Modern 5-year survival of resectable esophageal adenocarcinoma: single institution experience with 263 patients

Locoregional Recurrence of Esophageal Cancer Treated with Curative Intent Local Salvage Therapy: A Single Center Experience

PURPOSE

Locoregional recurrence of esophageal carcinoma after neoadjuvant therapy and en bloc esophagectomy, although uncommon, is challenging to manage. Currently, there are no standard treatment approaches prompting many health care providers to adopt a palliative approach. We describe our experience and outcomes of treating this specific group of patients with a focus on salvage curative intent local therapy.

METHODS

All patients undergoing en bloc esophagectomy following neoadjuvant therapy between 2007 and 2017 at the McGill University Health Centre, a tertiary referral center for esophageal cancer, were identified. Patient follow-up included a structured surveillance protocol with serial endoscopic and cross-sectional imaging studies. Local recurrence was defined as histologically confirmed recurrences at the anastomosis. Regional recurrence was defined as radiological evidence of celiac, mediastinal, or para-esophageal/conduit lymphadenopathy. Demographic, pathologic, therapeutic variables were extracted as well as disease free and overall survival.

RESULTS

Of 755 patients identified, locoregional recurrences occurred in 27 patients (3.6%) of whom 18 were included in the analysis. The median disease-free survival post index operation was 15 months (IQR 10-23). The sites of recurrence were local (6/18, 33.3%); regional (8/18, 44.4%); and locoregional (4, 22.2%). Chemoradiation was the most common modality used to treat recurrence (10/18, 55.6%) whilst 4 (22.2%) underwent surgery. Following treatment for locoregional recurrence, 1-year overall survival was 61.1% and at 5 years was 22.2%.

CONCLUSION

Consolidative salvage local therapy for locoregional recurrence after en bloc esophagectomy is feasible and can entail prolonged survival in a subset of patients.

Postoperative Outcomes and Quality of Life After Left Thoracoabdominal Esophagogastrectomy: Contrasting Esophagogastrostomy with Esophagojejunostomy

BACKGROUND

Following left thoracoabdominal (LTA) esophagogastrectomy, gastrointestinal continuity can be re-established via esophagogastrostomy or esophagojejunostomy. We explored how the method of reconstruction impacted postoperative outcomes and quality of life (QoL).

METHODS

From January 2007 to January 2022, patients undergoing LTA were identified from a single center's prospectively maintained database. Following esophagogastrectomy or extended total gastrectomy, an esophagogastrostomy (GAS) or Roux-en-Y esophagojejunostomy (R-Y) was fashioned. Postoperative outcomes were compared according to the method of reconstruction. The Functional Assessment of Cancer Therapy-Esophagus (FACT-E) questionnaire compared QoL.

RESULTS

Of the 147 LTA patients identified, 135 (92%) were included-97 GAS (72%) and 38 R-Y patients (28%). R-Y patients had more ypT3/4 lesions (97% vs. 61%, p ≤ 0.001) and a similar incidence of ypN+/M+ disease. Anastomotic leaks were more common among GAS patients (17% vs. 3%, p = 0.023), however grade 3/4 complications (26.6% vs. 19.4%, p = 0.498), reoperation, intensive care admission, hospital representation and readmission were similar. FACT-E data were available for 68/97 (70%) GAS patients and 22/38 (58%) R-Y patients, with scores for 80/21/24/18/23/24 patients at baseline/preoperatively/1 month/3-6 months/1-3 years/3+ years postoperatively, respectively. Comparing between the groups, the scores were similar at each timepoint. FACT-E improved between baseline and preoperatively (79, 34-124 vs. 102, 81-123, p = 0.027). Only at 3+ years were postoperative scores equivalent to preoperative values. GAS patients had more reflux and esophagitis >6 months postoperatively (54% vs. 13%, p = 0.048; 62% vs. 0%, p ≤ 0.001).

CONCLUSION

While the type of reconstruction did not affect QoL, it did affect the postoperative course.

Neoadjuvant versus definitive chemoradiation in locally advanced esophageal cancer for patients of advanced age or significant comorbidities

The addition of surgery to chemoradiation for esophageal cancer has not shown a survival benefit in randomized trials. Patients with more comorbidities or advanced age are more likely to be given definitive chemoradiation due to surgical risk. We aimed to identify subsets of patients in whom the addition of surgery to chemoradiation does not provide an overall survival (OS) benefit. The National Cancer Database was queried for patients with locally advanced esophageal cancer who received either definitive chemoradiation or neoadjuvant chemoradiation followed by surgery. Bivariate analysis was used to assess the association between patient characteristics and treatment groups. Log-rank tests and Cox proportional hazards models were performed to assess for differences in survival. A total of 15,090 with adenocarcinoma and 5,356 with squamous cell carcinoma met the inclusion criteria. Patients treated with neoadjuvant chemoradiation and surgery had significantly improved survival by Cox proportional hazards model regardless of histology if <50, 50-60, 61-70, or 71-80 years old. There was no significant benefit or detriment in patients 81-90 years old. Survival advantage was also significant with a Charlson/Deyo comorbidity condition score of 0, 1, 2, and ≥3 in adenocarcinoma squamous cell carcinoma with scores of 2 or ≥3 had no significant benefit or detriment. Patients 81-90 years old or with squamous cell carcinoma and a Charlson/Deyo comorbidity score ≥ 2 lacked an OS benefit from neoadjuvant chemoradiation followed by surgery compared with definitive chemoradiation. Careful consideration of esophagectomy-specific surgical risks should be used when recommending treatment for these patients.

Definitive chemoradiotherapy versus neoadjuvant chemoradiotherapy followed by radical surgery for locally advanced oesophageal squamous cell carcinoma: meta-analysis

BACKGROUND

The literature lacks robust evidence comparing definitive chemoradiotherapy (dCRT) with neoadjuvant chemoradiotherapy and surgery (nCRS) for oesophageal squamous cell carcinoma (ESCC). This study aimed to compare long-term survival of these approaches in patients with ESCC.

METHODS

A systematic review performed according to PRISMA guidelines included studies identified from PubMed, Scopus, and Cochrane CENTRAL databases up to July 2021 comparing outcomes between dCRT and nCRS for ESCC. The main outcome measure was overall survival (OS), secondary outcome was disease-free survival (DFS). A meta-analysis was conducted using random-effects modelling to determine pooled adjusted multivariable hazard ratios (HRs).

RESULTS

Ten studies including 14 092 patients were included, of which 30 per cent received nCRS. Three studies were randomized clinical trials (RCTs) and the remainder were retrospective cohort studies. dCRT and nCRS regimens were reported in six studies and surgical quality control was reported in two studies. Outcomes for OS and DFS were reported in eight and three studies respectively. Following meta-analysis, nCRS demonstrated significantly longer OS (HR 0.68, 95 per cent c.i. 0.54 to 0.87, P < 0.001) and DFS (HR 0.50, 95 per cent c.i. 0.36 to 0.70, P < 0.001) compared with dCRT.

CONCLUSION

Neoadjuvant chemoradiotherapy followed by oesophagectomy correlated with improved survival compared with definitive chemoradiation in the treatment of ESCC; however, there is a lack of literature on RCTs.

Neoadjuvant Chemoradiotherapy for Locally Advanced Gastric Cancer: Where Are We at?

