could improve the prognosis for the patients with high risk of poor clinical outcomes.

METHODS

We screened 326 pT2N0M0 ESCC patients who had complete resection with Ivor-Lewis esophagectomy. The expression profile of Ku80 was examined by immunohistochemistry and validated by Western blotting. Patients with high expression of Ku80 were divided randomly into the adjuvant radiotherapy group and control group. Patients with low expression of Ku80 were enrolled into the negative group. The overall survival (OS) and disease-free survival (DFS) was determined by Kaplan-Meier and log-rank analysis.

RESULTS

According to receiver operating characteristics curve analysis of Ku80 expression, 124 patients were enrolled into the negative group, 106 patients into the radiotherapy group, and 106 patients into the control group. Log-rank analysis showed that patients in the control group had worse OS and DFS than those in the negative group (P < 0.001, P < 0.001). There is no difference in OS and DFS of patients between radiotherapy group and negative group (P = 0.166, P = 0.648). Patients in the radiotherapy group had significantly better OS and DFS than those in the control group (P = 0.007, P < 0.001). Multivariate analysis further suggested that adjuvant radiotherapy was an independent prognostic indicator for patients with Ku80 overexpression.

CONCLUSIONS

In stage pT2N0M0 ESCC, Ku80 can be exploited as a predictor to identify patients with high risk of poor prognosis. Adjuvant radiotherapy could significantly improve survival for the patients with Ku80 overexpression.

Overexpression of RUNX3 inhibits malignant behaviour of Eca109 cells in vitro and vivo

Runt-related transcription factor 3 (RUNX3) is a tumor suppressor gene whose reduced expression may play an important role in the development and progression of esophageal squamous cell cancer (ESCC). The aim of this study was to investigate the clinical relevance of RUNX3 in ESCC patients and effects of overexpression on biological behaviour of Eca109 cells in vitro and in vivo. Immunohistochemistry was performed to detect the clinical relevance of RUNX3 and lymph node metastasis in 80 ESCC tissues and 40 non-cancerous tissues using the SP method. RT-PCR and Western blotting were applied to assess the RUNX3 level and verify the Eca109 cell line with stable overexpression. Localization of RUNX3 proteins was performed by cell immunofluorescence. CCK-8 and Scrape motility assays were used to determine proliferation and migration and the TUNEL assay to analyze cell apoptosis. Invasive potential was assessed in cell transwell invasion experiments. In nude mice, tumorigenesis in vivo was determined. Results showed decreased expression of RUNX3 in esophageal tissue to be significantly related to lymph node metastasis (LNM) (P<0.01). In addition, construction of a recombinant lentiviral vector and transfection into the human ESCC cell line Eca109 demonstrated that overexpression could inhibit cell proliferation, migration and invasion, and induce apoptosis. The in vivo experiments in mice showed tumorigenicity and invasiveness to be significantly reduced. Taken together, our studies indicate that underexpression of RUNX3 in human ESCC tissue is significantly correlated with progression. Restoration of RUNX3 expression significantly inhibits ESCC cells proliferation, migration, invasion and tumorigenesis.

Stathmin overexpression identifies high risk for lymphatic metastatic recurrence in pN0 esophageal squamous cell carcinoma patients

BACKGROUND AND AIM

Common patterns of the operative failure after Ivor-Lewis esophagectomy in esophageal squamous cell carcinoma (ESCC) patients are locoregional lymph node metastasis. It is clinically significant to investigate the biological markers to predict the subset of patients who are at higher risk of lymphatic metastatic recurrence. Our research aimed to investigate the association between the Stathmin (STMN-1) gene expression and lymphatic metastatic recurrence in pN0 ESCC patients after surgery.

METHODS

One hundred seventy-four patients who suffered from mid-thoracic ESCC and completely resected with Ivor-Lewis esophagectomy were enrolled in our study. The entire patients were restricted to pN0 ESCC. Tissue specimens were examined for STMN-1 expression levels by immunohistochemistry and Western blotting methods. The correlation of STMN-1 levels with clinicopathological variables, prognosis, and metastatic potential was analyzed.

