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Sugimura K, Miyata H, Kanemura T, Takeoka T, Sugase T, Yamamoto M, Shinnno N, Hara H, Omori T, Motoori M, Ohue M, Yano M. Clinical Impact of Metastatic Lymph Node Size on Therapeutic Effect and Prognosis in Patients with Esophageal Squamous Cell Carcinoma Who Underwent Preoperative Chemotherapy Followed by Esophagectomy. Ann Surg Oncol 2023; 30:4193-4202. [PMID: 37010661 DOI: 10.1245/s10434-023-13393-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/10/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Pretreatment metastatic lymph node (LN) size has been reported to be associated with prognosis in esophageal squamous cell carcinoma (ESCC). However, its relationship with response to preoperative chemotherapy or prognosis has not been clarified. We investigated the relationship between metastatic LN size and response to preoperative treatment, and prognosis in patients with metastatic esophageal cancer who underwent surgery. PATIENTS AND METHODS A total of 212 clinically node-positive patients who underwent preoperative chemotherapy followed by esophagectomy for ESCC were enrolled. Patients were stratified into three groups on the basis of the length of the short axis of the largest LN in pretreatment computed tomography images: < 10 mm (group A), 10-19 mm (group B), and ≥ 20 mm (group C). RESULTS Group A had 90 patients (42%), group B had 103 patients (49%), and group C had 19 patients (9%). Group C had significantly lower percent reduction in total metastatic LN size than groups A and B (22.5% versus 35.7%, P = 0.037). Group C had significantly more metastatic LNs based on histological examination than groups A and B (10.1 versus 2.4, P < 0.001). Group C patients whose LNs responded had significantly fewer metastatic LNs than nonresponders (5.1 versus 11.9, P = 0.042). Group C had significantly poorer overall survival than groups A and B (3-year survival, 25.4% versus 67.3%, P < 0.001). However, group C patients whose LNs responded had better survival than nonresponders (3-year survival, 57.1% versus 0%, P = 0.008). CONCLUSIONS Patients with large metastatic LNs have poor response and poor prognosis. However, if a response is obtained, long-term survival can be expected.
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Affiliation(s)
- Keijiro Sugimura
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan.
- Department of Surgery, Kansai Rosai Hospital, Amagasaki City, Hyogo, Japan.
| | - Hiroshi Miyata
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Takashi Kanemura
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Tomohira Takeoka
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Takahito Sugase
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masaaki Yamamoto
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Naoki Shinnno
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Hisashi Hara
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Takeshi Omori
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masaaki Motoori
- Department of Surgery, Osaka General Medical Center, Osaka, Japan
| | - Masayuki Ohue
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masahiko Yano
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
- Department of Surgery, Osaka Suita Municipal Hospital, Suita City, Osaka, Japan
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Patterns of Recurrence and Long-Term Survival of Minimally Invasive Esophagectomy Versus Open Esophagectomy for Locally Advanced Esophageal Cancer Treated with Neoadjuvant Chemotherapy: a Propensity Score-Matched Analysis. J Gastrointest Surg 2023:10.1007/s11605-023-05615-x. [PMID: 36749557 DOI: 10.1007/s11605-023-05615-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/27/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND The use of minimally invasive esophagectomy (MIE) as a treatment for patients with esophageal cancer has recently become more common worldwide. However, differences in the pattern of recurrence between MIE and open esophagectomy (OE) using the transthoracic approach have not been fully investigated, particularly in patients treated with neoadjuvant chemotherapy. METHODS We searched the prospective databases of two institutes for patients with esophageal cancer who underwent neoadjuvant chemotherapy followed by esophagectomy between 2011 and 2018. Propensity score-matched analysis was performed to reduce bias from confounding patient-related variables. Operative outcomes, regionally harvested lymph nodes (LNs), recurrence pattern, and prognosis were investigated in two groups. RESULTS We identified 410 patients who underwent OE (n = 263) and MIE (n = 147). After propensity score matching, 131 pairs of patients were selected. There were no significant differences in baseline characteristics after matching. The total number of harvested LNs in both groups was similar (55.1 vs. 58.9, P = 0.132). The incidence of LN recurrence in the MIE group was significantly lower than that in the OE group (27% vs. 15%, P = 0.010). In particular, the incidence of mediastinal LN recurrence in the MIE group was significantly lower than that in the OE group (16% vs. 6%, P = 0.017). There were no significant differences between the two groups in hematogenous (19% vs.12%, P = 0.173), dissemination (5% vs. 4%, P = 0.769), local (4% vs. 1%. P = 0.213), and other recurrence (3% vs. 3%, P = 1.000). The 3-year disease-free and overall survival of MIE were significantly better than OE (71.4% vs. 50.5%, P = 0.004 and 80.3% vs. 61.2%, P = 0.002, respectively). Multivariate analysis showed that the thoracic approach (OE vs. MIE) (HR 1.93, P = 0.004) was an independent prognostic factor, along with the pathological N stage (HR 3.05, P < 0.001). CONCLUSIONS MIE has less intramediastinal LN recurrence than OE and may lead to a better long-term prognosis in patients with advanced esophageal cancer who underwent neoadjuvant chemotherapy.
