Mortality and morbidity rates, postoperative course, quality of life, and prognosis after extended radical lymphadenectomy for esophageal cancer. Comparison of three-field lymphadenectomy with two-field lymphadenectomy

The seven-day cumulative post-esophagectomy inflammatory response predicts cancer recurrence

BACKGROUND

The relationship between postoperative cumulative systemic inflammation and cancer survival needs to be investigated. We developed an approach to the prognostication of postoperative esophageal cancer by establishing low and high cut-off values for the C-reactive protein (CRP) area under the curve (AUC) at 7 and 14 days after esophagectomy.

METHODS

One hundred and twenty-five consecutive patients with biopsy-proven invasive esophageal squamous cell carcinoma (SCC) who underwent esophagectomies were evaluated. Postoperative CRP levels were analyzed for the first 14 days after surgery. The AUC on days 7 and 14 were calculated and compared with clinicopathological features and survival. The cut-off values for CRP at 7 days (CRP 7 d) and 14 days (CRP 14 d) were 599 mg/L and 1153 mg/L, respectively.

RESULTS

The patients in the low CRP 7 d group had significantly better recurrence-free survival (RFS) and overall survival (OS), not that in the low CRP 14d group. The OS rates in the high CRP groups at PODs 1, 3, 10, and 14 were significantly lower than those in the low CRP groups. Postoperative complications were more common in the high CRP groups on PODs 3, 10, and 14. Univariate analyses revealed that pTNM stage, depth of tumor invasion, tumor location, lymph node involvement, and CRP 7 d were significant prognostic factors for both OS and RFS. The Cox proportional hazards model identified pTNM, tumor location, and CRP 7d as independent prognostic factors for the RFS and OS.

CONCLUSIONS

Early prediction of patients with postoperative complications, and adequate management will suppress the elevation of CRP 7 d and further suppress the CRP value in the late postoperative period, which may improve the prognosis of esophageal cancer patients after esophagectomy.

Impact of Metastatic Lymph Nodes on Survival of Patients with pN1-Category Esophageal Squamous Cell Carcinoma: A Long-Term Survival Analysis

BACKGROUND

The morbidity and mortality rates of esophageal squamous cell carcinoma (ESCC) are high in China. The overall survival (OS) of patients with ESCC is related to lymph node (LN) metastasis (LNM). This study aimed to discuss the impact of metastasis in LN stations on the OS of patients with pathologic N1 (pN1) ESCC.

METHODS

Data were obtained from the Esophageal Cancer Case Management database of Sichuan Cancer Hospital and Institute (SCCH-ECCM). Additionally, data of patients with pN1-category ESCC collected between January 2010 and December 2017 were retrospectively analyzed.

RESULTS

Data from 807 patients were analyzed. The median OS of the patients with one metastatic LN (group 1) was 49.8 months (95 % confidence interval [CI], 30.8-68.9 months), whereas the OS of those with two metastatic LNs (group 2) was only 33.3 months (P = 0.0001). Moreover, group 1 did not show a significantly longer OS than group 2.1 (patients with 2 metastatic LNs in 1 LNM station; P = 0.5736), but did show a significantly longer OS than group 2.2 (patients with 2 metastatic LNs in 2 LNM stations; P < 0.0001). After propensity score-matching, the 5-year survival rate for group 1 was 28 %, whereas that for group 2 was 14 % (P = 0.0027).

CONCLUSIONS

The OS for the patients with one metastatic LN in one LNM was not significantly longer than for the patients with two metastatic LNs in one LNM station. Patients with one LNM station had a significantly longer OS than those with two LNM stations. Thus, the number of LNM stations is a significant determinant of OS in pN1 ESCC.

Exploration of lymph node recurrence patterns and delineation guidelines of radiation field in middle thoracic oesophageal carcinomas after radical surgery: a real-world study

BACKGROUND

Oesophageal squamous cell carcinoma is one of the most commonly diagnosed carcinomas in China, and postoperative radiotherapy plays an important role in improving the prognosis of patients. Carcinomas in different locations of the oesophagus could have different patterns of lymph node metastasis after surgery.

METHODS

In this multicentric retrospective study, we enrolled patients with middle thoracic oesophageal squamous cell carcinomas from 3 cancer centres, and none of the patients underwent radiotherapy before or after surgery. We analysed the lymph node recurrence rates in different stations to explore the postoperative lymphatic recurrence pattern.

RESULTS

From January 1st, 2014, to December 31st, 2019, 132 patients met the criteria, and were included in this study. The lymphatic recurrence rate was 62.1%. Pathological stage (P = 0.032) and lymphadenectomy method (P = 0.006) were significant predictive factors of lymph node recurrence. The recurrence rates in the supraclavicular, upper and lower paratracheal stations of lymph nodes were 32.6%, 28.8% and 16.7%, respectively, showing a high incidence. The recurrence rate of the subcarinal node station was 9.8%, while 8.3% (upper, middle and lower) thoracic para-oesophageal nodes had recurrences.

CONCLUSIONS

We recommend including the supraclavicular, upper and lower paratracheal stations of lymph nodes in the postoperative radiation field in middle thoracic oesophageal carcinomas. Subcarinal station is also potentially high-risk, while whether to include thoracic para-oesophageal or abdominal nodes needs careful consideration.

Effect of cervical paraesophageal lymph node metastasis versus supraclavicular lymph node metastasis on the overall survival of patients with thoracic esophageal squamous cell carcinoma: an observational study

Background

Esophageal cancer (EC) is a major global health burden, with a particularly high incidence in East Asia. The authors aimed to investigate the effect of metastasis in cervical paraesophageal lymph nodes (station 101) and supraclavicular lymph nodes (station 104) on the survival of patients who underwent esophagectomy for esophageal squamous cell carcinoma (ESCC).

Materials and Methods

Data were obtained from the database of the authors' hospital. The authors retrospectively analyzed the patients with EC who underwent esophagectomy from January 2010 to December 2017. These patients were allocated into two groups based on the presence of lymph node metastasis (LNM) in the cervical paraesophageal or supraclavicular regions. Clinical outcomes and survival data were compared using the TNM staging system of the 8th edition of the American Joint Committee on Cancer (AJCC).

Results

After a median follow-up of 62.1 months, 122 patients with LNM in the supraclavicular region were included in the study. Among these patients, 53 showed cervical paraesophageal LNM and an overall survival (OS) of 19.9 months [95% confidence interval (CI): 16.3-23.5]. In contrast, 69 patients showed supraclavicular LNM with an OS of 34.9 months (95% CI 25.7-44.1). The OS rates at 1, 3, and 5 years were 77%, 29%, and 21%, respectively, for patients with cervical paraesophageal LNM. Moreover, patients with supraclavicular LNM demonstrated OS rates of 88%, 48%, and 34%, respectively [Hazard ratio (HR): 0.634, 95% CI: 0.402-1.000, P=0.042].

Conclusions

Patients with ESCC with cervical paraesophageal LNM had significantly worse OS than those with supraclavicular LNM. This study underscores the importance of accurately identifying and managing ESCC with cervical paraesophageal LNM, as it may require more tailored and aggressive treatment strategies to prolong patient survival.

Anatomical and anastomotic viability indexes for stratifying the risk of anastomotic leakage in esophagectomy with retrosternal reconstruction

Background

Risk prediction of anastomotic leakage using anatomical and vascular factors has not been well established. This study aimed to assess the anatomical and vascular factors affecting the hemodynamics of the gastric conduit and develop a novel risk stratification system in patients undergoing esophagectomy with retrosternal reconstruction.

Methods

This retrospective cohort study analyzed 202 patients with esophageal cancer who underwent subtotal esophagectomy with gastric tube retrosternal reconstruction between January 2008 and December 2020. Risk factors for anastomotic leakage (AL), including the anatomical index (AI) and anastomotic viability index (AVI), were evaluated using a logistic regression model.

Results

According to the logistic regression model, the independent risk factors for AL were preoperative body mass index ≥23.6 kg/m2 (odds ratio [OR], 7.97; 95% confidence interval [CI], 2.44-26.00; P < 0.01), AI <1.4 (OR, 23.90; 95% CI, 5.02-114.00; P < 0.01), and AVI <0.62 (OR, 8.02; 95% CI, 2.57-25.00; P < 0.01). The patients were stratified into four AL risk groups using AI and AVI as follows: low-risk group (AI ≥1.4, AVI ≥0.62 [2/99, 2.0%]), intermediate low-risk group (AI ≥1.4, AVI <0.62 [2/29, 6.9%]), intermediate high-risk group (AI <1.4, AVI ≥0.62 [8/53, 15.1%]), and high-risk group (AI <1.4, AVI <0.62 [11/21, 52.4%]).