Simple Summary

More than 50% of gastric cancer are at least locally advanced at presentation. For such patients, a multimodal approach rather than mere surgical resection leads to better long-term prognosis. Neoadjuvant chemoradiotherapy is one of the common treatment strategies for local advanced gastric cancer. Based on the experience and evidence from esophago-gastric cancers, the incorporation of systemic and locoregional therapy has shown superior disease control and reduced local recurrence. However, the optimal chemotherapy regimen, patient selection, technical consideration and potential biomarkers are still under investigation. Furthermore, the comparison of neoadjuvant chemoradiotherapy with neoadjuvant/perioperative chemotherapy is also an important issue to be answered. In the review article, we addressed the current available evidence to provide a comprehensive understanding and the use of neoadjuvant chemoradiotherapy for locally advanced gastric cancer. Future studies and ongoing trials will be necessary to determine the best candidate and the role of newer systemic and radiation therapies in such patients. NCRT is a feasible treatment option for LAGC, with the ability to achieve favorable disease control and enable higher radical resection rates over those afforded by perioperative chemotherapy or surgery alone. Large clinical trials examining the comparative efficacy of NCRT and NCT are underway. The discrepancy between the satisfactory pCR rates associated with NCRT and the nonsignificant association between NCRT and survival warrants further exploration. Furthermore, newer therapies such as immunotherapy and adaptive radiotherapy may be implemented in con-junction with NCRT, and the development of useful biomarkers may ultimately lead to the de-velopment of personalized treatments for LAGC. These research directions may lead to the dis-covery of the optimal approach to administering NCRT to patients with LAGC. They may also aid in the determination of the optimal candidates for undergoing NCRT.

Abstract

Locally advanced gastric cancer (LAGC) has a poor prognosis with surgical resection alone, and neoadjuvant treatment has been recommended to improve surgical and oncological outcomes. Although neoadjuvant chemotherapy has been established to be effective for LAGC, the role of neoadjuvant chemoradiotherapy (NCRT) remains under investigation. Clinical experience and research evidence on esophagogastric junction adenocarcinoma (e.g., cardia gastric cancers) indicate that the likelihood of achieving sustainable local control is higher through NCRT than through resection alone. Furthermore, NCRT also has an acceptable treatment-related toxicity and adverse event profile. In particular, it increases the likelihood of achieving an R0 resection and a pathological complete response (pCR). Moreover, NCRT results in higher overall and recurrence-free survival rates than surgery alone; however, evidence on the survival benefits of NCRT versus neoadjuvant chemotherapy (NCT) remains conflicting. For noncardia gastric cancer, the efficacy of NCRT has mostly been reported in retrospective studies, and several large clinical trials are ongoing. Consequently, NCRT might play a more essential role in unresectable LAGC, for which NCT alone may not be adequate to attain disease control. The continual improvements in systemic treatments, radiotherapy techniques, and emerging biomarkers can also lead to improved personalized therapy for NCRT. To elucidate the contributions of NCRT to gastric cancer treatment in the future, the efficacy, potential toxicity, predictive biomarkers, and clinical considerations for implementing NCRT in different types of LAGC were reviewed.

Transhiatal esophagectomy as a treatment for locally advanced adenocarcinoma of the gastroesophageal junction: postoperative and oncologic results of a single-center cohort THE for locally advanced GEJC

Background and purpose

To report the postoperative and oncological outcomes of transhiatal esophagectomy for locally advanced cancer of the gastroesophageal junction.

Methods

Medical records of 120 consecutive patients who underwent transhiatal esophagectomy for locally advanced cancer of the gastroesophageal junction with curative intent after neoadjuvant treatment between February 2006 and December 2018 at our center were reviewed.

Results

All patients received either chemotherapy (46.7%) or chemoradiation (53.3%). The 90-day mortality and overall morbidity rates were 0.8% and 56.7%, respectively. Respiratory complications were the most common (30.8%). Anastomotic leakage occurred in 19 patients (15.8%), who were treated by local wound care (n = 13) or surgical drainage (n = 6). Recurrent laryngeal nerve injury occurred in 12 patients (9.9%). The median length of hospital stay was 15.5 days. The rate of R0 resection was 95.8%, and the median number of nodes removed was 17.5. Over a median follow-up of 77 months, the rate of recurrence was 40.8%, and the overall survival rates at 1, 3, and 5 years were 91%, 75%, and 65%, respectively. The median survival time was not reached. In multivariate analysis, disease stage was the only independent significant prognostic factor.

Conclusions

Transhiatal esophagectomy is a safe and effective procedure with good long-term oncological outcomes for locally advanced tumors after neo-adjuvant treatment. It can be recommended for all patients with cancer of the gastroesophageal junction, regardless of the Siewert classification, tumor stage, and comorbidities.

Downregulation of miR-375 contributes to ERBB2-mediated VEGFA overexpression in esophageal cancer

Esophageal cancer (EC) is a lethal cancer with an extremely aggressive nature and poor survival rate. However, the molecular mechanisms driving the occurrence and progression of EC are not well understood. MicroRNAs (miRNAs) are small RNA molecules that regulate the expression of protein-coding genes. miRNA-mediated gene regulation plays an important role in EC. By cross-referencing studies from NCBI, we found that microRNA-375 (miR-375) is one of the most frequently downregulated miRNAs in EC. We assessed expression of miR-375 in EC cell lines and primary EC tissues and their matched normal tissues. We found significant downregulation of miR-375 in both cell lines and EC tissues. Forced expression of miR-375 attenuated EC cell proliferation and invasion. Human epidermal growth factor receptor 2 (HER2, ERBB2), a known proto-oncogene, was identified here as one of the potential target genes of miR-375. Ectopic expression of miR-375 significantly suppressed the expression of ERBB2 and subsequently downregulated one of its target genes, vascular endothelial growth factor A (VEGFA), which is related to cancer invasion and metastasis. These findings suggest that miR-375 acts as a tumor suppressor by blocking the ERBB2/VEGFA pathway with the potential to modulate the occurrence and/ or progression of EC.

Racial Disparities in Rates of Surgery for Esophageal Cancer: a Study from the National Cancer Database

BACKGROUND

Treatment guidelines for stage I-III esophageal cancer indicate that management should include surgery in appropriate patients. Variations in utilization of surgery may contribute to racial differences observed in survival. We sought to identify factors associated with racial disparities in surgical resection of esophageal cancer and evaluate associated survival differences.

METHODS

Patients diagnosed with stage I-III esophageal cancer from 2004 to 2015 were identified using the National Cancer Database. Matched patient cohorts were created to reduce confounding. Multivariate logistic regression was used to identify factors associated with receipt of surgery. Multi-level modeling was performed to control for random effects of individual hospitals on surgical utilization.

RESULTS

A total of 60,041 patients were included (4402 black; 55,639 white). After 1:1 matching, there were 5858 patients evenly distributed across race. For all stages, significantly fewer black than white patients received surgery. Black race independently conferred lower likelihood of receiving surgery in single-level multivariable analysis (OR (95% CI); stage I, 0.67 (0.48-0.94); stage II, 0.76 (0.60-0.96); stage III, 0.62 (0.50-0.76)) and after controlling for hospital random effects. Hospital-level random effects accounted for one third of the unexplained variance in receipt of surgery. Risk-adjusted 1-, 3-, and 5-year mortality was higher for patients who did not undergo surgery.

CONCLUSION

Black patients with esophageal cancer are at higher risk of mortality compared to white patients. This increased risk may be influenced by decreased likelihood of receiving surgical intervention for resectable disease, in part because of between-hospital differences. Improving access to surgical care may improve disparities in esophageal cancer survival.

Meta-analysis of prognostic factors of overall survival in patients undergoing oesophagectomy for oesophageal cancer

INTRODUCTION

Currently, the American Joint Commission on Cancer (AJCC) staging system is used for prognostication for oesophageal cancer. However, several prognostically important factors have been reported but not incorporated. This meta-analysis aimed to characterize the impact of preoperative, operative, and oncological factors on the prognosis of patients undergoing curative resection for oesophageal cancer.

METHODS

This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling to determine pooled univariable hazard ratios (HRs). The study was prospectively registered with the PROSPERO database (Registration: CRD42018157966).