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Dolan JP, McLaren PJ, Diggs BS, Schipper PH, Tieu BH, Sheppard BC, Gilbert EW, Conroy MA, Hunter JG. Evolution in the Treatment of Esophageal Disease at a Single Academic Institution: 2004-2013. J Laparoendosc Adv Surg Tech A 2017; 27:915-923. [PMID: 28486000 DOI: 10.1089/lap.2017.0069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Management of benign and malignant esophageal disease has changed rapidly over the past decade. The aim of this study was to analyze evolution in surgical management of esophageal disease at a single academic medical center during this period. MATERIALS AND METHODS We reviewed a retrospective cohort of patients who underwent esophagectomy between 2004 and 2013. Patient, institutional, treatment, and outcomes variables were reviewed. RESULTS 317 patients were analyzed. Median age was 63.5 years; 80% were male. Average inhospital mortality rate was 3.8%. Operative indications changed significantly from 2004 to 2013, with more operations performed for invasive malignancy (77% vs. 95%) and fewer for high-grade dysplasia (12% vs. 3%, P = .008). In 2004, Ivor Lewis esophagectomy was the most common surgical technique, but the three-field technique was the operation of choice in 2013. A minimally invasive approach was used in 19% of cases in 2004 and 100% of cases in 2013 (P < .001). Anastomotic leak ranged from 0% to 21% with no significant difference over the study period (P = .18). Median lymph node harvest increased from seven to 18 nodes from 2004 to 2013 (P = .001). Hospital length of stay decreased from 15 to 8 days (P = .001). In 2013, 79% of patients were discharged to home, compared to 73% in 2004 (P = .04). DISCUSSION Over the last decade, our treatment of esophageal disease has evolved from a predominantly open Ivor Lewis to a minimally invasive three-field approach. Operations for malignancy have also increased dramatically. Postoperative complications and mortality were not significantly changed, but were consistently low during the latter years of the study.
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Affiliation(s)
- James P Dolan
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Patrick J McLaren
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Brian S Diggs
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Paul H Schipper
- 2 Division of Cardiothoracic Surgery, Section of General Thoracic Surgery, Department of Surgery, Oregon Health & Science University , Portland, Oregon
| | - Brandon H Tieu
- 2 Division of Cardiothoracic Surgery, Section of General Thoracic Surgery, Department of Surgery, Oregon Health & Science University , Portland, Oregon
| | - Brett C Sheppard
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Erin W Gilbert
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Molly A Conroy
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - John G Hunter
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
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Dolan JP, Kaur T, Diggs BS, Luna RA, Sheppard BC, Schipper PH, Tieu BH, Bakis G, Vaccaro GM, Holland JM, Gatter KM, Conroy MA, Thomas CA, Hunter JG. Significant understaging is seen in clinically staged T2N0 esophageal cancer patients undergoing esophagectomy. Dis Esophagus 2016; 29:320-5. [PMID: 25707341 DOI: 10.1111/dote.12334] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This study aimed to determine the impact of preoperative staging on the treatment of clinical T2N0 (cT2N0) esophageal cancer patients undergoing esophagectomy. We reviewed a retrospective cohort of 27 patients treated at a single institution between 1999 and 2011. Clinical staging was performed with computed tomography, positron emission tomography, and endoscopic ultrasound. Patients were separated into two groups: neoadjuvant therapy followed by surgery (NEOSURG) and surgery alone (SURG). There were 11 patients (41%) in the NEOSURG group and 16 patients (59%) in the SURG group. In the NEOSURG group, three of 11 patients (27%) had a pathological complete response and eight (73%) were partial or nonresponders after neoadjuvant therapy. In the SURG group, nine of 16 patients (56%) were understaged, 6 (38%) were overstaged, and 1 (6%) was correctly staged. In the entire cohort, despite being clinically node negative, 14 of 27 patients (52%) had node-positive disease (5/11 [45%] in the NEOSURG group, and 9/16 [56%] in the SURG group). Overall survival rate was not statistically significant between the two groups (P = 0.96). Many cT2N0 patients are clinically understaged and show no preoperative evidence of node-positive disease. Consequently, neoadjuvant therapy may have a beneficial role in treatment.