Conclusion

The combination of AI and AVI strongly predicted AL. Additionally, the use of AI and AVI enabled the stratification of the risk of AL in patients who underwent esophagectomy with retrosternal reconstruction.

Three-Field Versus Two-Field Lymphadenectomy in Minimally Invasive Esophagectomy: 3-Year Survival Outcomes of a Randomized Trial

BACKGROUND

Minimally invasive esophagectomy (MIE) has been used widely for the treatment of esophageal cancer. However, the optimal extent of lymphadenectomy for esophagectomy in MIE remains unclear. This trial aimed to investigate the 3-year survival and recurrence outcomes in a randomized controlled trial comparing MIE with either three-field lymphadenectomy (3-FL) or two-field lymphadenectomy (2-FL).

METHODS

Between June 2016 and May 2019, 76 patients with resectable thoracic esophageal cancer were enrolled in a single-center randomized controlled trial and randomly assigned to MIE that included either 3-FL or 2-FL at a 1:1 ratio (n = 38 patients each). The survival outcomes and recurrence patterns were compared between the two groups.

RESULTS

The 3-year cumulative overall survival (OS) probability was 68.2 % (95 % confidence interval [CI], 52.72-83.68 %) for the 3-FL group and 68.6 % (95 % CI, 53.12-84.08 %) for the 2-FL group. The 3-year cumulative probability of disease-free survival (DFS) was 66.3 % (95 % CI, 50.03-82.57 %) for the 3-FL group and 67.1 % (95 % CI, 51.03-83.17 %) for the 2-FL group.. The OS and DFS differences in the two groups were comparable. The overall recurrence rate did not differ significantly between the two groups (P = 0.737). The incidence of cervical lymphatic recurrence in the 2-FL group was higher than in the 3-FL group (P = 0.051).

CONCLUSIONS

Compared with 2-FL in MIE, 3-FL tended to prevent cervical lymphatic recurrence. However, it was not found to add survival benefit for the patients with thoracic esophageal cancer.

Minimally invasive versus open esophagectomy for resectable thoracic esophageal cancer (NST 1502): a multicenter prospective cohort study

Background

Whether minimally invasive esophagectomy (MIE) is superior to open esophagectomy (OE) in the treatment of esophageal squamous cell carcinoma (ESCC) is still uncertain. Therefore, this multicenter prospective study aimed to compare MIE with OE in postoperative parameters and long-term survival.

Methods

All hospitalized patients with cT1b-3N0-1M0 thoracic ESCC treated by MIE or OE were enrolled from 19 selected centers from April 1, 2015 to December 31, 2018. The propensity score matching (PSM) was performed to minimize the selection bias. The basic clinicopathological characteristics and 3-year overall survival (OS) as well as disease-free survival (DFS) of two groups were compared by R version 3.6.2.

Results

MIE were performed in 1,387 patients and OE in 335 patients. 335 cases in each group were finally matched by PSM, and no significant differences in the essential demographic characteristics were observed between the MIE and OE groups after PSM. Compared with OE, MIE had significantly less intraoperative bleeding, less total drainage volume, shorter postoperative hospital stay, and harvested significantly more lymph nodes (LNs) (all P < 0.001). There were no significant differences in the major postoperative complications and death rates between MIE and OE. The 3-year OS and DFS were 77.0% and 68.1% in the MIE group versus 69.3% and 60.9% in the OE group (OS: P = 0.03; DFS: P = 0.09), and the rates were 75.1% and 66.5% in the MIE group versus 66.9% and 58.6% in the OE group for stage cII patients (OS: P = 0.04, DFS: P = 0.09), respectively.

Conclusions

Compared with OE, MIE is a safe and effective treatment approach with similar mortality and morbidity. It has the advantages in harvesting more LNs, improving postoperative recovery and survival of stage cII ESCC patients.

Non-curative resection for surgical T4b esophageal cancer: esophagectomy or non-esophagectomy?

BACKGROUND

Recently, with the development of multidisciplinary treatment, the treatment outcomes of esophageal cancer (EC) have improved. However, despite advances in diagnostic imaging modalities, preoperative diagnosis of T4 EC is still difficult, and the prognosis of T4 EC remains very poor. In addition, the prognosis of surgical T4b EC (sT4b EC) after surgery remains unclear. In this study, we retrospectively reviewed sT4b EC.

METHODS

We evaluated the clinical course of sT4b EC and compared palliative esophagectomy with R2 resection (PE group) with other procedures without esophagectomy (NE group) (e.g., only esophagostomy) for sT4b EC.

RESULTS

Forty-seven patients with thoracic EC underwent R2 resection at our institution between January 2009 and December 2020. Thirty-four patients were in the PE group, and 13 patients were in the NE group. The 2-year overall survival rate was 0% in the PE group and 20.2% in the NE group (p = 0.882). There was one case of long-term survival in the NE group that underwent surgery followed by definitive chemoradiation. Postoperative complications (Clavien-Dindo grade ≥ 3) were observed in 25 patients (73.5%) in the PE group and in three patients (23.1%) in the NE group (p = 0.031). The median time to the initiation of postoperative treatment was 68.1 days in the PE group and 18.6 days in the NE group (p = 0191).

CONCLUSIONS

If EC is diagnosed as sT4b, palliative esophagectomy should be avoided because of the high complication rate and the lack of long-term survival.

Use of Indocyanine Green Fluorescence Imaging in Thoracic and Esophageal Surgery

BACKGROUND

Fluorescence imaging using indocyanine green in thoracic and esophageal surgery is gaining popularity because of the potential to facilitate surgical planning, to stage disease, and to reduce postoperative complications. To optimize use of fluorescence imaging in thoracic and esophageal surgery, an expert panel sought to establish a set of recommendations at a consensus meeting.

METHODS

The panel included 12 experts in thoracic and upper gastrointestinal surgery from Asia-Pacific countries. Before meeting, 7 focus areas were defined: intersegmental plane identification for sublobar resections; pulmonary nodule localization; lung tumor detection; bullous lesion detection; lymphatic mapping of lung tumors; evaluation of gastric conduit perfusion; and lymphatic mapping in esophageal surgical procedures. A literature search of the PubMed database was conducted using keywords indocyanine green, fluorescence, thoracic, surgery, and esophagectomy. At the meeting, panelists addressed each focus area by discussing the most relevant evidence and their clinical experiences. Consensus statements were derived from the proceedings, followed by further discussions, revisions, finalization, and unanimous agreement. Each statement was assigned a level of evidence and a grade of recommendation.

RESULTS

A total of 9 consensus recommendations were established. Identification of the intersegmental plane for sublobar resections, localization of pulmonary nodules, lymphatic mapping in lung tumors, and assessment of gastric conduit perfusion were applications of fluorescence imaging that have the most robust current evidence.

CONCLUSIONS

Based on best available evidence and expert opinions, these consensus recommendations may facilitate thoracic and esophageal surgery using fluorescence imaging.

The Influence of Preoperative Smoking Status on Postoperative Complications and Long-Term Outcome Following Thoracoscopic Esophagectomy in Prone Position for Esophageal Carcinoma

BACKGROUND

Esophagectomy for esophageal carcinoma is associated with higher morbidity and mortality rates than other gastrointestinal surgeries. Smoking is an established risk factor for postoperative complications after esophagectomy. This study aimed retrospectively to investigate the impact of smoking status on short- and long-term outcomes for patients undergoing thoracoscopic esophagectomy in the prone position (TEP) for esophageal carcinoma.

METHODS

In this study, 234 patients with esophageal carcinoma who underwent TEP between 2012 and 2020 were divided into two groups based on smoking status (current or non-current smokers and the Brinkman index) by patients' declarations. Postoperative complications (Clavien-Dindo classification grade ≥2), overall survival (OS), and disease-free survival (DFS) were compared between smoking statuses.

RESULTS

The rates of postoperative complications did not differ significantly between the two groups (current smoker vs non-current smoker; Brinkman index ≥800 vs <800). The rate of postoperative pneumonia was higher in the combination group of current and higher Brinkman index (≥800) smokers than in the other group (25.0 % vs 11.8 %; P = 0.036). Multivariate analysis showed that smoking status was an independent risk factor for postoperative pneumonia (hazard ratio, 0.41; 95 % confidence interval, 0.18-0.93; P = 0.037). According to the long-term outcomes, no significant differences in OS and DFS were observed between the smoking statuses.