RESULTS

One-hundred and seventy-one articles including 73,629 patients were assessed quantitatively. Of the 122 factors associated with survival, 39 were significant on pooled analysis. Of these. the strongly associated prognostic factors were 'pathological' T stage (HR: 2.07, CI95%: 1.77-2.43, P < 0.001), 'pathological' N stage (HR: 2.24, CI95%: 1.95-2.59, P < 0.001), perineural invasion (HR: 1.54, CI95%: 1.36-1.74, P < 0.001), circumferential resection margin (HR: 2.17, CI95%: 1.82-2.59, P < 0.001), poor tumor grade (HR: 1.53, CI95%: 1.34-1.74, P < 0.001), and high neutrophil:lymphocyte ratio (HR: 1.47, CI95%: 1.30-1.66, P < 0.001).

CONCLUSION

Several tumor biological variables not included in the AJCC 8th edition classification can impact on overall survival. Incorporation and validation of these factors into prognostic models and next edition of the AJCC system will enable personalized approach to prognostication and treatment.

Role of 18F-FDG PET/CT in restaging of esophageal cancer after curative-intent surgical resection

OBJECTIVE

The aim of the study was to evaluate diagnostic performance of FDG PET-CT in suspected recurrence of carcinoma esophagus after curative-intent surgical resection and impact of FDG PET-CT on intended management.

MATERIAL AND METHODS

This was retrospective study of patients with clinical or radiological suspicion of recurrent esophageal carcinoma who were referred for PET-CT from January 2006 to December 2017. Diagnostic performance of PET-CT was evaluated for disease recurrence and its impact on management decisions. PET-CT findings were confirmed with tissue diagnosis. When tissue diagnosis was not available clinical and radiological follow-up was used as reference standard.

RESULTS

Relevant clinical data were available in 68 patients which were considered for analysis. In 91% (62/68) patients FDG PET-CT findings were suggestive of disease recurrence. Histopathological confirmation was available in 43 patients, whereas in remaining patients recurrence was confirmed by radiological and clinical follow-up. Forty percent (28/68) patients were detected with distant metastases. Sensitivity, specificity, positive and negative predictive values of FDG PET-CT was found to be 98.4, 80, 98 and 80% with accuracy of 97%. Change in management was observed in 41% (28/68) of patients from salvage radiotherapy/surgery to palliative chemotherapy/best supportive care based on evidence of distant metastases seen on FDG PET-CT.

CONCLUSION

FDG PET-CT is highly sensitive in detection of recurrent disease in esophageal cancer patients after surgical resection. It can detect distant metastases in high proportion of patients thus changing the intent of management from radical salvage to palliative chemotherapy/best supportive care.

Significance of Neoadjuvant Downstaging in Carcinoma of Esophagus and Gastroesophageal Junction

Objective

To determine the impact of downstaging on outcomes in esophageal cancer, the prognostic value of clinical and pathological stage, and the difference in survival in patients with similar pathological stages with and without neoadjuvant treatment.

Background

There is little data evaluating adenocarcinoma and squamous cell carcinoma (SCC) and difference in outcomes for similar pathological stage with and without neoadjuvant treatment.

Patients and Methods

Consecutive patients with esophageal cancer from a single center were evaluated. Patients with esophageal adenocarcinoma or SCC treated with transthoracic esophagectomy and two-field lymphadenectomy were included. Comparison of outcomes with those primarily treated with surgery was made. The cTNM and ypTNM 8th edition was used.

Results

This study included 992 patients, of whom 417 received surgery alone and 575 received neoadjuvant therapy and surgery. In the neoadjuvant group, 7 (1%) had cTNM stage 2 and 418 (73%) had cTNM stage 3. Downstaging rates were similar between adenocarcinoma and SCC (54% vs. 61%, p = 0.5). Downstaging was associated with longer survival than patients with no change (adenocarcinoma, median: 82 vs. 26 months, p < 0.001; SCC, median: NR vs. 29 months, p < 0.001). On Cox regression analysis, downstaging was associated with significantly longer survival in adenocarcinoma but not in SCC. For SCC and more advanced adenocarcinoma, overall survival was significantly better when comparing like-for-like ypTN to pTN groups.

Conclusions

Pathological stage provides a better estimate of prognosis compared with clinical stage. Downstaged patients may have an improved outcome over those with comparable pathological stage who did not receive neoadjuvant treatment.

Electronic supplementary material

The online version of this article (10.1245/s10434-020-08358-0) contains supplementary material, which is available to authorized users.

Margin Positivity in Resectable Esophageal Cancer: Are there Modifiable Risk Factors?

BACKGROUND

Patients with esophageal cancer have poor overall survival, with positive resection margins worsening survival. Margin positivity rates are used as quality measures in other malignancies, but modifiable risk factors are necessary to develop actionable targets for improvement. Our objectives were to (1) evaluate trends in esophageal cancer margin positivity, and (2) identify modifiable patient/hospital factors associated with margin positivity.

METHODS

Patients who underwent esophagectomy from 2004 to 2015 were identified from the National Cancer Database. Trends in margin positivity by time and hospital volume were evaluated using Cochrane-Armitage tests. Associations between patient/hospital factors and margin positivity were assessed by multivariable logistic regression.

RESULTS

Among 29,706 patients who underwent esophagectomy for cancer, 9.37% had positive margins. Margin positivity rates decreased over time (10.62% in 2004 to 8.61% in 2015; p < 0.001). Older patients (≥ 75 years) were more likely to have positive margins [odds ratio (OR) 2.04, 95% confidence interval (CI) 1.42-2.92], as were patients with a Charlson-Deyo Index ≥ 3 (OR 1.84, 95% CI 1.08-3.12). Patients who received neoadjuvant therapy were less likely to have positive margins (OR 0.37, 95% CI 0.29-0.47), while laparoscopic surgical approach was associated with increased margin positivity (OR 1.70, 95% CI 1.40-2.06). As the hospital annual esophagectomy volume increased, margin positivity rates decreased (7.76% in the fourth quartile vs. 11.39% in the first quartile; OR 0.70, 95% CI 0.49-0.99).

CONCLUSIONS

Use of neoadjuvant therapy, surgical approach, and hospital volume are modifiable risk factors for margin positivity in esophageal cancer. These factors should be considered in treatment planning, and margin positivity rates could be considered as a quality measure in esophageal cancer.

Management of Liver Oligometastatic Esophageal Cancer: Overview and Critical Analysis of the Different Loco-Regional Treatments

Esophageal cancer (EC) is an aggressive disease that is associated with a poor prognosis. Since metastastic EC is usually considered suitable only for palliative therapy with an estimated 5-year overall survival (OS) less than 5%, the optimal management of patients with liver oligometastatic EC (LOEC) is still undefined. The aim of this review is to provide an overview of the different treatment options for LOEC. A literature search was conducted using PubMed, Embase, and Cochrane to identify articles evaluating different treatment strategies for LOEC. Among 828 records that were identified, 20 articles met the inclusion criteria. These studies included patients who have undergone any type of surgical procedure and/or loco-regional therapy. Liver resection resulted in the best survival for patients with low tumor burden (3 lesions): 5-year OS 30–50% versus 8–12% after only chemotherapy (CHT). The 5-year OS of loco-regional therapies was 23% with a local recurrence risk ranging 0–8% for small lesions (2 to 3 cm). An aggressive multidisciplinary approach for LOEC patients may improve survival. Surgery seems to be the treatment of choice for resectable LOEC. If unfeasible, loco-regional therapies may be considered. In order to better select these patients and offer a chance of cure, prospective trials and a definition of treatment protocols are needed.

