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Terayama M, Okamura A, Kuriyama K, Takahashi N, Tamura M, Kanamori J, Imamura Y, Watanabe M. Minimally Invasive Esophagectomy Provides Better Short- and Long-Term Outcomes Than Open Esophagectomy in Locally Advanced Esophageal Cancer. Ann Surg Oncol 2024; 31:5748-5756. [PMID: 38896227 DOI: 10.1245/s10434-024-15596-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 05/26/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Minimally invasive esophagectomy (MIE) has been increasingly performed for locally advanced esophageal cancer in place of open transthoracic esophagectomy (OE). This study explored the significance of MIE for esophageal squamous cell carcinoma (ESCC), focusing mainly on the depth of primary esophageal tumors. METHODS This study retrospectively assessed short- and long-term outcomes of patients who underwent esophagectomy for ESCC from 2005 through 2021. The inverse probability of the treatment-weighting (IPTW) method was used to compare the outcomes between OE and MIE. The outcomes also were evaluated in the subgroups stratified by cT category. RESULTS Among 1117 patients, 447 (40%) underwent OE and 670 (60%) underwent MIE. After IPTW adjustment, the incidence of any postoperative complications was significantly higher in the OE group than in the MIE group (60.8% vs 53.7%; p = 0.032), whereas the R0 resection rate was significantly higher in the MIE group (98.6% vs 92.7%; p < 0.001). The MIE group showed better 3 year overall and cancer-specific survival than the OE group (p < 0.001). The incidence of locoregional recurrence within the surgical field was significantly more frequent in the OE group (p < 0.001). In the subgroup analysis stratified by cT category, the R0 resection rate was significantly higher and the incidence of locoregional recurrence was lower in the MIE group among the patients with cT3-4 tumors. In the patients with cT1-2 tumors, MIE showed no significant benefit over OE. CONCLUSIONS For the patients with cT3-4 tumors, MIE showed fewer postoperative complications, better locoregional control, and better prognosis than OE. Compared with OE, MIE is beneficial, especially for locally advanced ESCC.
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Affiliation(s)
- Masayoshi Terayama
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akihiko Okamura
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Kengo Kuriyama
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Naoki Takahashi
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masahiro Tamura
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Jun Kanamori
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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2
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Lv Z, Yuan L, He J, Gao S, Xue Q, Mao Y. Time-dependent prognostic impact of circumferential resection margin in T3 thoracic esophageal squamous cell carcinoma. Dis Esophagus 2024:doae065. [PMID: 39140869 DOI: 10.1093/dote/doae065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 07/17/2024] [Accepted: 08/05/2024] [Indexed: 08/15/2024]
Abstract
Esophageal cancer presents a clinical challenge due to its high incidence and unfavorable prognosis. The prognostic role of the circumferential resection margin (CRM) remains highly controversial, potentially due to its temporal dynamics coupled with variability in follow-up durations across studies. We aimed to explore the time-dependent prognostic significance of CRM in T3 esophageal squamous cell carcinomas (ESCCs). We systematically reviewed literature from 1990 to 2023 to determine how follow-up duration influences the prognostic role of CRM in esophageal cancer. Concurrently, we performed a retrospective examination of 354 patients who underwent treatment at the National Cancer Center between 2015 and 2018. Integrating a time interaction term in the Cox regression analyses enabled us to not only identify independent risk factors affecting overall survival (OS) but also to specifically scrutinize the potential temporal variations in CRM's prognostic impact. Our literature review suggested that CRM's influence on prognosis diminishes with longer follow-up durations for both classifications, namely the Royal College of Pathologists (RCP) (β = -0.003, P < 0.001) and the College of American Pathologists (CAP) (β = -0.007, P < 0.001). Time-dependent multivariate Cox regression analysis emphasized the evolving nature of CRM's prognostic effect, and the inclusion of the time interaction term enhanced model accuracy. In conclusion, CRM is an independent prognostic factor for T3 thoracic ESCC patients. Its influence appears to decrease over extended follow-up periods, shedding light on the heterogeneity seen in previous studies. With the time interaction term, CRM becomes a more precise post-operative prognostic indicator for esophageal cancer.