CONCLUSIONS

The combination of current smoking and heavy smoking history is a risk factor for postoperative pneumonia in patients who have esophageal carcinoma treated with TEP, although no correlation was observed between the long-term outcomes and smoking status.

Clinical advantage of transmediastinal esophagectomy in terms of postoperative respiratory complications

BACKGROUND

Although the transmediastinal approach as a radical esophagectomy for esophageal carcinoma patients has attracted attention, its advantages over the transthoracic approach remain unclear. This study aimed to evaluate the efficacy of transmediastinal esophagectomy (TME) in terms of postoperative respiratory complications compared to that of open transthoracic esophagectomy (TTE).

METHODS

We reviewed patients with thoracic and abdominal esophageal carcinoma who underwent TME or TTE between February 2014 and November 2021. We compared postoperative respiratory complications as the primary outcome. The secondary outcomes included perioperative operation time, blood loss, postoperative complications, and the number of harvested mediastinal lymph nodes.

RESULTS

Overall, 60 and 54 patients underwent TME and TTE, respectively. The baseline characteristics were similar between the two groups, except for age and histological type. There were no intraoperative lethal complications in either group. The incidence of respiratory complications was significantly lower in the TME group than in the TTE group (6.7 vs. 22.2%, p = 0.03). The TME group had a shorter operation time (403 vs. 451 min, p < 0.01), less blood loss (107 vs. 253 mL, p < 0.01), and slightly higher anastomotic leakage (11.7 vs. 5.6%, p = 0.33). The number of harvested lymph nodes was similar in both groups (24 vs. 26, p = 0.10). Multivariate analysis revealed that TME is an independent factor in reducing respiratory complications (odds ratio = 0.27, p = 0.04).

CONCLUSIONS

TME for esophageal carcinoma was performed safely. TME was superior to TTE in terms of postoperative respiratory complications; however, the relatively higher frequency of anastomotic leakage should be considered and requires further evaluation.

Short- and long-term outcomes of thoracoscopic esophagectomy in the prone position for esophageal squamous cell carcinoma in patients with obstructive ventilatory disorder: a propensity score-matched study

BACKGROUND

Many patients with esophageal squamous cell carcinoma (ESCC) have obstructive ventilatory disorder (OVD), which is considered a risk factor for postoperative pneumonia. It has been reported that thoracoscopic esophagectomy in the prone position (TEP) is less invasive and is associated with fewer postoperative respiratory complications compared with open esophagectomy. This matched-cohort study aimed to elucidate the safety and oncologic outcomes of ESCC patients with OVD who undergo TEP.

METHODS

In this matched-cohort study, 237 patients with ESCC who underwent TEP between 2010 and 2018 were divided into two groups based on forced expiratory volume in 1 s/forced vital capacity. Postoperative complications (Clavien-Dindo classification grade II or higher), overall survival (OS), and disease-free survival (DFS) were compared between the two groups.

RESULTS

Based on their propensity scores, 75 patients with normal respiratory function (NRF) and 75 with OVD were selected. The rates of postoperative pneumonia were not significantly different between the two groups (NRF group vs OVD group: 18.7% vs 18.7%; P = 1.000). The rates of recurrent laryngeal nerve palsy and anastomotic leakage were also not significantly different (NRF group vs OVD group: 12.0% vs 18.7%, P = 0.365; 18.7% vs 18.7%, P = 1.000). The 5-year OS and DFS rates in the NRF vs OVD groups were 66.2% vs 54.9% and 63.5% vs 52.9%, respectively, with no significant differences (P = 0.421, 0.197).

CONCLUSIONS

TEP can be safely performed on ESCC patients with OVD and can result in an oncological efficiency equal to that of the NRF group.

Early volume loss of skeletal muscle after esophagectomy: a risk for late-onset postoperative pneumonia

Late-onset postoperative pneumonia (LOPP) after esophagectomy is poorly understood. This study was designed to clarify the features and risk factors for this event. Patients who underwent esophagectomy for esophageal cancer between 2006 and 2016 were included. LOPP was defined as radiologically proven pneumonia that occurred over 3 months after surgery, and clinically relevant late-onset postoperative pneumonia (CR-LOPP) was defined as LOPP that required administration of oxygen and antibiotics in the hospital and/or more intensive treatment. The total psoas muscle area (TPA) was measured using preoperative and postoperative (at 3 months after surgery) computed tomography scan images. Potential risk factors for CR-LOPP were investigated. Among 175 study patients, 46 (26.3%) had LOPP, 29 (16.6%) of whom exhibited CR-LOPP with a cumulative incidence of 15.6% at 3 years and 22.4% at 5 years. Four (13.8%) of these patients died of LOPP. Univariable analysis showed that clinical stage ≥III (P = 0.005), preoperative prognostic nutritional index (PNI) <45 (P = 0.035), arrhythmia (P = 0.014), postoperative hospital stay ≥40 days (P = 0.003), and percent decrease of TPA more than 5% (P < 0.001) were associated with CR-LOPP but not early onset postoperative pneumonia. Multivariable analysis revealed that clinical stage ≥III (hazard ratio [HR] 3.01, P = 0.004), postoperative hospital stay ≥40 days (HR 2.51, P = 0.015), and percent decrease of TPA >5% (HR 9.93, P < 0.001) were independent risk factors for CR-LOPP. CR-LOPP occurred in over 20% of patients at 5 years, and early postoperative loss of TPA was a potential trigger for this delayed complication.

Initial Learning Curve and Stereotypical Use of Extra Arm During da Vinci Chest Procedures of McKeown Esophagectomy

Objective: McKeown esophagectomy facilitates extensive lymphadenectomy for the optimal management of esophageal cancer. Robot-assisted esophagectomy (RAE) was introduced in an attempt to reduce the incidence of postoperative complications. The da Vinci System has 3 active robotic arms in addition to the camera scope, and an extra robotic arm (ERA) is generally used to maintain a fine and stable operative field. However, the optimal use of an ERA has not been documented. In addition, the learning curve of the RAE using the da Vinci System remains controversial. In this study, we aimed to determine the optimal use of an ERA in association with the initial learning curve of robotic McKeown esophagectomy with extremely extensive lymphadenectomy. Methods: We reviewed 81 consecutive patients who underwent RAE. To determine whether stereotypical use of an ERA after establishment of its optimal use accounted for the learning curve, we measured the duration of 14 steps and the duration when performed with optimal use of an ERA in the corresponding step by reviewing video-recorded procedures. We then calculated the ratio as the degree of stereotypical use of the ERA during the da Vinci chest procedures. Results: The cumulative sum method showed that the learning curve required 27 cases of RAE. In addition, stereotypical use of the ERA was significantly associated with the learning curve of RAE. Conclusions: Establishment of optimal use of an ERA could help to accelerate the learning curve in da Vinci chest procedures during McKeown esophagectomy with extensive lymphadenectomy.

Intraoperative nerve monitoring during esophagectomy reduces the risk of recurrent laryngeal nerve palsy

BACKGROUND

Despite the risk of recurrent laryngeal nerve (RLN) palsy during esophagectomy, no established method of monitoring RLN injury is currently available.

METHODS

This study included 187 patients who underwent esophagectomy between 2011 and 2018. Among these, intraoperative nerve monitoring (IONM) was done in 142 patients (IONM group), while the remaining 45 patients underwent conventional surgery without IONM (control group). We investigated the incidence of postoperative complications with regard to the use of IONM.

RESULTS

The overall incidence of postoperative RLN palsy was 28% (52/187). The IONM group showed a significantly lower incidence of postoperative RLN palsy as compared to that in the control group (p = 0.004). The overall incidence of postoperative pneumonia was 22% (41/187) in those with Clavien-Dindo (CD) classification beyond grade 2. There were no significant differences between the incidence of any grade of postoperative pneumonia and the use of IONM (p = 0.195 and 0.333; CD > 2 and > 3, respectively). Multivariate analysis demonstrated that tumors in the upper third [odds ratio (OR) 3.12; 95% confidence interval (CI) 1.04-9.29] and lack of IONM use (OR 2.51; 95% CI 1.17-5.38) were independent factors causing postoperative RLN palsy after esophagectomy.

CONCLUSION

IONM helps to reduce the risk of postoperative RLN palsy after esophageal cancer surgery.