Presentation, Treatment, and Outcomes of Vulnerable Populations With Esophageal Cancer Treated at a Safety-Net Hospital

Social determinants of health have been associated with poor outcomes in esophageal cancer. Primary language and immigration status have not been examined in relation to esophageal cancer outcomes. This study aims to investigate the impact of these variables on stage of presentation, treatment, and outcomes of esophageal cancer patients at an urban safety-net hospital. Clinical data of patients with esophageal cancer at our institution between 2003 and 2018 were reviewed. Demographic, tumor, and treatment characteristics were obtained. Outcomes included median overall survival, stage-specific survival, and utilization of surgical and perioperative therapy. Statistical analysis was conducted using Chi-square test, Fisher's exact tests, Kaplan-Meier method, and logistic regression. There were 266 patients; 77% were male. Mean age was 63.9 years, 23.7% were immigrants, 33.5% were uninsured/Medicaid, and 16.2% were non-English speaking. Adenocarcinoma was diagnosed in 55.3% and squamous cell in 41.0%. More patients of non-Hispanic received esophagectomies when compared to those of Hispanic origin (64% vs 25%, P = 0.012). Immigrants were less likely to undergo esophagectomy compared to US-born patients (42% vs 76%, P = 0.001). Patients with adenocarcinoma were more likely than squamous cell carcinoma patients to undergo esophagectomy (odds ratio = 4.40, 95% confidence interval 1.61-12.01, P = 0.004). More commercially/privately insured patients (75%) received perioperative therapy compared to Medicaid/uninsured (54%) and Medicare (49%) patients (P = 0.030). There was no association between demographic factors and the utilization of perioperative chemoradiation for patients with operable disease. Approximately 23% of patients with operable disease were too frail or declined to undergo surgical intervention. In this small single-center study, race and primary language were not associated with median survival for patients treated for esophageal cancer. US-born patients experienced higher surgical utilization and privately insured patients were more likely to receive perioperative therapy. Many patients with operable cancer were too frail to undergo a curative surgery. Studies should expand on the relationships between social determinants of health and nonclinical services on delivery of care and survival of vulnerable populations with esophageal cancer.

Upregulation of IBSP Expression Predicts Poor Prognosis in Patients With Esophageal Squamous Cell Carcinoma

Esophageal squamous cell carcinoma (ESCC), which is characterized by invasiveness and poor prognosis, is the sixth most common leading cause of cancer-related death worldwide. Despite advances in multimodality therapy, ESCC mortality remains high, and an understanding of the molecular changes that lead to ESCC development and progression remains limited. In the present study, Integrin Binding Sialoprotein (IBSP) upregulation was found in 182 of 269 (67.7%) primary ESCC cells at the mRNA level by quantitative real-time polymerase chain reaction (qRT-PCR). Additionally, IHC staining further demonstrated that IBSP was upregulated in ESCC patients and IBSP protein upregulation was significantly related to the lymph node metastasis (P = 0.017), clinicopathologic stage (P = 0.001) and poor disease survival (P = 0.002). Moreover, functional studies illustrated that the IBSP gene can promote the proliferation and metastasis of ESCC cells. Furthermore, IBSP was found to regulate epithelial-mesenchymal transition (EMT), which promotes tumor cell metastasis. In conclusion, our study suggests that IBSP may be a valuable prognostic marker for ESCC patients.

Identification of crucial miRNAs and genes in esophageal squamous cell carcinoma by miRNA-mRNA integrated analysis

Esophageal squamous cell carcinoma (ESCC) is a malignancy that severely threatens human health and carries a high incidence rate and a low 5-year survival rate. MicroRNAs (miRNAs) are commonly accepted as a key regulatory function in human cancer, but the potential regulatory mechanisms of miRNA-mRNA related to ESCC remain poorly understood.The GSE55857, GSE43732, and GSE6188 miRNA microarray datasets and the gene expression microarray datasets GSE70409, GSE29001, and GSE20347 were downloaded from Gene Expression Omnibus databases. The differentially expressed miRNAs (DEMs) and differentially expressed genes (DEGs) were obtained using GEO2R. Gene ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis for DEGs were performed by Database for Annotation, Visualization and Integrated Discovery (DAVID). A protein-protein interaction (PPI) network and functional modules were established using the STRING database and were visualized by Cytoscape. Kaplan-Meier analysis was constructed based on The Cancer Genome Atlas (TCGA) database.In total, 26 DEMs and 280 DEGs that consisted of 96 upregulated and 184 downregulated genes were screened out. A functional enrichment analysis showed that the DEGs were mainly enriched in the ECM-receptor interaction and cytochrome P450 metabolic pathways. In addition, MMP9, PCNA, TOP2A, MMP1, AURKA, MCM2, IVL, CYP2E1, SPRR3, FOS, FLG, TGM1, and CYP2C9 were considered to be hub genes owing to high degrees in the PPI network. MiR-183-5p was with the highest connectivity target genes in hub genes. FOS was predicted to be a common target gene of the significant DEMs. Hsa-miR-9-3p, hsa-miR-34c-3p and FOS were related to patient prognosis and higher expression of the transcripts were associated with a poor OS in patients with ESCC.Our study revealed the miRNA-mediated hub genes regulatory network as a model for predicting the molecular mechanism of ESCC. This may provide novel insights for unraveling the pathogenesis of ESCC.

Extent of lymphadenectomy for Barrett's cancer

Adenocarcinoma of the esophagus and esophagogastric junction (EGJ) has become the predominant histological cell type in western countries due to the prevalence of obesity, gastroesophageal reflux disease and Barrett's esophagus. There is some evidence that this is increasing in the East as well. Surgery aims at achieving an R0 resection with clear margins, together with adequate and appropriate lymphadenectomy. Siewert type I and II cancers are more likely to be associated with Barrett's esophagus (especially in western countries), while type III cancers are mostly proximal gastric cancers that have grown upwards to involve the EGJ. For type I cancers, most surgeons would perform an esophagectomy, with at least an infra-carinal lymphadenectomy. It is more controversial for type II tumors, with some surgeons preferring an esophagectomy, while others may opt for a proximal or total radical gastrectomy via an abdominal approach. All procedures can be performed using open or minimally invasive methods. In addition to oncologic reasons, the chosen surgical approach also depends on expertise available, safety issues, and postoperative quality-of-life considerations. More data are needed in this area. How to integrate knowledge and also multimodality treatment strategies is an active area of research.

Detection of Circulating Tumor DNA in Plasma: A Potential Biomarker for Esophageal Adenocarcinoma

BACKGROUND

Recent literature has demonstrated the potential of "liquid biopsy" and detection of circulating tumor (ct)DNA as a cancer biomarker. However, to date there is a lack of data specific to esophageal adenocarcinoma (EAC). This study was conducted to determine how detection and quantification of ctDNA changes with disease burden in patients with EAC and evaluate its potential as a biomarker in this population.

METHODS

Blood samples were obtained from patients with stage I to IV EAC. Longitudinal blood samples were collected from a subset of patients. Imaging studies and pathology reports were reviewed to determine disease course. Tumor samples were sequenced to identify mutations. Mutations in plasma DNA were detected using custom, barcoded, patient-specific sequencing libraries. Mutations in plasma were quantified, and associations with disease stage and response to therapy were explored.

RESULTS

Plasma samples from a final cohort of 38 patients were evaluated. Baseline plasma samples were ctDNA positive for 18 patients (47%) overall, with tumor allele frequencies ranging from 0.05% to 5.30%. Detection frequency of ctDNA and quantity of ctDNA increased with stage. Data from longitudinal samples indicate that ctDNA levels correlate with and precede evidence of response to therapy or recurrence.

CONCLUSIONS

ctDNA can be detected in plasma of EAC patients and correlates with disease burden. Detection of ctDNA in early-stage EAC is challenging and may limit diagnostic applications. However, our data demonstrate the potential of ctDNA as a dynamic biomarker to monitor treatment response and disease recurrence in patients with EAC.