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Affiliation(s)
- J P Dolan
- Department of Surgery, Digestive Health Center & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - T Kaur
- Department of Surgery, Digestive Health Center & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - B S Diggs
- Department of Surgery, Digestive Health Center & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - R A Luna
- Department of Surgery, Digestive Health Center & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - B C Sheppard
- Department of Surgery, Digestive Health Center & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - P H Schipper
- Department of Surgery, Division of Cardiothoracic Surgery & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - B H Tieu
- Department of Surgery, Division of Cardiothoracic Surgery & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - G Bakis
- Department of Medicine, Division of Gastroenterology & the Digestive Health Center, Oregon Health and Science University, Portland, Oregon, USA
| | - G M Vaccaro
- Department of Medicine, Division of Hematology & Medical Oncology, Oregon Health and Science University, Portland, Oregon, USA
| | - J M Holland
- Department of Radiation Medicine & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - K M Gatter
- Department of Pathology, Oregon Health and Science University, Portland, Oregon, USA
| | - M A Conroy
- Department of Surgery, Digestive Health Center & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - C A Thomas
- Department of Radiation Medicine & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - J G Hunter
- Department of Surgery, Digestive Health Center & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
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Rahmi G, Perretta S, Pidial L, Vanbiervliet G, Halvax P, Legner A, Lindner V, Barthet M, Dallemagne B, Cellier C, Clément O. A Newly Designed Enterocutaneous Esophageal Fistula Model in the Pig. Surg Innov 2016; 23:221-8. [PMID: 26989046 DOI: 10.1177/1553350616639144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Fistulas after esophagectomy are a significant cause of morbidity and mortality. Several endoscopic treatments have been attempted, with varying success. An experimental model that could validate new approaches such as cellular therapies is highly desirable. The aim of this study was to create a chronic esophageal enterocutaneous fistula model in order to study future experimental treatment options. Methods Eight pigs (six 35-kg young German and two 50-kg adult Yucatan pigs) were used. Through a left and right cervicotomy, under endoscopic view, 1 (group A, n = 6) or 2 (group B, n = 7) plastic catheters were introduced into the esophagus 30 cm from the dental arches bilaterally and left in place for 1 month. Radiologic and endoscopic fistula tract evaluations were performed at postoperative day (POD; 30) and at sacrifice (POD 45). Results Three fistulas were excluded from the study because of early (POD 5) dislodgment of the catheter, with complete fistula closure. At catheter removal (POD 30), the external orifice was larger in group B (5.2 ± 1.1 mm vs 2.6 ± 0.4 mm) with more severe inflammation (72% vs 33%). At POD 45, the external orifice was closed in all fistulas in group A and in 1/7 in group B. At necropsy, the fistula tract was still present in all animals. Yucatan pigs showed more complex tracts, with a high level of necrosis and substantial fibrotic infiltration. Conclusions In this article, we show a reproducible, safe, and effective technique to create an esophagocutaneous fistula model in a large experimental animal.
