Evaluation of post-operative surveillance strategies for esophageal and gastric cancers: a systematic review and meta-analysis

Renal metastasis from esophageal adenocarcinoma: A rare recurrence

Esophageal cancer, consisting primarily of squamous cell carcinoma and adenocarcinoma pathology, is a leading cause of morbidity and mortality worldwide with rates of metastasis at time of diagnosis up to 50%. Renal metastasis is rare, with most pathological diagnosis yielding squamous cell carcinoma. We present the unique case of a 78-year-old man with biopsy proven adenocarcinoma metastasis to the kidney on routine surveillance following initial esophagectomy, chemoradiation and adjuvant immunotherapy. Imaging features of the solitary renal metastasis highly mimicked a primary renal cell carcinoma. Additional unique features included renal pelvis invasion and disease recurrence despite adjuvant immunotherapy. This case underscores the role of routine surveillance in this patient population, varied radiologic appearance, and importance for pathologic diagnosis.

Does Thoracic Duct Ligation at the Time of Esophagectomy Impact Long-Term Survival? An Individual Patient Data Meta-Analysis

Background: Thoracic duct ligation (TDL) during esophagectomy has been proposed to reduce the risk of postoperative chylothorax. Because of its role in immunoregulation, some authors argued that it had an unfavorable TDL effect on survival. The aim of this study was to analyze the effect of TDL on overall survival (OS). Methods: PubMed, MEDLINE, Scopus, and Web of Science were searched through December 2023. The primary outcome was 5-year OS. The restricted mean survival time difference (RMSTD), hazard ratios (HRs), and 95% confidence intervals (CI) were used as pooled effect size measures. The GRADE methodology was used to summarize the certainty of the evidence. Results: Five studies (3291 patients) were included. TDL was reported in 54% patients. The patients' age ranged from 49 to 69, 76% were males, and BMI ranged from 18 to 26. At the 5-year follow-up, the combined effect from the multivariate meta-analysis is -3.5 months (95% CI -6.1, -0.8) indicating that patients undergoing TDL lived 3.5 months less compared to those without TDL. TDL was associated with a significantly higher hazard for mortality at 12 months (HR 1.54, 95% CI 1.38-1.73), 24 months (HR 1.21, 95% CI 1.12-1.35), and 28 months (HR 1.14, 95% CI 1.02-1.28). TDL and noTDL seem comparable in terms of the postoperative risk for chylothorax (RR = 0.66; p = 0.35). Conclusions: In this study, concurrent TDL was associated with reduced 5-year OS after esophagectomy. This may suggest the need of a rigorous follow-up within the first two years of follow-up.

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.

Clinical Utility of 18F-2-Fluoro-deoxy-d-glucose PET Imaging in Locally Advanced Esophageal/Gastroesophageal Junction Adenocarcinoma

Esophageal adenocarcinoma, including adenocarcinoma of the gastroesophageal junction, is uncommon in the United States, but is associated with a rising incidence in young adults, and has a traditionally poor prognosis. Despite the incremental benefits that have been made with multimodality approaches to locally advanced disease, most patients will go on to develop metastatic disease, and long-term outcomes remain suboptimal. Over the last decade, PET-CT has emerged as a key tool in the management of this disease, with several prospective and retrospective studies evaluating its role in this disease. Herein, we review the key data pertaining to the use of PET-CT in the management of locally advanced esophageal and GEJ adenocarcinoma, with a focus on staging, prognostication, PET-CT adapted therapy in the neoadjuvant setting, and surveillance.

Quality performance indicator compliance for the treatment of gastric adenocarcinoma

BACKGROUND

Quality performance indicators (QPI) are objective measurements of aspects of patient care that affect clinical outcome. This study investigates the compliance rate to published QPIs of gastric adenocarcinoma (GA) management, in a single institution, to determine areas of strong performance and those requiring improvement.

METHODS

All patients with GA treated from 2010 to 2015, and 2020 to 2021 were included. Electronic data in the form of clinic letters, operation notes, and histology and radiology reports were reviewed with ethics approval. QPI adherence was collected in binary form.

RESULTS

QPIs with high compliance rate include preoperative radiological staging and histological diagnosis, subspecialty surgeon training and pathology report documentation. QPIs with low compliance include perioperative chemotherapy (31.6%), postoperative radiological surveillance (32.5%) and minimally invasive approaches to surgical resection (12.5%).

CONCLUSIONS

QPIs from the systematic review are variably implemented in clinical practice, thus informing on their relevance to real world clinical practice whilst also identifying the areas requiring focus for improvement.

Detection of asymptomatic recurrence following curative surgery improves survival in patients with gastric cancer: A systematic review and meta-analysis

Background

To date, there is no evidence that intensive follow-up provides survival benefit in gastric cancer patients undergoing curative gastrectomy. The aim of this study is to investigate the efficacy of detection of asymptomatic recurrence using intensive surveillance strategy in long-term survival after curative gastric cancer surgery.

Methods

A systematic review of electronic databases including PubMed, Embase, Web of Science, the Cochrane Library and China National Knowledge Infrastructure, Clinical Trials Registry and Google Scholar was performed up to April 2022. The primary outcomes were survival outcomes: overall survival, recurrence-free survival and post-recurrence survival. The secondary endpoints were clinicopathological features, recurrence patterns and treatment after recurrence. The registration number of this protocol is PROSPERO CRD42022327370.

Results

A total of 11 studies including 1898 participants were included. In the pooled analysis, the detection of asymptomatic recurrence was significantly associated with an improved overall survival compared to patients showing symptoms of recurrence (HR=0.67; 95%CI: 0.57-0.79; P<0.001), which was primarily driven by the prolongation of post-recurrence survival (HR=0.51; 95%CI: 0.42-0.61; P<0.001), since there was no significant difference observed in recurrence-free survival (HR=1.12; 95%CI: 0.81-1.55; P=0.48) between the two groups. Meanwhile, male sex and advanced T stage were more frequently observed in the symptomatic recurrence group. Furthermore, patients in the symptomatic recurrence group had a higher proportion of peritoneal relapse but lower proportion of distant lymph node metastasis. Additionally, patients in the symptomatic recurrence group were less likely to receive surgery treatment and post-recurrence chemotherapy.

Conclusion

The detection of asymptomatic recurrence using intensive follow-up was associated with an appreciable improvement in overall survival. However, more robust data from high-quality studies are still required to verify this issue.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=327370, identifier CRD42022327370.