The role of magnetic anchoring and traction technique in thoracoscopic lymphadenectomy along the left recurrent laryngeal nerve

BACKGROUND

Dissecting lymph nodes along the left recurrent laryngeal nerve (LRLN) is the most challenging step in thoracoscopic-assisted esophagectomy. To retract the proximal esophagus in the existing lymphadenectomy methods, either a special trocar is required to insert and take out endoscopic instruments or thoracic punctures are needed to externally retract the esophageal loop. Therefore, advanced skills for esophageal traction are important to facilitate the LRLN lymphadenectomy and to reduce the incidence of trauma to the chest wall. Herein, we present the magnetic anchoring and traction technique, a novel method for LRLN lymphadenectomy during thoracoscopic esophagectomy.

METHODS

The magnetic anchoring traction system was successfully used to retract the upper thoracic esophagus and to help expose the upper mediastinum in 10 cases of thoracoscopic-assisted esophagectomy. When the external magnet was moved outside of body, the internal magnet was coupled with a magnetic force to pull the proximal esophagus to the appropriate direction, which helped to expose the LRLN and adjacent lymph nodes. The lymph nodes adjacent to the LRLN could then be dissected completely without any damage to the nerve.

RESULTS

In all surgeries, the LRLN and adjacent lymph nodes were well visualized, and the number of trocars used to pass endoscopic instruments for retraction of the proximal esophagus or the number of thoracic punctures for external traction of the esophagus during the surgery were reduced.

CONCLUSIONS

In thoracoscopic-assisted esophagectomy, the magnetic anchoring and traction technique can improve the exposure of the LRLN, facilitate LRLN lymphadenectomy, and reduce chest wall trauma.

Postoperative lymphatic recurrence distribution and delineation of the radiation field in lower thoracic squamous cell esophageal carcinomas: a real-world study

Background

To study lymphatic recurrence distribution after radical surgery in the real world and guide clinical tumor volume delineation for regional lymph nodes during postoperative radiotherapy for lower thoracic squamous cell esophageal carcinomas.

Methods

We enrolled patients who underwent radical esophagectomy, without radiation before or after surgery, at 3 cancer hospitals. Patients were classified into groups according to tumor locations. We included patients with tumors in the lower thoracic segment and analyzed the postoperative lymph node recurrence mode. A cutoff value of 10% was used to differentiate high-risk lymph node drainage areas from others.

Results

We enrolled 1905 patients in the whole study series, including 652 thoracic esophageal carcinomas that met our inclusion criteria; there were 241 cases of lower thoracic esophageal carcinomas. 1st, 2nd, 4th, 7th, 8th groups of lymph nodes, according to the 8th edition of the AJCC classification, displayed as high-risk recurrence areas, representing 17.8%, 23.9%, 11.7%, 10.9% and 12.2% of lymph node recurrence. Stage III-IV tumors located in the lower segment of the thoracic esophagus showed a tendency to recur in the left gastric nodes (7.9%) and celiac nodes (10.6%).

Conclusions

According to our results, we recommended including the 4th, 7th and 8th groups of lymph nodes in the radiation field, and for patients with stage III-IV disease, the 17th and 20th groups of nodes should be irradiated during postoperative treatment. Whether including 1st/2nd groups in preventive irradiation needed more proofs.

Advantages of McKeown minimally invasive oesophagectomy for the treatment of oesophageal cancer: propensity score matching analysis of 169 cases

BACKGROUND

Oesophagectomy, the gold standard for oesophageal cancer treatment, causes significantly high morbidity and mortality. McKeown minimally invasive oesophagectomy (MIE) is preferred for treating oesophageal malignancies; however, limited studies with large sample sizes focusing on the surgical and oncological outcomes of this procedure have been reported. We aimed to compare the clinical safety and efficacy of McKeown MIE with those of open oesophagectomy (OE).

PATIENTS AND METHODS

Overall, 338 oesophageal cancer patients matched by gender, age, location, size, and T and N stages (McKeown MIE: 169 vs OE: 169) were analysed. The clinicopathologic features, operational factors, postoperative complications, and prognoses were compared between the groups.

RESULTS

McKeown MIE resulted in less bleeding (200 mL vs 300 mL, p<0.01), longer operation time (335.0 h vs 240.0 h, p<0.01), and higher number of harvested lymph nodes (22 vs 9, p<0.01) than OE did. Although the rate of recurrent laryngeal nerve injury in the two groups was not significantly different, incidence of anastomotic leakage (8 vs 24, p=0.003) was significantly lower in the McKeown MIE group. In addition, patients who underwent McKeown MIE had higher 5-year overall survival than those who underwent OE (69.9% vs 40.4%, p<0.001).

CONCLUSION

McKeown MIE is proved to be feasible and safe to achieve better surgical and oncological outcomes for oesophageal cancer compared with OE.

Three-field versus two-field lymphadenectomy for esophageal squamous cell carcinoma: A long-term survival meta-analysis

BACKGROUND

In the setting of esophageal squamous cell carcinoma, controversy exists regarding the optimal extent of lymphadenectomy, while conclusive evidence regarding the advantages of 3-field versus 2-field lymphadenectomy remains controversial. The purpose of the present meta-analysis was to investigate the effect of 3-field lymphadenectomy versus 2-field lymphadenectomy on overall survival.

METHODS

Systematic review and meta-analyses were computed to compare 3-field lymphadenectomy versus 2-field lymphadenectomy in the setting of esophageal squamous cell carcinoma. Risk ratio, weighted mean difference, hazard ratio, and restricted mean survival time difference were used as pooled effect size measures.

RESULTS

Fourteen studies (3,431 patients) were included. Overall, 1,664 (48.8%) patients underwent 3-field lymphadenectomy, and 1,767 (51.5%) underwent 2-field lymphadenectomy. Three-field lymphadenectomy was associated with a significantly improved 5-year overall survival (hazard ratio: 0.80; 95% confidence interval 0.71-0.90; P < .001). The restricted mean survival time difference showed a statistically significant difference between 3-field lymphadenectomy versus 2-field lymphadenectomy up to 48 months (1.6 months; P = .04), however, no significant differences were found at 60-month follow-up (1.2 months; P = .14). No significant differences were found in term of postoperative mortality, anastomotic leak, pulmonary complications, chylothorax, and recurrent nerve palsy.

CONCLUSION

For resectable esophageal squamous cell carcinoma, 3-field lymphadenectomy seems associated with a slight trend toward improved 5-year overall survival; however, its clinical benefit remains limited.

Postoperative complications and perioperative management of lung resection in patients with a history of oesophagectomy for oesophageal carcinoma

 

OBJECTIVES

Advances in chemoradiation have improved the long-term prognosis of oesophageal cancer, although perioperative management for lung resection postoesophagectomy is unknown. The purpose of this study was to investigate postoperative complications and perioperative management for lung resection postoesophagectomy.

METHODS

Between 2002 and 2017, a total of 4694 patients underwent lung resections; of these, 79 were performed postoesophagectomy. Using propensity score matching, we analysed postoperative complications between groups with and without postoesophagectomy lung resection. We also investigated the risk factors of Clavien-Dindo classification grade ≥2 complications by logistic regression analysis.

RESULTS

Sixty-nine of the patients were men with a median age of 67 years. The types of lung resections were as follows: lobectomy in 34, segmentectomy in 12 and wedge resection in 33 patients. Postoperative complications were detected in 35 patients, including grade ≥2 complications in 24. After matching, aspiration pneumonia (P = 0.09) tended to be common in the postoesophagectomy group. Until 2008, non-fasting management before lung resection was performed in all 31, and intraoperative aspiration pneumonia was detected in 2 patients. After switching to fasting management before lung resection, there were no cases of intraoperative aspiration pneumonia. Multivariable analysis revealed that lung resection ipsilateral to oesophagectomy (P = 0.04) and lobectomy (P = 0.03) were predictors of grade ≥2 morbidity.

CONCLUSIONS

Patients having a lung resection postoesophagectomy tended to have a higher risk of aspiration pneumonia. Fasting management before lung resection is important in preventing intraoperative aspiration pneumonia. Lung resection ipsilateral to oesophagectomy and lobectomy may result in complications requiring therapeutic intervention.

Risk stratification of anastomotic leakage using eGFR and FIB-4 index in patients undergoing esophageal cancer surgery

PURPOSE

Renal insufficiency and liver cirrhosis are identified as independent risk factors for anastomotic leakage (AL) after esophagectomy. However, research evaluating the incidence of AL using quantitative data to measure renal function and liver fibrosis remain to be limited. Therefore, this study was conducted to evaluate postoperative AL after esophagectomy using estimated glomerular filtration rate (eGFR) and fibrosis-4 (FIB-4) index.