Molecular landscape of esophageal cancer: implications for early detection and personalized therapy

Esophageal cancer (EC) is one of the most lethal cancers and a public health concern worldwide, owing to late diagnosis and lack of efficient treatment. Esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC) are main histopathological subtypes of EC that show striking differences in geographical distribution, possibly due to differences in exposure to risk factors and lifestyles. ESCC and EAC are distinct diseases in terms of cell of origin, epidemiology, and molecular architecture of tumor cells. Past efforts aimed at translating potential molecular candidates into clinical practice proved to be challenging, underscoring the need for identifying novel candidates for early diagnosis and therapy of EC. Several major international efforts have brought about important advances in identifying molecular landscapes of ESCC and EAC toward understanding molecular mechanisms and critical molecular events driving the progression and pathological features of the disease. In our review, we summarize recent advances in the areas of genomics and epigenomics of ESCC and EAC, their mutational signatures and immunotherapy. We also discuss implications of recent advances in characterizing the genome and epigenome of EC for the discovery of diagnostic/prognostic biomarkers and development of new targets for personalized treatment and prevention.

Adenocarcinoma of the oesophagus: neoadjuvant chemoradiation and radical surgery : Long-term results

PURPOSE

To retrospectively evaluate long-term treatment results following neoadjuvant chemoradiation (CRT) and radical surgery in patients with advanced adenocarcinoma (AC) of the oesophagus.

PATIENTS AND METHODS

Between 2005 and 2015, a total of 102 consecutive patients with a median age of 64 years (range, 44-86 years) and AC of the oesophagus were evaluated of whom 84 received a full CRT. A group of 51 patients was treated with neoadjuvant intent followed by radical surgery. A total dose of 50.4 Gy with mostly weekly paclitaxel/fluorouracil chemotherapy was administered. Six to eight weeks following CRT, a transthoracic subtotal oesophageal and proximal gastric resection was performed. Survival curves for overall survival and no evidence of disease (NED) survival (primary endpoints) were calculated according to Kaplan-Meier, and possible prognostic factors were evaluated by the log-rank test as well as by a Cox regression analysis.

RESULTS

Median follow-up time of the surviving patients was 48 months (range, 14-134 months). Overall and NED survival rates for patients of the study group (n = 51) were 40 and 32%, respectively, at 5 years. Age (p = 0.04), ypT category (p = 0.1) and the development of distant metastases (p = 0.05) were identified as (marginally) independent prognostic variables with impact on survival. Median survival time for patients of the study group (n = 51) was 45 ± 18 months (95%CI 9-81 months). Clear resection margins were achieved in 46/51 patients (92%). Regression rates with complete regression rare residual cancer and increased number of residual cells, but predominantly fibrosis were 33, 41, and 10%, respectively. Patterns of failure revealed local with distant recurrence in 2/51 (4%), regional recurrence alone in 2/51 (4%), and distant metastases in 27/51 (53%) patients.

CONCLUSION

Neoadjuvant CRT in patients with AC of the oesophagus followed by thoracoabdominal surgery is a locally very effective concept. A significant tumour regression in almost 75% of the patients may stimulate prospective trials on the omission of radical surgery for some elderly patients. Due to a high rate of distant metastases further investigations in terms of effective systemic therapy may be warranted.

Racial Disparity in Utilization of High-Volume Hospitals for Surgical Treatment of Esophageal Cancer

BACKGROUND

Utilization of high-volume hospitals (HVH) for esophagectomy has been associated with improved perioperative outcomes and reduced mortality. We aimed to test the hypothesis that black-white racial disparities exist in HVH utilization and identify predictors of in-hospital surgical outcomes of esophageal cancer while adjusting for HVH utilization patterns.

METHODS

We queried the New York Statewide Planning and Research Cooperative System database (1995 to 2012) for esophageal cancer patients who underwent surgical resection exclusively. Only records for patients with self-reported white or black race and a valid New York State ZIP code were included (n = 2,895). Analysis was performed to identify factors associated with HVH hospital (≥20 esophagectomies/year) utilization and determine predictors of complications and in-hospital mortality.

RESULTS

Black patients (361 [12.5%]) were significantly different (p < 0.001) than their white counterparts in the proportion of women, Medicaid, income distribution, and privately insured individuals. Although 55% patients overall utilized an HVH, blacks were significantly less likely to utilize an HVH than whites (odds ratio [OR], 0.18; 95% confidence interval [CI], 0.14 to 0.24), even though 74.5% resided within 8.9 miles of one. Operations performed at HVHs were associated with lower in-hospital mortality (OR, 0.48; 95% CI, 0.35 to 0.65); however, mortality remained higher for blacks (OR, 2.04; 95% CI, 1.65 to 3.30; propensity matched OR, 2.45; 95% CI, 1.5 to 4.03).

CONCLUSIONS

Black patients were less likely to undergo esophagectomy at an HVH and experienced higher mortality. Efforts should be made to understand factors influencing patients' decision process and improve referral practices to ensure optimal care is provided across all segments of the population, irrespective of race, insurance, or income status.

Intakes of citrus fruit and risk of esophageal cancer: A meta-analysis

Esophageal cancer (EC) is the eighth most common cancer and the sixth most frequent cause of cancer death in the whole world. Many studies have investigated the association between citrus fruit intake and the risk of EC, but the results are inconsistent and not analyzed by category. We aimed to perform a meta-analysis of studies to evaluate the incidence between citrus fruit consumption and subtypes of esophageal cancer and derive a more precise estimation.Through searches of PubMed, OVID, and Web of Science we updated 1988 systematic review up to April 2016. Based on an inclusion and exclusion criteria, conventional meta-analysis according to DerSimonian and Laird method was used for the pooling of the results. Random-effect models were used to calculate subgroups.Twenty-five English articles (20 case-control studies and 5 cohort studies) comprising totally 5730 patients of esophageal cancer would be suitable for use in this study. The result indicated the inverse associations between intakes of citrus fruit and EC (relative risk [RR] = 0.65, 95% confidence interval [CI] 0.56-0.75, I  = 51.1%, P = .001), Esophageal squamous cell carcinoma (ESCC) (RR = 0.59, 95% CI 0.47-0.76, I  = 60.7%, P = .002), no significant relationship between citrus fruit and esophageal adenocarcinoma (EAC) (RR = 0.86, 95% CI 0.74-1.01, I  = 0.0%, P = .598).This meta-analysis indicates that intakes of citrus fruit significantly reduce the risk of ESCC and is no obvious relationship with EAC. Further studies about constituents in citrus fruit and its mechanism are warranted.

Definitive chemoradiotherapy versus neoadjuvant chemoradiotherapy followed by surgery for stage II to III esophageal squamous cell carcinoma

OBJECTIVE

Definitive chemoradiotherapy (CRT) remains the most commonly used treatment for locally advanced esophageal squamous cell carcinoma (SCC), because of perceptions that esophagectomy offers an unclear survival advantage. We compare recurrence, overall survival (OS), and disease-free survival (DFS) in patients treated with definitive CRT or neoadjuvant CRT followed by surgery (trimodality).

METHODS

This was a retrospective cohort study of patients with stage II and III SCC of the middle and distal esophagus in patients who completed CRT. Treatment groups were matched (1:1) on covariates using a propensity score-matching approach. The effect of trimodality treatment, compared with definitive CRT, on OS, DFS, and site-specific recurrence was evaluated as a time-dependent variable and analyzed using Cox regression with a gamma frailty term for matched units.

RESULTS

We included 232 patients treated between 2000 and 2016: 124 (53%) with definitive CRT and 108 (47%) with trimodality. Trimodality was used less frequently over time (61% before 2009 and 29% after 2009; P < .0001). After matching, each group contained 56 patients. Median OS and DFS were 3.1 and 1.8 years for trimodality versus 2.3 and 1.0 years for CRT. Surgery was independently associated with improved OS (hazard ratio, 0.57; 95% confidence interval, 0.34-0.97; P = .039) and DFS (hazard ratio, 0.51; 95% confidence interval, 0.32-0.83; P = .007).