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Affiliation(s)
- Zhuoheng Lv
- Department of Thoracic Surgery, National Cancer Center/ National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ligong Yuan
- Department of Thoracic Surgery, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Jie He
- Department of Thoracic Surgery, National Cancer Center/ National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shugeng Gao
- Department of Thoracic Surgery, National Cancer Center/ National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Qi Xue
- Department of Thoracic Surgery, National Cancer Center/ National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yousheng Mao
- Department of Thoracic Surgery, National Cancer Center/ National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Takiguchi H, Koyanagi K, Ozawa S, Oguma T, Asano K. Detrimental impact of late-onset pneumonia on long-term prognosis in oesophageal cancer survivors. Respir Investig 2024; 62:531-537. [PMID: 38642419 DOI: 10.1016/j.resinv.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 02/15/2024] [Accepted: 04/08/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUD Oesophageal cancer patients are prone to early- and late-onset pneumonia after oesophagectomy. We aimed to investigate the incidence rate and impact on the long-term prognosis of late-onset pneumonia in oesophageal cancer survivors who survived for at least one year after oesophagectomy without cancer recurrence. METHODS We retrospectively reviewed 233 patients with thoracic oesophageal cancer who underwent oesophagectomy with gastric conduit reconstruction between September 2009 and June 2019 at a tertiary referral hospital in Japan. Pneumonia that occurred ≥1 year after oesophagectomy was defined as late-onset pneumonia. RESULTS Among the 185 oesophageal cancer survivors, 31 (17%) developed late-onset pneumonia. The cumulative incidence rates of late-onset pneumonia 24, 36, and 60 months after oesophagectomy were 6.4%, 10%, and 21%, respectively, whereas pneumonia recurred at 21%, 31%, and 52% within 6, 12, and 24 months, respectively, after the first pneumonia. Chronic obstructive pulmonary disease, postoperative anastomotic leakage, and loss of skeletal muscle mass were independently associated with late-onset pneumonia, and a combination of these factors further increased the risk. Late-onset pneumonia with hospitalisation had the greatest negative impact on the long-term prognosis as non-cancer deaths (HR, 21; p < 0.001), followed by recurrent late-onset pneumonia (HR, 18; p < 0.001). CONCLUSIONS Late-onset pneumonia in oesophageal cancer survivors is significantly associated with an increased risk of recurrent infections and non-cancer deaths. Chronic obstructive pulmonary disease and postoperative muscle loss are risk factors for late-onset pneumonia, and more intensive pharmacological and nutritional interventions should be considered to improve long-term prognosis after oesophagectomy.
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Affiliation(s)
- Hiroto Takiguchi
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, 2591193, Japan
| | - Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Kanagawa, 2591193, Japan
| | - Soji Ozawa
- Department of Surgery, Tamakyuryo Hospital, Tokyo, 1940202, Japan
| | - Tsuyoshi Oguma
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, 2591193, Japan
| | - Koichiro Asano
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, 2591193, Japan.