METHODS

In total, 184 patients who underwent esophagectomy were included in this study; then, they were divided into the non-AL group (n = 161) and AL group (n = 23), after which their background data and intraoperative and postoperative outcomes were compared. In addition, risk factors for AL were evaluated using a logistic regression model.

RESULTS

Preoperative body mass index of ≥21.5 kg/m², hemoglobin A1c level of ≥7.3%, FIB-4 index of ≥1.44, and eGFR of <59 ml/min/1.73 m² were found to be significantly frequent in the AL group compared with the non-AL group. Multivariate analysis revealed FIB-4 index of ≥1.44 (p = 0.013; OR, 3.780; 95% CI, 1.320-10.800) and eGFR of <59 ml/min/1.73 m² (p = 0.018; OR, 3.110; 95% CI, 1.220-8.020) as the independent risk factors for AL. In addition, we stratified the patients into three groups based on the incidence of AL as follows: low risk (5.5%, low FIB-4 index), intermediate risk (13.0%, high FIB-4 index and eGFR), and high risk (37.5%, high FIB-4 index and low eGFR).

CONCLUSION

Preoperative eGFR and FIB-4 index were found to be useful markers to predict AL after esophagectomy.

Comparison of the outcomes between total eversion and conventional triangulating stapling technique in cervical esophagogastric anastomosis after esophagectomy: a propensity score-matched analysis

BACKGROUND

Anastomotic leakage and stenosis remain major problems after esophageal reconstruction. This study evaluated the clinical outcomes between the total eversion (TE) triangulating stapling technique (TST) and conventional (C) TST.

METHODS

The study included 404 consecutive patients with esophageal cancer who underwent cervical esophagogastrostomy by TST between January 2013 and December 2018. The postoperative outcomes were compared between TE-TST and C-TST using propensity score-matched analysis.

RESULTS

Before matching, the cT stage and the cTNM stage were different between the groups. After matching, each group consisted of 128 patients. The patients' background characteristics were similar between the groups. Although the incidence of anastomotic leakage was similar between the groups (p = 0.216), anastomotic stricture occurred in 19 (14.8%) and 7 (5.5%) patients in the C-TST and the TE-TST groups, respectively (p = 0.021).

CONCLUSIONS

The incidence of anastomotic stenosis was significantly lower in the TE-TST group than in the C-TST group. TE-TST decreases the incidence of anastomotic stricture and can improve the quality of life in patients undergoing esophagectomy.

Prognostic Significance of Preoperative Osteopenia in Patients Undergoing Esophagectomy for Esophageal Cancer

BACKGROUND

Osteopenia, which exhibits low bone mineral density (BMD), has been linked to sarcopenia and recently reported as a prognostic factor in various cancers. However, the prognostic significance of osteopenia in esophageal cancer remains unclear. Hence, this study aimed to clarify the impact of osteopenia on the prognosis of patients undergoing esophagectomy for esophageal cancer.

METHODS

We included 229 patients who underwent esophagectomy. BMD was calculated as the average pixel density (Hounsfield unit) within a circle in midvertebral core at the 11th thoracic vertebra on preoperative computed tomography. We then divided the patients into the Osteopenia group (n = 159) and the Non-Osteopenia group (n = 70) according to the optimal cutoff value obtained from the receiver operating characteristic curve. Their clinicopathological data, prognosis, and recurrence were analyzed.

RESULTS

The mean age was significantly older in the Osteopenia group (p = 0.047). The Osteopenia group had significantly worse overall survival (OS) and relapse-free survival (RFS) than the Non-Osteopenia group (p = 0.001 and p = 0.012, respectively). Multivariate analysis revealed osteopenia was an independent prognostic factor for OS (p < 0.001; hazard ratio [HR], 2.243; 95% confidence interval [CI], 1.422-3.538) and RFS (p = 0.008; HR, 1.739; 95% CI, 1.154-2.620). In logistic regression model, advanced age and cStage III-IV were independent risk factors for preoperative osteopenia.

CONCLUSIONS

Preoperative osteopenia is associated with poor survival and recurrence in patients undergoing esophagectomy for esophageal cancer.

Photon Versus Proton Beam Therapy for T1-3 Squamous Cell Carcinoma of the Thoracic Esophagus Without Lymph Node Metastasis

Background and Purpose

We compared treatment outcomes and toxicities of photon radiotherapy versus proton beam therapy (PBT) and evaluated radiation field effects for T1–3 squamous cell carcinoma of the thoracic esophagus (EC) without lymph node metastasis.

Methods

Medical records of 77 patients with T1–3N0M0 thoracic EC treated with radiotherapy between 2011 and 2019 were retrospectively analyzed. Among these patients, 61 (79.2%) individuals had T1 EC. The initial clinical target volume encompassed the whole esophagus with or without supraclavicular and/or abdominal lymph nodes (extended-field radiotherapy; 67 patients, 87.0%) or the area 3–5 cm craniocaudally and 1–2 cm radially from the gross tumor volume (involved-field radiotherapy; 10 patients, 13.0%). The final clinical target volume included margins of at least 1 cm from the gross tumor volume, with total radiation doses of 50–66 (median, 66) cobalt gray equivalent. Three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, and PBT were used in twenty-four, five, and forty-eight patients, respectively. Concurrent chemotherapy was administered to 17 (22.0%) patients overall and only five (8.0%) T1 patients.

Results

PBT showed significantly lower lung and heart radiation exposure in mean dose, V5, V10, V20, and V30 than photon radiotherapy. The median follow-up for all patients was 46 (interquartile range, 22–72) months. The 5-year progression-free survival and overall survival rates were 56.5 and 64.9%, respectively, with no significant survival difference between photon radiotherapy and PBT. In patients with T1 EC, 5-year progression-free survival and overall survival rates were 62.6 and 73.5%, respectively.

Conclusions

Extended-field radiotherapy using modern radiotherapy techniques without chemotherapy showed satisfactory clinical outcomes for lymph node-negative T1 EC.

Preoperative computed tomography predicts the risk of recurrent laryngeal nerve paralysis in patients with esophageal cancer undergoing thoracoscopic esophagectomy in the prone position

BACKGROUND

Recurrent laryngeal nerve paralysis (RLNP) after thoracoscopic esophagectomy for esophageal cancer (EC) is known to be a major complication leading to poor quality of life. RLNP is mainly associated with surgical procedures performed near the RLN. Therefore, with focus on the region of the RLN, we used preoperative computed tomography to investigate the risk factors of RLNP in patients with EC undergoing thoracoscopic esophagectomy.

METHODS

We retrospectively examined 77 EC patients who underwent thoracoscopic esophagectomy in the prone position at our department between January 2010 and December 2018. Bilateral cross-sectional areas (mm²) of the fatty tissue around the RLN at the level of the lower pole of the thyroid gland were measured on preoperative axial computed tomography (CT) images. Univariate and multivariate logistic regression analysis was used to evaluate the association between the incidence of RLNP and patient clinical factors, including the cross-sectional areas.

RESULTS

RLNP occurred in 24 of 77 patients (31.2%). The incidence of RLNP was significantly more frequent on the left side than on the right. (26% vs. 5.2%, respectively). Univariate analysis identified the following left RLNP risk factors: intrathoracic operative time (> 235 min), and area around the RLN (> 174.3 mm²). Multivariate analysis found that the area around the RLN was an independent risk factor of left RLNP.

CONCLUSION

An increased area around the RLN measured on an axial CT view at the level of the lower pole of the thyroid gland was a risk factor of RLNP in EC patients undergoing thoracoscopic esophagectomy in the prone position.

Long non-coding RNA SPRY4-IT1 as a promising indicator for three field lymph-node dissection of thoracic esophageal carcinoma

Background

Esophageal squamous cell carcinoma(ESCC) is one of the most common tumors worldwide. Esophagectomy with three-field lymph node dissection(3FLND) is the radical surgical procedure for esophageal cancer. However, 3FLND is not widely used due to it’s higher mortality rate and higher incidence of postoperative complications. There is an urgent need to identify novel biomarkers that can guide the most proper lymph-node dissection in esophageal cancer patients.

Method

Ninety-two patients with thoracic ESCC undergoing 3FLND were enrolled into our study from the Department of Thoracic Surgery of the Fourth Hospital affiliated to the Hebei Medical University and Hebei General Hospital between Jun 2011 and Dec 2015. Retrospectively collected data from these 92 patients was used to explore the relationship between the lymph-node metastasis、recurrence and the SPRY4-IT1 expression level and to determine whether 3FLND should be performed in patients with thoracic ESCC.