CONCLUSIONS

CRT followed by surgery might decrease local recurrence and increase DFS and OS in patients with esophageal SCC. Until better tools to select patients with pathological complete response are available, surgery should remain an integral component of the treatment of locally advanced esophageal SCC.

The effects of NF-κB signal pathway on the process of anastomotic stricture after the radical resection of esophageal carcinoma

The aim of this article is to identify the relationship between the nuclear factor κB (NF-κB) signal pathway expression and the anastomotic stricture. It particularly focuses on the expression of p65, bcl-2, and cIAP-1 in the anastomotic stricture formation after radical resection of esophageal cancer. A total of 82 esophageal squamous carcinoma patients who had undergone esophagectomy by Ivor Lewis procedure were enrolled in the study. Tissues were collected from the patients who developed the anastomotic stricture after the operation, while para anastomotic tissues served as the control. The protein expression of p65, bcl-2, and cIAP-1 was analyzed by immunohistochemistry and western blot analyses, while the messenger RNA (mRNA) levels of p65, bcl-2, and cIAP-1 were evaluated by reverse transcription polymerase chain reaction (RT-PCR). The results showed that lower expression of p65, bcl-2, and cIAP-1 proteins was observed in the para anastomotic tissue; in the esophageal stricture’s tissue, the expression of these proteins was significantly higher ( P < 0.05). The mRNA levels of P56, bcl-2, and cIAP-1 in the stricture tissue were remarkably increased ( P < 0.05) compared with the para anastomotic tissues, and the mRNA levels in the sample of grade 3 dysphagia were higher ( P < 0.05) than the levels of grade 1 and 2. In the normal esophageal epithelial cell of stricture patients was upregulated compared with that of no stricture patients. We can confirm that the anastomotic stricture has the relationship with the NF-κB signal pathway. The bcl-2 and cIAP-1, located downstream of NF-κB signal pathway, could be a new preventive and therapeutic target for the anastomotic stricture.

Predictive significance of HMGCS2 for prognosis in resected Chinese esophageal squamous cell carcinoma patients

Despite a series of attempts during the last decades, the prognosis of esophageal squamous cell carcinoma (ESCC) remains poor. Different responses of individual tumors encouraged us to look for valuable prognostic markers. As a key regulator controlling the anabolic ketogenic pathway, 3-hydroxy-3-methylglutaryl-CoA synthase 2 (HMGCS2) has been reported to play a crucial role in colorectal cancer and prostate cancer. However, its importance to ESCC has not been verified. Therefore, a large cohort retrospective study was planned, to investigate the relationship between HMGCS2 expression and ESCC prognosis. By adopting real-time polymerase chain reaction (PCR) and immunohistochemical (IHC) staining, HMGCS2 expression was examined in tissues of 300 ESCC patients with complete resection. Besides, the association between HMGCS2 protein expression and survival time was evaluated through chi-square test and Kaplan–Meier analysis. With the use of Cox-proportional hazards model, the prognostic impact of clinicopathologic variables and biomarker expression was evaluated. Compared with their non-tumor counterparts, HMGCS2 downregulation occurred in 65.5% and 37.6% of primary ESCCs on the mRNA and protein levels (P<0.001), respectively. On the protein level, HMGCS2 expression was associated with tumor cell differentiation (P=0.003), pT status (P=0.006), and TNM stage (P=0.010). In the down-HMGCS2 expression group, the 5-year overall survival (OS) and relapse-free survival (RFS) are poorer than those in the normal expression group (19 months vs 24 months, P=0.002; 13 months vs 17 months, P=0.007, respectively). According to the TNM stage, stratified analysis revealed that its discernibility on RFS was only pronounced in patients with advanced clinical stage (P=0.001). In addition, multivariate Cox regression analysis showed that HMGCS2 expression was an independent risk factor for RFS (P=0.032) instead of OS (P=0.099). The findings of this study provided the evidence that HMGSC2 represented a potential novel prognostic biomarker for ESCC patients.

Tyrosine kinase inhibitor induced growth factor receptor upregulation enhances the efficacy of near-infrared targeted photodynamic therapy in esophageal adenocarcinoma cell lines

Esophageal carcinoma (EC) is a global health problem, with disappointing 5-year survival rates of only 15-25%. Near-infrared targeted photodynamic therapy (NIR-tPDT) is a novel strategy in which cancer-targeted phototoxicity is able to selectively treat malignant cells. In this in vitro report we demonstrate the applicability of antibody-based NIR-tPDT in esophageal adenocarcinoma (EAC), using the phototoxic compounds cetuximab-IRDye700DX and trastuzumab-IRDye700DX, targeting respectively epidermal growth factor receptor 1 (EGFR) and 2 (HER2). Furthermore, we demonstrate that NIR-tPDT can be made more effective by tyrosine kinase inhibitor (TKI) induced growth receptor upregulation. Together, these results unveil a novel strategy for non-invasive EAC treatment, and by pretreatment-induced receptor upregulation its future clinical application may be optimized.

Non-inferiority of minimally invasive oesophagectomy: an 8-year retrospective case series

BACKGROUND

The trend towards laparoscopic surgery seen in other specialties has not occurred at the same pace in oesophagectomy. This stems from concerns regarding compromised oncological clearance, and complications associated with gastric tube necrosis and anastomotic failure. We present our experience of minimally invasive oesophagectomy (MIO) compared to open and hybrid surgery. We aim to ascertain non-inferiority of MIO by evaluating impact on survival, oncological clearance by resection margin and lymph node harvest and post-operative complications.

METHODS

Data were sourced retrospectively 2008-2015. Three approaches were studied. MIO (3-stage Mckeown), hybrid (2-stage Ivor Lewis, laparoscopy, thoracotomy) and open (2-stage Ivor Lewis).

RESULTS

Five-year survival was 54.2%. Surgical approach had no significant impact on survival at any stage of disease (Stage 0/I p = 0.98; stage II p = 0.2; stage III p = 0.76). There was no statistically significant difference in oncological clearance by resection margins between procedures when compared by disease stage (p = 0.49). A higher number of nodes were harvested in hybrid [median 27.5 (6-65)] and open surgeries [median 26 (4-54)] than in MIO [median 20 (7-44)] (p > 0.01). Numbers of nodes resected did not impact risk of recurrence [recurrence, median 25 (6-54), no recurrence, 26 (4-65)] (p = 0.25). Anastomotic strictures (22.4%) and potential leaks (17.9%) were more common in MIO (strictures p > 0.01, leaks p = 0.08), although associated morbidity was lower. Respiratory complications were less common in MIO (2.9%) versus hybrid (13.3%) (p = 0.02). Wound infection and chyle leak were also lower (wound 1.5% MIO 3.5% open, p = 0.6; chyle leak 1.5% MIO, 6.7% hybrid, p = 0.2).

CONCLUSIONS

Our results show no negative impact of MIO on survival or oncological clearance. Respiratory and wound complications are lower in MIO, but rates of anastomotic strictures and potential anastomotic leaks are increased. This may be due to the longer length of conduit and subclinical ischaemia at the anastomosis and merits further evaluation.

Reduction of AZGP1 predicts poor prognosis in esophageal squamous cell carcinoma patients in Northern China

BACKGROUND

As a key regulator in lipid mobilization, AZGP1 has been reported to play a significant role in various cancers. This study was carried out to investigate the role of AZGP1 in the development of esophageal squamous cell carcinoma (ESCC) patients in Northern China.

MATERIALS AND METHODS

Through the application of quantitative real-time polymerase chain reaction and immunohistochemical staining, AZGP1 expression in ESCC tissues from Northern China was examined.