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Dellaportas D, Margaris I, Latsonas P, Pikouli A, Vlachos I, Papakonstantinou D, Pararas N, Nastos C, Myoteri D, Pikoulis E. Contemporary Role of Open Left Thoracoabdominal Approach in Esophageal Malignancy Treatment. Cureus 2024; 16:e62922. [PMID: 39040781 PMCID: PMC11262707 DOI: 10.7759/cureus.62922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2024] [Indexed: 07/24/2024] Open
Abstract
INTRODUCTION Despite the widespread use of minimally invasive techniques, open left thoracoabdominal esophagectomy (LTE) can offer excellent visualization and adaptability. The current study aimed to present and evaluate the outcomes related to an open LTE in esophageal malignancy treatment. METHODS A retrospective cohort analysis of data collected from two institutions was performed, including patients with distal esophageal or junctional tumors who underwent open LTE between November 2018 and December 2023. RESULTS Twenty-two patients were included (16 males; mean age 62.8 years). Postoperative complications occurred in eight patients (36%), with pulmonary complications being the most prevalent (seven patients; 32%). One patient experienced a clinical anastomotic leak. No reoperations or escalation to a higher level of care were required. In-hospital and 30-day mortality were zero. Tumor cells were found at the surgical margins in six patients (27%). The mean lymph node yield was 27. During the follow-up period, there were nine deaths and 11 cases of disease recurrence. Isolated locoregional recurrence was seen in five patients (23%). The one-year and two-year overall survival rates were 79% and 47%, respectively. CONCLUSION In selected cases, open LTE remains a valid and safe operation with acceptable morbidity and oncological efficacy.
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Affiliation(s)
- Dionysios Dellaportas
- 3rd Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Ioannis Margaris
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Panagiotis Latsonas
- 3rd Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Anastasia Pikouli
- 3rd Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Iakovos Vlachos
- Department of Pathology, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Dimitrios Papakonstantinou
- 3rd Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Nikolaos Pararas
- 3rd Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Constantinos Nastos
- 3rd Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Despoina Myoteri
- Department of Pathology, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Emmanuel Pikoulis
- 3rd Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
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Linder G, McGregor RJ, Lindblad M. Intraoperative assessment of the curative potential to predict survival after gastric cancer resection: A national cohort study. Scand J Surg 2024; 113:109-119. [PMID: 38102973 DOI: 10.1177/14574969231216594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
BACKGROUND The surgeon's intraoperative assessment of the curative potential of tumor resection following gastrectomy adds new information that could help clinicians and patients by predicting survival. METHODS All patients in Sweden undergoing gastric cancer resection between 2006 and 2018 were grouped according to a prospectively registered variable; the surgeon's intraoperative assessment of the curative potential of surgery: curative, borderline curative, or palliative. Factors affecting group allocation were analyzed with multivariable logistic regression, while survival was analyzed using multivariable Cox regression and the Kaplan-Meier method. Positive predictive value (PPV) and negative predictive value (NPV) were calculated. RESULTS Of 2341 patients undergoing gastric cancer resection, 1547 (71%) were deemed curative, 340 (15%) borderline curative, and 314 (14%) palliative (140 missing assessments). Advanced stage increased the risk of borderline curative resection (Stage III, odds ratio (OR) = 6.04, 95% confidence interval (CI) = 3.92-9.31), as did emergency surgery OR = 3.31 (1.74-6.31) and blood loss >500 mL; OR = 1.63 (1.06-2.49). Neoadjuvant chemotherapy and multidisciplinary team (MDT) discussion both decreased the risk of borderline curative resection, OR = 0.58 (0.39-0.87) and 0.57 (0.40-0.80), respectively. In multivariable Cox regression, the surgeon's assessment independently predicted worse survival for borderline curative (hazard ratio (HR) = 1.54, 95% CI = 1.29-1.83) and palliative resections (HR = 1.76, 95% CI = 1.45-2.19), compared to curative resections. The sensitivity of the surgeon's assessment of long-term survival was 96.7%. The PPV was 50.7% and the NPV was 92.1%. CONCLUSION The surgeon's intraoperative assessment of the curative potential of gastric cancer surgery may independently aid survival prediction and is analogous to prognostication by pathologic Staging. Advanced disease, emergency surgery, and a high intraoperative blood loss, increases the risk of a borderline curative or palliative resection. Conversely, neoadjuvant treatment and MDT discussion reduce the risk of borderline curative or palliative resection.