Results

The findings revealed that the SPRY4-IT1 expression was significantly higher in esophageal cancer tissues than in adjacent noncancerous tissues. (P < 0.01). Furthermore, the high expression of SPRY4-IT1 was significantly correlated with tumor differentiation (P = 0.029), T classification (P = 0.013), lymph node metastasis(P = 0.022) and pathological stage (P = 0.001). The increased expression of SPRY4-IT1 was associated with a higher risk of cervical and superior mediastinal lymph-node metastasis(P = 0.039).However, no significant association was observed between the risk of cervical and superior mediastinal lymph-node recurrence and the SPRY4-IT1 expression level in the thoracic ESCC patients performed 3FLND(P = 0.509).

Conclusions

Our data support the assumption that the high expression of SPRY4-IT1 is associated with a high risk of lymph node metastasis and it has potential application as a indicator for guiding on three-field lymph node dissection in patients with thoracic ESCC. Randomized controlled trials with a large cohort of patients will be needed to confirm this conclusion in the future.

Performance of Indocyanine-Green Imaging for Sentinel Lymph Node Mapping and Lymph Node Metastasis in Esophageal Cancer: Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Lymphatic mapping with indocyanine-green (ICG) and near-infrared light fluorescent imaging is widely used for sentinel lymph node staging in different types of cancer but is not fully accepted for all procedures because studies have reported heterogeneous results. This study aimed to assess the detection rate (DR) of ICG imaging for sentinel lymph node mapping (SLNM) and lymph node metastases (LNMs) in esophageal cancer.

METHODS

A systematic search was performed to identify relevant studies examining the use of ICG imaging for SLNM in patients with esophageal cancer. Extracted results were pooled in a single-proportion meta-analysis, with a random-effects model, presented as forest plots.

RESULTS

Six studies were included in the analysis. The ICG DR for SLNM was 89% [95% confidence interval (CI) 71%-96%]. The pooled sensitivity and specificity values for the detection of LNMs were 84% (95% CI 64%-94%) and 15% (95% CI 3%-45%), respectively. A trend towards a lower DR was found with increasing mean latency time between ICG injection and SLNM.

CONCLUSIONS

ICG imaging is a technique that potentially could improve lymph node yield excision and, as a consequence, improve the detection of lymph node metastases.

CYP2C9 inhibits the invasion and migration of esophageal squamous cell carcinoma via downregulation of HDAC

Cytochrome P450 2C9 (CYP2C9) is involved in the metabolism of cancer drugs and exogenous carcinogens. In our study, CYP2C9 was downregulated in multiple cohorts of human esophageal squamous cell carcinoma (ESCC). Until now, its role and epigenetic regulation of CYP2C9 repression in ESCC remain poorly understood. CYP2C9 repression in collected ESCC patient tumor tissues was demonstrated by RT-qPCR and Western blot. The histone acetylation level was carried out by the treatment of histone deacetylase inhibitor TSA and RNA interference. Epigenetic analysis revealed that the increased expression of CYP2C9 in KYSE-150 and TE1 cells was characterized by inhibition of HDAC8 and HDAC1, respectively. TSA decreased the levels of HDAC occupancy around CYP2C9 promoter region greatly. Overexpression of CYP2C9 reduced the invasion and migration of ESCC cells.

Intraoperative neuromonitoring during prone thoracoscopic esophagectomy for esophageal cancer reduces the incidence of recurrent laryngeal nerve palsy: a single-center study

The incidence of recurrent laryngeal nerve palsy (RLNP) following minimally invasive esophagectomy has yet to be satisfactorily reduced. Use of intraoperative neuromonitoring (IONM), specifically of the RLN, during thyroidectomy has been reported to reduce the incidence of RLN injury. We now apply IONM during curative prone thoracoscopic esophagectomy, and we conducted a retrospective study to evaluate the feasibility and efficacy of intermittent monitoring of the RLN during the surgery. The study involved 32 consecutive patients who underwent esophagectomy with radical lymph node dissection for esophageal cancer. The patients were of two groups: an IONM group (n = 17) and a non-IONM group (n = 15). We chiefly strip around the esophagus preserving the membranous structure, which contains the tracheoesophageal artery, lymph nodes, and RLN. In the IONM group patients, we stimulated the RLN and measured the electromyography (EMG) amplitude after dissection, at the dissection starting point and dissection end point on both sides. For the purpose of the study, we compared outcomes between the two groups of patients. IONM was carried out successfully in all 17 patients in the IONM group. The incidence of RLNP was significantly reduced in this group. We found that both RLNs can be identified by mean of IONM easily, immediately, and safely and that the EMG amplitude attenuation rate is particularly useful for predicting RLNP.

Progress in Multimodal Treatment for Advanced Esophageal Squamous Cell Carcinoma: Results of Multi-Institutional Trials Conducted in Japan

In Japan, the therapeutic strategies adopted for esophageal carcinoma are based on the results of multi-institutional trials conducted by the Japan Esophageal Oncology Group (JEOG), a subgroup of the Japan Clinical Oncology Group (JCOG). Owing to the differences in the proportion of patients with squamous cell carcinoma among all patients with esophageal carcinoma, chemotherapeutic drugs available, and surgical procedures employed, the therapeutic strategies adopted in Asian countries, especially Japan, are often different from those in Western countries. The emphasis in respect of postoperative adjuvant therapy for patients with advanced esophageal squamous cell carcinoma (ESCC) shifted from postoperative radiotherapy in the 1980s to postoperative chemotherapy in the 1990s. In the 2000s, the optimal timing of administration of perioperative adjuvant chemotherapy returned from the postoperative adjuvant setting to the preoperative neoadjuvant setting. Recently, the JEOG commenced a three-arm randomized controlled trial of neoadjuvant therapies (cisplatin + 5-fluorouracil (CF) vs. CF + docetaxel (DCF) vs. CF + radiation therapy (41.4 Gy) (CRT)) for localized advanced ESCC, and patient recruitment has been completed. Salvage and conversion surgeries for ESCC have been developed in Japan, and the JEOG has conducted phase I/II trials to confirm the feasibility and safety of such aggressive surgeries. At present, the JEOG is conducting several trials for patients with resectable and unresectable ESCC, according to the tumor stage. Herein, we present a review of the JEOG trials conducted for advanced ESCC.

Three-Field Lymphadenectomy in Minimally Invasive Esophagectomy for Squamous Cell Carcinoma

BACKGROUND

Minimally invasive esophagectomy (MIE) has been used widely for the treatment of esophageal cancer. However, there is still a lack of consensus on the extent of lymphadenectomy in MIE. The objective of this study was to investigate the safety and efficacy of three-field lymphadenectomy (3-FL) in MIE, compared with the standard two-field lymphadenectomy (2-FL).

METHODS

A single-center randomized controlled trial was conducted, enrolling patients with resectable thoracic esophageal cancer (cT1-3,N0-3,M0) between June 2016 and May 2019. Eligible patients were randomized into two groups to receive either 3-FL or 2-FL during MIE procedures. Perioperative outcomes of the two groups were compared. The trial was registered in the Chinese Clinical Trial Registry (ChiCTR-INR-16007957).

RESULTS

Seventy-six eligible patients were randomly assigned to the 3-FL group (n = 38) and the 2-FL group (n = 38). Compared with patients in the 2-FL group, patients in the 3-FL group had more lymph nodes harvested (54.7 ± 16.5vs 30.9 ± 9.6, P < .001) and more metastatic lymph nodes identified (3.5 ± 4.5 vs 1.7 ± 2.0, P = .027). Patients in the 3-FL group were diagnosed with a more advanced final pathologic TNM stage than patients in the 2-FL group. There was no significant difference between the two groups in blood loss, major postoperative complications, or duration of hospital stay, except that the operation time was longer in the 3-FL group than in the 2-FL group (270.5 ± 45.4 minutes vs 236.7 ± 47.0 minutes, P = .002).

CONCLUSIONS

Three-field lymphadenectomy allowed harvesting of more lymph nodes and more accurate staging without increased surgical risks compared with 2-FL MIE for esophageal cancer.

Does staged surgical training for minimally invasive esophagectomy have an impact on short-term outcomes?