RESULTS

One hundred patients had STMN-1 protein overexpression (57.47%), and the patients with overexpression were accompanied by significantly higher rate of lymphatic metastatic recurrence as compared with patients who had low STMN-1 expression (P = 0.003). Multivariable Cox regression analysis revealed that the STMN-1 protein expression and T classification were independent factors to predict the lymphatic metastatic recurrence (P = 0.007, P = 0.000, respectively).

CONCLUSIONS

Even pN0 ESCC are a potential to lymphatic metastatic recurrence. Stathmin overexpression can be used as a marker to identify those patients who are at high risk for lymphatic metastatic recurrence in pN0 ESCC after an Ivor-Lewis esophagectomy.

Prospective study of adjuvant radiotherapy on preventing lymph node metastasis after Ivor-lewis esophagectomy in esophageal cancer

PURPOSE

To investigate whether Ivor-Lewis esophagectomy combined with adjuvant radiotherapy prevents lymphatic metastatic recurrence in esophageal cancer patients.

METHODS

A total of 113 stage IIA esophageal squamous cell carcinoma patients after Ivor-Lewis esophagectomy were accepted mRNA expression of Mucoid 1 (MUC1) gene detection. Positive patients were enrolled onto the adjuvant radiotherapy group (with postoperative adjuvant radiotherapy). Negative patients were enrolled onto the control group (without postoperative adjuvant radiotherapy or chemotherapy). The radiotherapy area consisted of the neck, supraclavicular region, and superior mediastinum (including paraesophageal and paratracheal region). Survival difference was compared by the χ(2) test, and the Kaplan-Meier method was performed to calculate the survival rate and recurrence rate. Logistic regression analysis was performed to determined independent risk factors.

RESULTS

The radiotherapy area lymphatic metastatic recurrence rate in adjuvant radiotherapy group (16.7 %, 5 of 30) was lower than patients without postoperative adjuvant radiotherapy (45.8 %, 38 of 83) (P < 0.05). Only compared to positive patients without postoperative adjuvant radiotherapy (60.0 %, 6 of 10) was the rate (16.7 %, 5 of 30) significantly lower (P < 0.01). Cancer recurrence was recognized in 48.6 % (55 of 113) patients within 3 years after surgery, including 38.1 % (43 of 113) patients with radiotherapy area recurrence. Logistic analysis revealed that T status (P < 0.01) and adjuvant radiotherapy (P < 0.05) were independent risk factors of lymph node metastasis in the first 3 years after surgery.

CONCLUSIONS

In MUC1 mRNA-positive esophageal squamous cell carcinoma patients, adjuvant radiotherapy could significantly reduce the lymph node metastasis rate in the radiotherapy area after Ivor-Lewis esophagectomy. Compared with traditional therapeutic methods, Ivor-Lewis esophagectomy combined with adjuvant radiotherapy can achieve similar curative effects in MUC1 mRNA-positive patients.

Role of preoperative chemoradiotherapy in the comprehensive treatment of esophageal cancer

Preoperative chemoradiotherapy plays an important role in the comprehensive treatment of patients with esophageal cancer. Concurrent administration of radiation and chemotherapy can produce additive or even synergistic effects, improve local control rate, help kill tumor cells in metastatic lesions located outside the target area, raise resection rate, reduce recurrence, and improve prognosis. However, preoperative chemoradiotherapy is also associated with many side effects, such as hematologic toxicity, cardiac toxicity, and radioactive lung damage, and often causes surgical difficulties, such as difficulty in intraoperative tumor manipulation and increased risk of complications. This paper focuses on the theoretical basis and possible mechanisms of preoperative chemoradiotherapy and discusses its role in reducing esophageal cancer stage and improving resection rate, pathologic response rate, and survival rate. We also briefly discuss the pathogenesis and prevention of adverse reactions associated with preoperative chemoradiotherapy.