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Affiliation(s)
- Gustav Linder
- Department of Surgical Sciences Uppsala University Ingång 70, 1 tr SE-751 85 Uppsala Sweden
| | - Richard J McGregor
- Clinical Surgery, The University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Mats Lindblad
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
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6
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van der Zijden CJ, van der Sluis PC, Mostert B, Nuyttens JJME, Spaander VMCW, Valkema R, Ruurda JP, Wijnhoven BPL, Lagarde SM. Adjuvant Therapy for Patients with a Tumor-Positive Resection Margin After Neoadjuvant Chemoradiotherapy and Esophagectomy. Ann Surg Oncol 2024; 31:3813-3818. [PMID: 38245648 PMCID: PMC11076321 DOI: 10.1245/s10434-024-14912-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/03/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND Approximately 4-9% of patients have a tumor-positive resection margin after neoadjuvant chemoradiotherapy (nCRT) and esophagectomy. Although it is associated with decreased survival, Western guidelines do not recommend adjuvant treatment. OBJECTIVE The aim of this study was to assess the proportion of patients who received adjuvant therapy, and to evaluate overall survival (OS) after esophagectomy in patients with a tumor-positive resection margin. METHODS Patients diagnosed with resectable (cT2-4a/cTxN0-3/NxM0) esophageal cancer between 2015 and 2022, and treated with nCRT followed by irradical esophagectomy, were selected from the Netherlands Cancer Registry. The primary outcome was the proportion of patients with a tumor-positive resection margin who started adjuvant treatment ≤16 weeks after esophagectomy, including chemotherapy/radiotherapy, immunotherapy, or targeted therapy. OS was calculated from the date of surgery until the date of death or last day of follow-up. RESULTS Overall, 376 patients were included in our study, of whom 357 were treated with nCRT. Of these 357 patients, 98.3% had a microscopically irradical resection and 1.7% had a macroscopically irradical resection. Approximately 72.3% of tumors showed a partial response (Mandard 2-3) and 11.8% showed little/no pathological response (Mandard 4-5) to nCRT. One of 357 patients underwent adjuvant chemoradiotherapy and 39 patients (61%) underwent adjuvant immunotherapy (nivolumab). The median and 5-year OS rate of all patients was 16.4 months (95% confidence interval 13.1-19.8) and 21%, respectively. CONCLUSION Real-world population-level data showed that no patients with a tumor-positive resection margin underwent adjuvant therapy following nCRT and esophagectomy prior to 2021. Interestingly, 61% of patients were treated with adjuvant nivolumab in 2021-2022. OS after irradical esophagectomy is poor and long-term data will explore the added value of nivolumab.
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Affiliation(s)
- C J van der Zijden
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - P C van der Sluis
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - B Mostert
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - J J M E Nuyttens
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - V M C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - R Valkema
- Department of Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B P L Wijnhoven
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S M Lagarde
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
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Partridge T, Wolfson P, Jiang J, Massimi L, Astolfo A, Djurabekova N, Savvidis S, Jones CJM, Hagen CK, Millard E, Shorrock W, Waltham RM, Haig IG, Bate D, Ho KMA, Mc Bain H, Wilson A, Hogan A, Delaney H, Liyadipita A, Levine AP, Dawas K, Mohammadi B, Qureshi YA, Chouhan MD, Taylor SA, Mughal M, Munro PRT, Endrizzi M, Novelli M, Lovat LB, Olivo A. T staging esophageal tumors with x rays. OPTICA 2024; 11:569-576. [PMID: 39006164 PMCID: PMC11239146 DOI: 10.1364/optica.501948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 03/05/2024] [Accepted: 04/07/2024] [Indexed: 07/16/2024]
Abstract
With histopathology results typically taking several days, the ability to stage tumors during interventions could provide a step change in various cancer interventions. X-ray technology has advanced significantly in recent years with the introduction of phase-based imaging methods. These have been adapted for use in standard labs rather than specialized facilities such as synchrotrons, and approaches that enable fast 3D scans with conventional x-ray sources have been developed. This opens the possibility to produce 3D images with enhanced soft tissue contrast at a level of detail comparable to histopathology, in times sufficiently short to be compatible with use during surgical interventions. In this paper we discuss the application of one such approach to human esophagi obtained from esophagectomy interventions. We demonstrate that the image quality is sufficiently high to enable tumor T staging based on the x-ray datasets alone. Alongside detection of involved margins with potentially life-saving implications, staging tumors intra-operatively has the potential to change patient pathways, facilitating optimization of therapeutic interventions during the procedure itself. Besides a prospective intra-operative use, the availability of high-quality 3D images of entire esophageal tumors can support histopathological characterization, from enabling "right slice first time" approaches to understanding the histopathology in the full 3D context of the surrounding tumor environment.