BACKGROUND

sophageal cancer has a low incidence, and the anatomy is difficult to understand during esophagectomy. This necessitates a precise and lengthy operation. Therefore, the establishment of a training system in esophageal surgery is of critical importance. In this study, we compared the short-term outcomes of minimally invasive esophagectomy (MIE) performed by consultants versus trainees and explored the factors that impacted the thoracic operation time for each group.

METHODS

We have introduced standardized MIE surgical techniques to our trainees in 2016. Our procedure consists of a laparoscopic phase and a thoracoscopic phase and is systematically designed to be learned in a step-by-step manner in each phase. We retrospectively identified 308 patients who underwent MIE from April 2016 to April 2018. The patients were divided into those who underwent MIE by consultants and those who underwent MIE by trainees. The preoperative background factors, operation-related factors, and postoperative complications were compared between the two groups. We also assessed the association between a prolonged thoracic operation time and tumor-and patient-related factors in each of the consults and trainees.

RESULTS

Significantly more patients had stage ≥ III cancer in the consultant than trainee group. However, the postoperative complications were comparable, specifically pneumonia (11% vs. 18%), anastomotic leakage (11% vs. 13%), and mortality (0.6% vs. 1.3%). There was no significant difference in the lymph node yield (20 vs. 17) or R0 resection rate (94% vs. 91%) between the two groups. However, the trainees had a significantly longer thoracic operation time (143 ± 34 vs. 190 ± 28 min) and significantly greater blood loss (93 vs. 183 ml). Oncological factors were correlated with a prolonged thoracic operation time in the consultants, but not in the trainees.

CONCLUSIONS

Under standardized surgical management using a stepwise educational program, performance of MIE by trainees has no impact on short-term outcomes.

Application of neck anastomotic muscle flap embedded in 3-incision radical resection of oesophageal carcinoma: A protocol for systematic review and meta analysis

BACKGROUND

Oesophageal cancer is one of the most common malignant tumors and has been identified as one of the leading causes of cancer death worldwide. Surgery is considered to be the optimal treatment for patients with resectable oesophageal cancer. Oesophagectomy for oesophageal cancer can significantly extend the survival period of patients and provide a potential opportunity for a cure. However, there is still controversy regarding application of neck anastomotic muscle flap embedded. This systematic review and meta-analysis will be performed to determine whether the application of neck anastomotic muscle flap embedded would benefit patients more.

METHODS

We will search PubMed, Web of Science, Embase, Cancerlit, the Cochrane Central Register of Controlled Trials, and Google Scholar databases for relevant clinical trials published in any language before October 1, 2020. Randomized controlled trials (RCTs), quasi-RCTs, propensity score-matched comparative studies, and prospective cohort studies of interest, published or unpublished, that meet the inclusion criteria will be included. Subgroup analysis of the type of operation, tumor pathological stage, and ethnicity will be performed. INPLASY registration number: INPLASY202080059.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

As far as we know, this study will be the first meta-analysis to compare the efficacy of the application of neck anastomotic muscle flap embedded in 3-incision radical resection of oesophageal carcinoma. Due to the nature of the disease and intervention methods, RCTs may be inadequate, and we will carefully consider inclusion in high-quality, non-RCTs, but this may result in high heterogeneity and affect the reliability of the results.

Advances in the pharmacotherapeutic management of esophageal squamous cell carcinoma

INTRODUCTION

Esophageal squamous cancer remains an important cause of mortality worldwide with two new immunotherapy drugs recently approved for metastatic disease.

AREAS COVERED

The authors review the epidemiology and genomics of esophageal squamous cell carcinoma. They also examine prior trials involving targeted agents under investigation as well immunotherapies that have been approved and novel combinations.

EXPERT OPINION

Great advances have been made in characterizing the molecular changes in esophageal carcinoma. However, relatively few drugs have shown benefit in this disease. Targeted therapies have not shown to improve survival although many of these trials did not explore potential biomarkers. Pembrolizumab and nivolumab are now approved for esophageal squamous carcinoma but much more data are needed to understand how these agents may be used in non-metastatic settings. Novel treatments are still required as overall prognosis remains poor.

The Role of Modern Radiotherapy Technology in the Treatment of Esophageal Cancer

Radiation therapy (RT) has improved patient outcomes, but treatment-related complication rates remain high. In the conventional 2-dimensional and 3-dimensional conformal RT (3D-CRT) era, there was little room for toxicity reduction because of the need to balance the estimated toxicity to organs at risk (OARs), derived from dose-volume histogram data for organs including the lung, heart, spinal cord, and liver, with the planning target volume (PTV) dose. Intensity-modulated RT (IMRT) is an advanced form of conformal RT that utilizes computer-controlled linear accelerators to deliver precise radiation doses to the PTV. The dosimetric advantages of IMRT enable better sparing of normal tissues and OARs than is possible with 3D-CRT. A major breakthrough in the treatment of esophageal cancer (EC), whether early or locally advanced, is the use of proton beam therapy (PBT). Protons deposit their highest dose of radiation at the tumor, while leaving none behind; the resulting effective dose reduction to healthy tissues and OARs considerably reduces acute and delayed RT-related toxicity. In recent studies, PBT has been found to alleviate severe lymphopenia resulting from combined chemo-radiation, opening up the possibility of reducing immune suppression, which might be associated with a poor prognosis in cases of locally advanced EC.

Near-Infrared Fluorescent Image-Guided Lymphatic Mapping in Esophageal Squamous Cell Carcinoma

BACKGROUND

Recently, the feasibility of near-infrared (NIR) image-guided sentinel lymph node (SLN) mapping has been tested in patients with gastrointestinal cancer. The aim of this study is to investigate whether SLN mapping can be used to identify mediastinal lymph node metastases during minimally invasive esophagectomy and explore the lymphatic drainage pattern of esophageal squamous cell carcinoma (ESCC) using NIR fluorescent imaging.

PATIENTS AND METHODS

A total of 21 patients diagnosed with cT1-3 stage ESCC were enrolled. Patients received submucosal injection of indocyanine green diluted with sodium chloride (0.9%) at the start of the esophagectomy procedure followed by NIR mapping.

RESULTS

Thoracoscopic-assisted McKeown esophagectomy with NIR imaging was successfully performed in all patients. The detection rate and number of NIR+ lymph nodes were 95.2% (20/21) and 4.0 (2.0-6.5), respectively. The accuracy, false-negative rates, and negative predictive value were 100% (10 of 10 cases), 0% (0 of 4), and 100% (6 of 6), respectively, for pT1/T2 diseases; and 80.0% (8 of 10), 40% (2 of 5), and 71.4% (5 of 7), respectively, for pT3 diseases. The NIR+ region was the most commonly detected in the right recurrent laryngeal nerve (80%), and the NIR+ region was identified in the upper mediastinal zone in 20 patients.

CONCLUSIONS

Evaluation of the lymphatic drainage pattern and the application of sentinel lymph node in ESCC with real-time NIR imaging could be effective, especially in pT1/2 disease. NIR imaging-guided SLN navigation appears to be a clinically beneficial less-invasive method for treating ESCC.

Three-Field versus Two-Field Lymphadenectomy for Esophageal Squamous Cell Carcinoma: A Meta-analysis

BACKGROUND

Most surgeons now accept lymphadenectomy as an essential feature of the operative treatment of esophageal squamous cell carcinoma. Three-field and two-field lymphadenectomy are two of the most popular excision scopes among surgeons. Over recent years, researchers have performed a range of comparative studies regarding these techniques, although the conclusions remain inconsistent.

METHOD

We systematically retrieved the records of PubMed, Embase, The Cochrane Library, and ClinicalTrials.gov until October 2019 and performed preliminary and full-text screening of the articles. We used the NOS scale to evaluate the quality of the enrolled studies, with only medium- and high-quality studies included. Review Manager 5.3 and Stata15 were used for the meta-analysis.

RESULTS

A total of eight studies involving 1676 patients were included in the meta-analysis. The results showed that for esophageal squamous cell carcinoma using with two-field and three-field lymphadenectomy, although three-field lymphadenectomy led to the gaining of a higher number of lymph nodes, there were no significant differences between the two in terms of the number of positive lymph nodes and overall survival. Three-field lymphadenectomy also caused higher levels of intraoperative blood loss and higher morbidity of the anastomotic fistula. No significant differences in operation time, recurrent laryngeal nerve injury, pneumonia, chylothorax, anastomotic stenosis, ileus, cervical nodal recurrence and hospital mortality were observed.

CONCLUSIONS

According to our meta-analysis, two-field lymphadenectomy is recommended as a first-choice surgical treatment for esophageal squamous cell carcinoma. However, since the results showed a risk of bias, they should be treated with caution.