RESULTS

Decreased expression of AZGP1 was observed in ~60% ESCC patients. AZGP1 downregulation was significantly associated with lymph node metastasis (P=0.035), advanced clinical stage (P=0.018), poor prognosis for 5-year disease-specific survival (DSS; P<0.001), local recurrence-free survival (LRFS; P=0.016), and metastasis-free survival (MeFS; P=0.014). In addition, Cox multivariate analysis revealed that AZGP1 downregulation remained to be an independent prognosticator for shorter DSS (P=0.001), LRFS (P=0.011), and MeFS (P=0.004).

CONCLUSION

AZGP1 might be a candidate tumor suppressor and a potential novel prognostic biomarker for ESCC patients in Northern China.

Esophageal Cancer Treatment Is Underutilized Among Elderly Patients in the USA

OBJECTIVES

Large numbers of elderly patients in the USA receive no treatment for esophageal cancer, despite evidence that multimodality treatment can increase survival. Our goal is to identify factors that may contribute to lack of treatment.

MATERIALS AND METHODS

Using Surveillance Epidemiology and End Results (SEER)-Medicare Linked Database (2001-2009), we identified regional esophageal cancer patients ≥65 years old. Treatment was defined as receiving any medical or surgical therapy for esophageal cancer. Logistic regression analysis was performed to identify factors associated with failure to receive treatment. Overall survival (OS) was analyzed using the Kaplan-Meier method and Cox proportional hazard model.

RESULTS

There were 5072 patients (median age, 75 years; interquartile range (IQR), 71-81 years). Majority were treated with definitive chemoradiation (48.49 %). Factors associated with lack of treatment included West geographic region and ≥80 years old. Patients who received therapy had better OS (log-rank, p < 0.001). Compared with treated patients, non-treated patients had worse adjusted OS (HR, 1.43; 95 % confidence interval (CI), 1.33-1.55; p < 0.001).

CONCLUSIONS

Elderly patients with locally advanced esophageal cancer who received treatment had improved 5-year survival compared with patients without treatment. Disparities in utilization of treatment are associated with regional and socioeconomic factors, not presence of comorbidities.

Proximal Resection Margin in Ivor-Lewis Oesophagectomy for Cancer

OBJECTIVE

The purpose of this study was to investigate whether a long proximal oesophageal resection margin (PRM) is associated with improved survival after oesophagectomy for cancer and to identify the optimal margin to aim for in this patient group.

METHODS

A prospectively maintained database identified 174 patients who underwent Ivor-Lewis oesophagectomy for cancer. Demographic, clinical, and pathological data were collected. X-tile software was used to identify the optimal resection point. Two models were analysed: single point resection with comparison of two groups (short and long), and two resection points with three groups (short, medium, and long) to provide a range.

RESULTS

The median PRM was 4.0 cm (interquartile range: 2.5-6.0 cm). After adjustment for significant confounders, multivariable Cox PH analysis demonstrated that the optimal resection margin was 1.7 cm, and in the three-group analysis the optimum PRM was between 1.7 and 3 cm. In the two-group analysis, the long margin had no effect on DFS (p = 0.37), but carried a significantly improved overall survival (hazard ratio [HR] = 0.46, 95 % confidence interval [CI] 0.25-0.87, p = 0.02). In the three-group analysis, the medium and long groups had improved OS compared with the short group (on average 54 %, HR ≥ 0.45, p ≤ 0.04). The 5-year disease-free and overall survival rates were highest in the medium PRM group (48 and 57 % respectively).

CONCLUSIONS

Optimal survival following oesophagectomy for cancer is achieved with a PRM > 1.7 cm, but a PRM > 3 cm does not yield a further survival advantage. Thus, the optimal PRM is likely to be between 1.7 and 3 cm.

Transhiatal Esophagectomy for Esophageal Cancer

Survival for esophageal cancer has improved over the past four decades, probably as a result of a combination of more accurate staging, improved surgical outcomes, advances in adjuvant and neoadjuvant therapies, and the increasing implementation of multimodality treatment. Surgical resection still remains the mainstay in the treatment of localized esophageal adenocarcinoma. Multiple techniques have been described for esophagectomy, which are based on either a transthoracic or transhiatal approach. Despite proponents of each technique touting potential advantages such as superior oncologic resection with more extensive transthoracic lymphadenectomy compared to the relatively limited morbidity and mortality with a transhiatal resection, the superiority of one technique over another is not clear and may be relegated to a topic of historical significance in the era of minimally invasive surgery. With the increased acceptance of neoadjuvant multimodality therapy, both approaches have been shown to have acceptable outcomes. And in the hands of experienced surgeons, both techniques can provide excellent short-term results. Moreover, surgeon and hospital volume have shown to be strongly associated with improved operative morbidity and oncologic outcomes, which may supersede the type of approach selected for an individual patient.

Outcomes after endoscopic versus surgical therapy for early esophageal cancers in an older population

BACKGROUND AND AIMS

Endoscopic treatment of early esophageal cancer provides an alternative to esophagectomy, which older patients may not tolerate. Population-based data regarding short-term outcomes and recurrence after endoscopic treatment for esophageal cancer are limited. We compared short-term outcomes, treated recurrence, and survival after endoscopic versus surgical therapy for early esophageal cancers in an older population.

METHODS

We conducted a retrospective cohort study identifying patients aged ≥66 years with Tis or T1a tumors without nodal involvement diagnosed from 1994 to 2011 from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database.

RESULTS

Of 2193 patients, 41% (n = 893) underwent esophagectomy, and 12% (n = 255) underwent endoscopic treatment within 6 months of diagnosis. Those treated endoscopically were older and more likely to have a Charlson comorbidity score ≥2. A composite endpoint, hospitalization and/or adverse events at 60 days, was higher in surgical patients than in the endoscopic treatment group (30% vs 12%; P < .001). In a Cox model stratified by histology, adjusting for other factors, endoscopic treatment was associated with improved 2-year survival (hazard ratio 0.51; 95% CI, 0.36-0.73).

CONCLUSIONS

In this older population, a composite short-term endpoint was worse in the surgical group. Endoscopic treatment was associated with improved survival through 2 years. These results suggest that endoscopic treatment is a reasonable approach for early esophageal cancers in the elderly.

Use of single-lumen tube for minimally invasive and hybrid esophagectomies with prone thoracoscopic dissection: case series

Minimally invasive and hybrid minimally invasive esophagectomy (MIE) is a technically challenging procedure. Anesthesia for the same is equally challenging due to special requirements of the video-assisted thoracoscopic technique used and shared operative and respiratory fields. Standard ventilatory strategy for this kind of surgery has been 1-lung ventilation with the help of a double-lumen tube. Prone positioning for thoracoscopic dissection facilitates gravity-dependant collapse of the operative side lung induced by a unilateral capnothorax, thus making the use of single-lumen endotracheal tube a feasible option for this surgery. We report our experience of 10 consecutive cases of minimally invasive esophagectomy conducted in prone position at our center and the use of single-lumen endotracheal tube for ventilation.

[Surgical treatment of esophageal cancer : Evolution of management and prognosis over the last 3 decades]

BACKGROUND

An increasing incidence of adenocarcinoma, a modified surgical strategy and the increasing use of multimodal therapeutic protocols have had a major impact on the surgical treatment of esophageal cancer during the last 3 decades.

OBJECTIVES

This study analyzed the development of these factors and their impact on the short and long-term prognosis of esophageal cancer over the last 25 years.

PATIENTS AND METHODS

The study included 366 patients with esophageal cancer treated by esophagectomy at the University Hospital in Freiburg from 1988 to 2012. The study period was split into four time periods for further comparisons, i.e. 1988-1994, 1995-2001, 2001-2006 and 2007-2012.