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Affiliation(s)
- T. Partridge
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 6BT, UK
| | - P. Wolfson
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 6BT, UK
- Division of Surgery and Interventional Science, UCL, London WC1E 6BT, UK
| | - J. Jiang
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 6BT, UK
- Current address: Advanced Photon Source, Argonne National Laboratory, Lemont, Illinois 60439, USA
| | - L. Massimi
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 6BT, UK
| | - A. Astolfo
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 6BT, UK
- Nikon X-Tek Systems Ltd., Tring, Herts HP23 4JX, UK
| | - N. Djurabekova
- Department of Computer Science, UCL, London WC1E 6BT, UK
| | - S. Savvidis
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 6BT, UK
| | - C. J. Maughan Jones
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 6BT, UK
| | - C. K. Hagen
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 6BT, UK
| | - E. Millard
- Nikon X-Tek Systems Ltd., Tring, Herts HP23 4JX, UK
| | - W. Shorrock
- Nikon X-Tek Systems Ltd., Tring, Herts HP23 4JX, UK
| | | | - I. G. Haig
- Nikon X-Tek Systems Ltd., Tring, Herts HP23 4JX, UK
| | - D. Bate
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 6BT, UK
- Nikon X-Tek Systems Ltd., Tring, Herts HP23 4JX, UK
| | - K. M. A. Ho
- Division of Surgery and Interventional Science, UCL, London WC1E 6BT, UK
| | - H. Mc Bain
- Division of Surgery and Interventional Science, UCL, London WC1E 6BT, UK
| | - A. Wilson
- Division of Surgery and Interventional Science, UCL, London WC1E 6BT, UK
| | - A. Hogan
- Division of Surgery and Interventional Science, UCL, London WC1E 6BT, UK
| | - H. Delaney
- Department of Histopathology, UCL, London WC1E 6BT, UK
| | - A. Liyadipita
- Department of Histopathology, UCL, London WC1E 6BT, UK
| | - A. P. Levine
- Department of Histopathology, UCL, London WC1E 6BT, UK
| | - K. Dawas
- Department of Upper Gastro-Intestinal Surgery, UCLH, London NW1 2BU, UK
| | - B. Mohammadi
- Department of Upper Gastro-Intestinal Surgery, UCLH, London NW1 2BU, UK
| | - Y. A. Qureshi
- Department of Upper Gastro-Intestinal Surgery, UCLH, London NW1 2BU, UK
| | - M. D. Chouhan
- Center for Medical Imaging, Division of Medicine, UCL, London WC1E 6BT, UK
- Princess Alexandra Hospital Medical Imaging Department, Brisbane, Queensland, Australia
- University of Queensland Medical School, Saint Lucia, Queensland, Australia
| | - S. A. Taylor
- Center for Medical Imaging, Division of Medicine, UCL, London WC1E 6BT, UK
| | - M. Mughal
- Department of Upper Gastro-Intestinal Surgery, UCLH, London NW1 2BU, UK
| | - P. R. T. Munro
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 6BT, UK
| | - M. Endrizzi
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 6BT, UK
| | - M. Novelli
- Research Department of Pathology, Cancer Institute, UCLH, London NW1 2BU, UK
| | - L. B. Lovat
- Division of Surgery and Interventional Science, UCL, London WC1E 6BT, UK
| | - A. Olivo
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 6BT, UK
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8
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Abou Chaar MK, Godin A, Harmsen WS, Wzientek C, Saddoughi SA, Hallemeier CL, Cassivi SD, Nichols FC, Reisenauer JS, Shen KR, Tapias LF, Wigle DA, Blackmon SH. Determinants of Long-term Survival Decades After Esophagectomy for Esophageal Cancer. Ann Thorac Surg 2023; 116:1036-1044. [PMID: 37353102 DOI: 10.1016/j.athoracsur.2023.