A review of radiation-induced lymphopenia in patients with esophageal cancer: an immunological perspective for radiotherapy

Radiotherapy is a frequently utilized therapeutic modality in the treatment of esophageal cancer (EC). Even though extensive studies are carried out in radiotherapy for EC, the design of the clinical target volume and the radiation dose is not satisfactorily uniform. Radiotherapy acts as a double-edged sword on the immune system; it has both an immunostimulatory effect and an immunosuppressive effect. Radiation-induced lymphopenia and its potential association with tumor control and survival outcomes remain to be understood. The advent of immunotherapy has renewed the focus on preserving a pool of functioning lymphocytes in the circulation. In this review, we summarize the potential impact mechanisms of radiotherapy on peripheral blood lymphocytes and the prognostic role of radiation-induced lymphopenia in patients with EC. We also propose the concept of organs-at-risk of lymphopenia and discuss potential strategies to mitigate its effects on patients with EC. From an immunological perspective, we put forward the hypothesis that optimizing radiation modalities, radiation target volume schemes, and radiation doses could help to reduce radiation-induced lymphopenia risks and maximize the immunomodulatory role of radiotherapy. An optimized radiotherapy plan may further enhance the feasibility and effectiveness of combining immunotherapy with radiotherapy for EC.

Morbidity After Esophagectomy With Three-Field Lymph Node Dissection in Patients With Esophageal Cancer: Looking for the Best Predictive Model

Purpose

Esophagectomy with three-field lymphadenectomy (3FLD) is a potentially curative treatment option for resectable esophageal cancer (EC), which is associated with significant morbidity. Risk scores are useful for patient assessment; this study compares 7 different scores and indexes to find the best model for predicting morbidity in patients undergoing 3FLD.

Methods

Six years of data from January 2010 to January 2016 were reviewed, patients with EC who underwent 3FLD were retrospectively scored using 4 predictive scores and 3 predictive index models. Postoperative morbidity was assessed according to the extended Clavien-Dindo classification. The outcomes were the presence and severity of morbidity. Validation was performed by calculating the area under the ROC curve and by the assessment of collinearity among the variables independently associated with morbidity in the overall model to determine the best predictive model.

Results

We included 230 patients were included in the final analysis. Complications after 3FLD occurred in 168 patients (73%; minor complications, n = 96 [41%]; major complications, n=72 [31%]). The AUC values (&lt;0.7) indicated that all scores and indexes had poor discrimination power in predicting the presence and severity of morbidity. Overall, the Steyerberg score was associated with the lowest risk of misestimation in predicting morbidity (P = 0.0330).

Conclusion

No score or index could predict the presence or severity of morbidity after 3FLD with good discrimination power. Age (&gt;68 years) was the most critical factor affecting morbidity. The Steyerberg score model, based on the addition and subtraction of risk values was the best model for predicting morbidity after 3FLD.

Three-field versus two-field lymphadenectomy in transthoracic oesophagectomy for oesophageal squamous cell carcinoma: short-term outcomes of a randomized clinical trial

BACKGROUND

The benefit and harm of three-field lymphadenectomy for oesophageal cancer are still unknown. The aim of this study was to compare overall survival and morbidity and mortality between three- and two-field lymphadenectomy in patients with oesophageal squamous cell carcinoma.

METHODS

Between March 2013 and November 2016, patients with squamous cell carcinoma of the middle or distal oesophagus were assigned randomly to open oesophagectomy with three-field (cervical-thoracic-abdominal) or two-field (thoracic-abdominal) lymphadenectomy. No chemo(radio) therapy was given before surgery. This paper reports on the secondary outcomes of the study: pathology and surgical complications.

RESULTS

Some 400 patients were randomized, 200 in each group. A median of 37 (i.q.r. 30-49) lymph nodes were dissected in the three-field group, compared with 24 (18-30) in the two-field group (P < 0·001). Some 43 of 200 patients (21·5 per cent) in the three-field group had cervical lymph node metastasis. More patients in the three-field group had pN3 disease: 21 of 200 (10·5 per cent) versus 10 of 200 (5·0 per cent) (P = 0·040). The rate and severity of postoperative complications were comparable between the two groups, except that six patients in the three-field arm needed reintubation compared with none in the two-field group (3·0 versus 0 per cent; P = 0·030). The 90-day mortality rate was 0 per cent in the three-field group and 0·5 per cent (1 patient) in the two-field group (P = 1·000).

CONCLUSION

Oesophagectomy with three-field lymphadenectomy increased the number of lymph nodes dissected and led to stage migration owing to a 21·5 per cent rate of cervical lymph node metastasis. Postoperative complications were largely comparable between two- and three-field lymphadenectomy. Registration number: NCT01807936 ( https://www.clinicaltrials.gov).

Long-term complete response in supraclavicular lymph node metastases of esophageal cancer using systemic chemotherapy-a case report

Esophageal cancer (EC) is a highly lethal disease. We report here a patient with supraclavicular lymph node metastases of esophageal cancer, who was successfully treated by systemic chemotherapy containing 5-fluorouracil (5-FU), docetaxel and cisplatin (CDDP). The patient, a 53-year-old woman, was diagnosed as having squamous cell carcinoma of the esophagus upon endoscopic examination. She underwent neoadjuvant chemotherapy with cisplatin (CDDP), 5-fluorouraol (5-FU)(CF) for four courses. Then, a chest CT revealed that the esophageal tumor and mediastina lymph node metastases had markedly decreased in size to the point of being unmeasurable. Due to the patient refusing surgery and radiotherapy, and because her general condition was favorable, 2 courses of systemic chemotherapy with docetaxel, CDDP, 5-FU (DCF) were administered. CT showed the supraclavicular lymph node and esophageal tumor disappeared. No tumor recurrence has occurred in the 5 years and 8 months since the first cancer cure. Therefore, in patents whose general conditions are favorable, DCF should be considered as a treatment option for advanced esophageal cancer.

Comparison of short- and long-term outcomes between 3-field and modern 2-field lymph node dissections for thoracic oesophageal squamous cell carcinoma: a propensity score matching analysis

OBJECTIVES

Our goal was to compare short- and long-term outcomes between 3-field lymphadenectomy (3-FL) and modern 2-field lymphadenectomy (2-FL) in patients with thoracic oesophageal squamous cell carcinoma.

METHODS

We reviewed clinical outcomes for 298 patients with thoracic oesophageal squamous cell carcinoma who underwent 3-FL or modern 2-FL from March 2008 to December 2013 at a major cancer hospital in Guangzhou, southern China. Propensity score matching was used to balance baseline differences, and 83 pairs of cases were selected. Postoperative complications, recurrence patterns and survival outcomes were compared between the 2 groups.

RESULTS

Compared with modern 2-FL, 3-FL led to higher overall operative morbidity rates [78.3% vs 61.4%, odds ratio (OR) 2.266, 95% confidence interval (CI) 1.143-4.490; P = 0.019], with higher recurrent nerve palsy rates (47.0% vs 19.3%, OR 3.712, 95% CI 1.852-7.438; P < 0.0001), more respiratory failures (18.1% vs 6.0%, OR 3.441, 95% CI 1.189-9.963; P = 0.023) and longer postoperative hospital stays (23 vs 17 days, P = 0.002). The 5-year overall survival rate (58.5% vs 59.4%; P = 0.960) and the 5-year disease-free survival rate 50.1% vs 54.5%; P = 0.482) were comparable between the 2 groups. Multivariable analysis showed that additional cervical lymph node dissection was not associated with overall survival [hazard ratio (HR) 1.039, 95% CI 0.637-1.696; P = 0.878] and disease-free survival (HR 0.868, 95% CI 0.548-1.376; P = 0.547). The overall recurrence rate and cervical nodal recurrence rate were not significantly different between the 2 groups.

CONCLUSIONS

Additional cervical lymphadenectomy did not lead to added survival benefit when compared with modern 2-FL in patients with thoracic oesophageal squamous cell carcinoma. Recurrence was similar in patients undergoing 3-FL and modern 2-FL. 3-FL resulted in more postoperative complications.

Current status and future direction of lymph node dissection in radical surgery for esophageal cancer

Surgical resection is the main treatment for esophageal cancer. Lymph node dissection is an essential part of radical surgery for esophageal cancer. However, the extent of dissection, numbers of lymph nodes, and sentinel lymph nodes in lymphadenectomy are still under debate. However, a clinical practice consensus has gradually formed despite this dispute.