RESULTS

Within the time periods analyzed a marked increase in adenocarcinoma was found (time periods1988-1994, 1995-2001, 2001-2006 and 2007-2012: 21%, 37%, 61% and 64%, respectively, p<0.001). The initially commonly used transhiatal approach and reconstruction with cervical anastomosis was gradually replaced by the thoracoabdominal procedure with intrathoracic reconstruction (i.e. Ivor Lewis esophagectomy, 2007-2012: 98 %). During the study period increasingly more patients received multimodal therapy (13%, 85%, 72% and 84%, p<0.001), the overall rate of perioperative complications (70%, 88%, 73% and 56%, p<0.001) and perioperative mortality (16%, 18%, 8% and 2.5%, p<0.001) were significantly reduced, while the overall 5-year survival (12%, 34%, 41% and 62%, p<0.001) improved. An early tumor stage (p=0.002), N0 status (p<0.001) and histological type of adenocarcinoma (p=0.011) were identified as independent predictors of improved survival.

CONCLUSION

During the period from 1988 to 2012 a significant improvement of long-term survival as well as a marked reduction of perioperative mortality after esophagectomy were observed. The improved outcome was associated with an increased use of multimodal therapeutic protocols, the preferred use of thoracoabdominal esophagectomy and epidemiological changes in histology over the study period.

Submucosal invasion and risk of lymph node invasion in early Barrett's cancer: potential impact of different classification systems on patient management

BACKGROUND

Due to the high mortality and morbidity rates of esophagectomy, endoscopic mucosal resection (EMR) is increasingly used for the curative treatment of early low risk Barrett's adenocarcinoma.

OBJECTIVE

This retrospective cohort study aimed to assess the prevalence of lymph node metastases (LNM) in submucosal (T1b) esophageal adenocarcinomas (EAC) in relation to the absolute depth of submucosal tumor invasion and demonstrate the efficacy of EMR for low risk (well and moderately differentiated without lymphovascular invasion) EAC with sm1 invasion (submucosal invasion ≤500 µm) according to the Paris classification.

METHODS

The pathology reports of patients undergoing endoscopic resection and surgery from January 1994 until December 2013 at one center were reviewed and 54 patients with submucosal invasion were included. LNM were evaluated in surgical specimens and by follow up examinations in case of EMR.

RESULTS

No LNM were observed in 10 patients with sm1 adenocarcinomas that underwent endoscopic resection. Three of them underwent supplementary endoscopic eradication therapy with a median follow up of 27 months for patients with sm1 tumors. In the surgical series two patients (29%) with sm1 invasion according to the pragmatic classification (subdivision of the submucosa into three equal thirds), staged as sm2-3 in the Paris classification, had LNM. The rate of LNM for surgical patients with low risk sm1 tumors was 10% according to the pragmatic classification and 0% according to Paris classification.

CONCLUSION

Different classifications of the tumor invasion depth lead to different LNM risks and treatment strategies for sm1 adenocarcinomas. Patients with low risk sm1 adenocarcinomas appear to be suitable candidates for EMR.

Statin use reduces risk of esophageal adenocarcinoma in US veterans with Barrett's esophagus: a nested case-control study

BACKGROUND & AIMS

Statins have been reported to protect against esophageal adenocarcinoma (EAC) in patients with Barrett's esophagus (BE). However, there are few data from adequately powered cohort studies of subjects with BE.

METHODS

We conducted a nested case-control study of a cohort of BE patients identified from national Veteran Affairs (VA) outpatient files, diagnosed with BE from 2004 through 2009. New cases of EAC recorded after BE diagnosis were identified during a follow-up period that ended in 2011 and verified using electronic medical records. We selected patients with BE without EAC (controls) using incidence density sampling; 3 controls were matched to each case based on birth year and date of BE diagnosis. Our analysis included only male patients with at least 1 VA visit per year of follow up. We identified prescriptions for statins and non-statin lipid lowering medications filled after BE diagnosis and up to 90 days before EAC diagnosis for cases and controls (during the corresponding time period); we examined the association between statin use and EAC in conditional logistic regression models.

RESULTS

We compared 311 EAC cases to 856 controls. Cases were less likely to use any statins than controls (40.2% vs 54.0%; P < .01). Significantly lower proportions of cases used statins for 6-18 months (10.0% cases vs 17.1% controls) and >18 months (19.3% vs 24.0%, respectively; P < .01). Simvastatin was the most commonly prescribed statin (accounting for 86.9% of statin use); the defined daily dose of simvastatin was lower in cases than in controls (21-40 mg/day, 9.3% vs 14.5%, respectively; and >40 mg/day, 8.4% vs 12.6%, respectively; P < .01). In multivariate analysis, statin use was inversely associated with development of EAC (adjusted odds ratio [OR], 0.65; 95% confidence interval [CI], 0.47-0.91). This protective association was strongest for patients with advanced-stage EAC: in a stratified analysis, comparison of 189 cases with stage 0-1 EAC to 520 controls produced an adjusted OR of 0.85 (95% CI, 0.54-1.33). Among patients with late-stage EAC (stages 2-4, n = 106) and 291 controls, the adjusted OR was 0.44 (95% CI, 0.25-0.79). We found no association between EAC and non-statin lipid-lowering medications.

CONCLUSIONS

In a case-control study of US veterans, statin use among those with BE appeared to decrease the risk of EAC. This protective effect was strongest against advanced-stage EAC, and increased with statin dose.

HER2 expression in oesophageal carcinoma and Barrett's oesophagus associated adenocarcinoma: An Australian study

BACKGROUND

Several studies have evaluated the prognostic value of HER2 in oesophageal cancer, but the prognostic influence of HER2 overexpression in oesophageal cancer remains uncertain. The aim of this study was to assess the incidence of HER2 positivity and relationship with clinicopathological features in patients with oesophageal cancer.

DESIGN

The study cohort consisted of 269 patients diagnosed with oesophageal carcinoma in a single institution. HER2 expression was analysed by immunohistochemistry (IHC) and silver in situ hybridization (SISH) in 152 archival oesophageal cancer specimens. Survival analysis was assessed using Hazard models.

RESULTS

HER2 expression was IHC3+ in 14 (9.2%), IHC2+ in 14 (9.2%), IHC1+ in 57 (37.5%), and IHC0 in 67 (44.1%) cases. SISH results confirmed that 15 specimens (9.9%) were HER2 gene amplified. Among 27 squamous cell carcinomas (SCCs) only 3.7% were HER2 positive whereas 11.2% of 125 adenocarcinomas were HER2 positive. The HER2 positive tumours were more likely to occur in men (OR: 5.00, 95% CI: 1.69-14.29), smokers (OR: 10.00, 95% CI: 4.17-25) and in patients with Barrett's oesophagus (OR: 8.33, 95% CI: 3.71-20.00). There was no significant difference in survival between the (HER2 +ve, 14.3 months vs HER2 -ve, 24.6 months, p = 0.42) CONCLUSION: A HER2 prevalence rate of 9.9% was found among patients with oesophageal cancer and no correlation with survival was detected overall.

Understanding Complete Pathologic Response in Oesophageal Cancer: Implications for Management and Survival

Despite significant improvement over recent decades, oesophageal cancer survival rates remain poor. Neoadjuvant chemoradiotherapy followed by oesophageal resection is mainstay of therapy for resectable oesophageal tumours. Operative morbidity and mortality associated with oesophagectomy remain high and complications arise in up to 60% of patients. Management strategies have moved towards definitive chemoradiotherapy for a number of tumour sites (head and neck, cervical, and rectal) particularly for squamous pathology. We undertook to perform a review of the current status of morbidity and mortality associated with oesophagectomy, grading systems determining pathologic response, and data from clinical trials managing patients with definitive chemoradiotherapy to inform a discussion on the topic.