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Affiliation(s)
- Gabriel Rahmi
- Laboratoire Imagerie de l'Angiogénèse, Plateforme d'Imagerie du Petit Animal, INSERM U970, Université Paris Descartes, Paris, France Gastroenterology and Endoscopy Department, Hôpital Européen Georges Pompidou, APHP, Paris, France INSERM U633, Laboratory of Biosurgical Research, Paris, France
| | - Silvana Perretta
- Department of Digestive and Endocrine Surgery, Nouvel Hôpital Civil, Institut de Recherche contre les Cancers de l'Appareil Digestif (IRCAD), Strasbourg, France Minimally Invasive Hybrid Surgical Institute, Strasbourg, France
| | - Laetitia Pidial
- Laboratoire Imagerie de l'Angiogénèse, Plateforme d'Imagerie du Petit Animal, INSERM U970, Université Paris Descartes, Paris, France INSERM U633, Laboratory of Biosurgical Research, Paris, France
| | - Geoffroy Vanbiervliet
- University Hospital of Nice, Nice, France Centre d'Enseignement et de Recherche Chirurgical (CERC), Aix-Marseille University, Marseille, France
| | - Peter Halvax
- Department of Digestive and Endocrine Surgery, Nouvel Hôpital Civil, Institut de Recherche contre les Cancers de l'Appareil Digestif (IRCAD), Strasbourg, France Minimally Invasive Hybrid Surgical Institute, Strasbourg, France
| | - Andras Legner
- Department of Digestive and Endocrine Surgery, Nouvel Hôpital Civil, Institut de Recherche contre les Cancers de l'Appareil Digestif (IRCAD), Strasbourg, France Minimally Invasive Hybrid Surgical Institute, Strasbourg, France
| | | | - Marc Barthet
- Centre d'Enseignement et de Recherche Chirurgical (CERC), Aix-Marseille University, Marseille, France Department of Gastroenterology, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Bernard Dallemagne
- Department of Digestive and Endocrine Surgery, Nouvel Hôpital Civil, Institut de Recherche contre les Cancers de l'Appareil Digestif (IRCAD), Strasbourg, France Minimally Invasive Hybrid Surgical Institute, Strasbourg, France
| | - Christophe Cellier
- Gastroenterology and Endoscopy Department, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Olivier Clément
- Laboratoire Imagerie de l'Angiogénèse, Plateforme d'Imagerie du Petit Animal, INSERM U970, Université Paris Descartes, Paris, France Gastroenterology and Endoscopy Department, Hôpital Européen Georges Pompidou, APHP, Paris, France
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Dolan JP, Kaur T, Diggs BS, Luna RA, Schipper PH, Tieu BH, Sheppard BC, Hunter JG. Impact of comorbidity on outcomes and overall survival after open and minimally invasive esophagectomy for locally advanced esophageal cancer. Surg Endosc 2013; 27:4094-103. [PMID: 23846365 PMCID: PMC7102391 DOI: 10.1007/s00464-013-3066-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 06/06/2013] [Indexed: 01/10/2023]
Abstract
Background The aim of this study was to examine the impact of the Charlson Comorbidity Index-Grade (CCI-G) on predicting outcomes and overall survival after open and minimally invasive esophagectomy (MIE). Methods One hundred and forty-six patients who underwent esophagectomy between 1995 and 2011 for stage II and III cancer were selected and separated into open esophagectomy (Open) and MIE groups. Risk adjustment was performed using the CCI-G. The outcomes of interest were operative time, estimated blood loss (EBL), lymph node harvest, length of hospital stay (LOS), major complications, 30-day mortality, and overall survival. Results Sixty-four patients (44 %) underwent Open while 71 (49 %) had MIE. An additional (7 %) were converted and classified with MIE. There was no significant difference between MIE and Open in terms of operative time. MIE had less EBL (mean difference = 234 mL, p < 0.001), higher lymph node harvest (mean = 7.4 nodes, p < 0.001), and shorter LOS (median = 1.5 days, p = 0.02). Atrial arrhythmias were the most frequent complication, occurring in 33 % of patients in both the MIE and the Open group (p = 0.988). Thirty-day mortality was 2 % for MIE and 5 % for Open (p = 0.459). Five-year survival was 41 % for MIE and 33 % for Open (p = 0.513). Operative approach, age, gender, BMI, clinical stage, and neoadjuvant therapy did not have any significant effect on the outcomes or overall survival. CCI-G influenced outcomes with operative time, LOS, cardiovascular complication, and anastomotic leak rate, favoring CCI-G 0 compared to CCI-G 3. Overall survival was worse for CCI-G 1 in comparison with CCI-G 0 [hazard ratio (HR) 1.99, p = 0.027]. Conclusions MIE is a safe alternative to open esophagectomy for the treatment of locally advanced esophageal cancer. The presence of comorbidities increased operative time, length of hospital stay, and postoperative complications while worsening overall survival.
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Affiliation(s)
- James P Dolan
- Division of Gastrointestinal and General Surgery, Department of Surgery, and the Digestive Health Center, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L223A, Portland, OR, 97239, USA,
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