A meta-analysis of lymph node metastasis rate for patients with thoracic oesophageal cancer and its implication in delineation of clinical target volume for radiation therapy

OBJECTIVES

The objective of this study was to pool the lymph node metastasis rate (LNMR) in patients with thoracic oesophageal cancer (TOC) and to determine which node level should be included when undergoing radiation therapy.

METHODS

Qualified studies were identified on Medline, Embase, CBM and the Cochrane Library through to the end of April 2011. Pooled estimates of LNMR were obtained through a random-effect model. Possible effect modifiers which might lead to the statistical heterogeneity were identified through meta-regression, and further subgroup analyses of factors influencing LNMR were performed.

RESULTS

45 observational studies with a total of 18 415 patients were included in the meta-analysis. The pooled estimates of LNMR in upper, middle and lower TOC were 30.7%, 16.8% and 11.0% cervical, 42.0%, 21.1% and 10.5% upper mediastinal, 12.9%, 28.1% and 19.6% middle mediastinal, 2.6%, 7.8% and 23.0% lower mediastinal, and 9%, 21.4% and 39.9% abdominal, respectively. Lymph node metastasis most frequently happened to paratracheal, paraoesophageal, perigastric 106recR and station 7. The most obvious difference (≥15%) of LNMR between two-field and three-field lymphatic dissection occurred in cervical, paratracheal, 106recR and 108.

CONCLUSIONS

Through the meta-analysis, more useful information was obtained about clinical target volume (CTV) delineation of TOC patients treated with radiotherapy. However, our study is predominantly a description of squamous carcinoma and the results may not be valid for adenocarcinoma.

Gastric tube resection due to metachronic cancer and a recurrence in anastomosis after Ivor-Lewis esophagectomy--case report

Gastric tube after esophagectomy can be the site of local recurrence or the development of second primary tumor which implies poor prognosis. The study presents an extremely rare case of a patient after Ivor-Lewis esophagectomy for squamous cell carcinoma, in whom there was detected local recurrence in the anastomosis associated with metachronous primary tumor in gastric tube. Esophageal reresection with the upper part of the stomach was performed. Left colonic segment supplied by middle colic vessels transposed through retrosternal route was used as new esophageal substitute.

Clinical study on lymph node metastatic recurrence in patients with N0 esophageal squamous cell cancer

Esophageal squamous cell cancer (ESCC) is one of the most common malignancies treated by thoracic surgeons. It is aggressive and generally associated with a poor prognosis. One of the most important prognostic factors is the presence of the lymph node metastasis (LNM). The purpose of the present study was to investigate the risk factor with lymph node metastatic recurrence in patients with N0 esophageal squamous cancer after Ivor Lewis esophagectomy based on the detection of mucin1 (MUC1) mRNA. The subjects were 82 patients with pN0 ESCC who underwent Ivor Lewis esophagectomy with two-field lymph node dissection from January 2001 to January 2005. All lymph nodes (501 stations) obtained from these patients were reevaluated by reverse transcriptase-polymerase chain reaction (RT-PCR) to detect MUC1mRNA. The diagnosis of lymph node micrometastasis (LNMM) was based on the detection of MUC1 mRNA. The Kaplan-Meier method was used to calculate the survival rate and lymph nodal metastatic rate. Log-rank test was performed to compare the recurrence rate, and Cox regression multivariate analysis was performed to determine independent prognostic factors. The overall 3-year survival rates of 82 patients were 78.0%, and the first recurrence exhibiting lymph nodal metastasis was recognized in 37 patients (45.1%) in the first 3 years after operation. Lymph node metastatic rate in patients in the first 3 years after operation was significantly associated with the T status (P < 0.05). MUC1 mRNA was identified in at least one lymph node station from 23 (28.1%) patients. Also, lymph node metastatic rate of the patients with LNMM was significantly higher than that of the patients without LNMM (P < 0.01).The results of multivariate analysis confirmed that LNMM and T status in patients with N0 ESCC were independent risk factors for 3-year lymph node metastatic recurrence after Ivor Lewis esophagectomy. Adjunctive therapy might be beneficial in controlling the locoregional recurrence and elevated healing rates for certain patients.

Radiation therapy in the postoperative management of esophageal cancer

The optimal management of esophageal cancer is complicated since institutional preferences vary, patient characteristics often guide management, and there are data to support multiple approaches for locally advanced esophageal cancer. Although surgery is an important component of therapy, alone it results in unacceptably high rates of local relapse and poor long-term survival rates. Well-studied adjuvant approaches include upfront chemoradiation therapy with or without surgery, periopera-tive chemotherapy, adjuvant radiation or adjuvant chemoradiation. This review article seeks to examine thoroughly the role of postoperative therapeutic options for the management of esophageal cancer, and in so doing, also overviews prospective trials in the neoadjuvant, definitive and perioperative settings. Studies evaluating radiation field design are also discussed.

Impact of neoadjuvant chemoradiotherapy on surgery and survival in patients with esophageal carcinoma

Neoadjuvant chemotherapy is often used to treat solid tumors before surgery or during the perioperative period. It is often combined with radiotherapy to improve survival and cure rate and to protect normal organs. Surgery is still the most effective therapy for esophageal cancer. Preoperative (neoadjuvant) chemotherapy and radiotherapy as a treatment modality has been in existence for nearly 20 years. However, it remains controversial over whether neoadjuvant chemoradiotherapy can be used as the standard treatment for esophageal cancer. This paper sums up the impact of neoadjuvant chemotherapy on surgery and survival in patients with esophageal cancer. Moreover, we discuss the limitations and future directions of neoadjuvant chemotherapy for esophageal carcinoma.

Effect of neoadjuvant chemoradiotherapy on prognosis and surgery for esophageal carcinoma

AIM: To investigate the role of neoadjuvant chemoradiotherapy in prognosis and surgery for esophageal carcinoma by a meta-analysis.

METHODS: PubMed and manual searches were done to identify all published randomized controlled trials (RCTs) that compared neoadjuvant chemoradiotherapy plus surgery (CRTS) with surgery alone (S) for esophageal cancer. According to the test of heterogeneity, a fixed-effect model or a random effect model was used and the odds ratio (OR) was the principal measure of effects.

RESULTS: Fourteen RCTs that included 1737 patients were selected with quality assessment ranging from A to C (Cochrane Reviewers’ Handbook 4.2.2). OR (95% CI, P value), expressed as CRTS vs S (values > 1 favor CRTS arm), was 1.19 (0.94-1.48, P = 0.28) for 1-year survival, 1.33 (1.07-1.65, P = 0.69) for 2-year survival, 1.76 (1.42-2.19, P = 0.11) for 3-year survival, 1.41 (1.06-1.87, P = 0.11) for 4-year survival, 1.64 (1.28-2.12, P = 0.40) for 5-year survival, 0.82 (0.39-1.73, P < 0.0001) for rate of resection, 1.53 (1.33-2.84, P = 0.007) for rate of complete resection, 1.78 (1.14-2.78, P = 0.79) for operative mortality, 1.12 (0.89-2.48, P = 0.503) for all treatment mortality, 1.33 (0.94-1.88, P = 0.04) for the rate of adverse treatment, 1.38 (1.23-1.63, P = 0.0002) for local-regional cancer recurrence, 1.28 (0.85-1.58, P = 0.60) for distant cancer recurrence, and 1.27 (0.86-1.65, P = 0.19) for all cancer recurrence. A complete pathological response to chemoradiotherapy occurred in 10%-45.5% of patients. The 5-year survival benefit was most pronounced when chemotherapy and radiotherapy were given concurrently (OR: 1.45, 95% CI: 1.26-1.79, P = 0.015) instead of sequentially (OR: 0.85, 95% CI: 0.64-1.35, P = 0.26).

CONCLUSION: Compared with surgery alone, neoadjuvant chemoradiotherapy can improve the long-term survival and reduce local-regional cancer recurrence. Concurrent administration of neoadjuvant chemoradiotherapy was superior to sequential chemoradiotherapy.