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 03/26/2023] [Accepted: 05/01/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Long-term survival in esophagectomy patients with esophageal cancer is low due to tumor-related characteristics, with few reports of modifiable variables influencing outcome. We identified determinants of overall survival, time to recurrence, and disease-free survival in this patient cohort. METHODS Adult patients who underwent esophagectomy for primary esophageal cancer from January 5, 2000, through December 30, 2010, at our institution were identified. Univariate Cox models and multivariable logistic regression analyses were used to identify associations between modifiable and unmodifiable patient and clinical variables and outcome of survival for the total cohort and a subgroup with locally advanced disease. RESULTS We identified 870 patients with esophageal cancer who underwent esophagectomy. The median follow-up time was 15 years, and the 15-year overall survival rate was 25.2%, survival free of recurrence was 57.96%, and disease-free survival was 24.21%. Decreased overall survival was associated with the following unmodifiable variables: older age, male sex, active smoking status, history of coronary artery disease, advanced clinical stage, and tumor location. Decreased overall survival was associated with the following modifiable variables: use of neoadjuvant therapy, advanced pathologic stage, resection margin positivity, surgical reintervention, and blood transfusion requirement. The overall survival probability 6 years after esophagectomy was 0.920 (95% CI, 0.895-0.947), and time-to-recurrence probability was 0.988 (95% CI, 0.976-1.000), with a total of 17 recurrences and 201 deaths. CONCLUSIONS Once patients survive 5 years, recurrence is rare. Long-term survival can be achieved in high-volume centers adhering to National Comprehensive Cancer Network guidelines using multidisciplinary care teams that is double what has been previously reported in the literature from national databases.
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Affiliation(s)
- Mohamad K Abou Chaar
- Department of Surgery, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Anny Godin
- Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - William S Harmsen
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Camryn Wzientek
- Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | | | - K Robert Shen
- Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Luis F Tapias
- Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Dennis A Wigle
- Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
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9
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Fransen LFC, Verhoeven RHA, Janssen THJB, van Det MJ, Gisbertz SS, van Hillegersberg R, Klarenbeek B, Kouwenhoven EA, Nieuwenhuijzen GAP, Rosman C, Ruurda JP, van Berge Henegouwen MI, Luyer MDP. The association between postoperative complications and long-term survival after esophagectomy: a multicenter cohort study. Dis Esophagus 2023; 36:6874520. [PMID: 36477850 DOI: 10.1093/dote/doac086] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 05/30/2023]
Abstract
Conflicting results are reported on the association between post-esophagectomy complications and long-term survival. This multicenter study assesses the association between complications after an esophagectomy and long-term overall survival. Five Dutch high-volume centers collected data from consecutive patients undergoing esophagectomy between 2010 and 2016 and merged these with long-term survival data from the Netherlands Cancer Registry. Exclusion criteria were non-curative resections and 90-day mortality, among others. Primary outcome was overall survival related to the presence of a postoperative complication in general. Secondary outcomes analyzed the presence of anastomotic leakage and cardiopulmonary complications. Propensity score matching was performed and the outcomes were analyzed via Log-Rank test and Kaplan Meier analysis. Among the 1225 patients included, a complicated course occurred in 719 patients (59.0%). After matching for baseline characteristics, 455 pairs were successfully balanced. Patients with an uncomplicated postoperative course had a 5-year overall survival of 51.7% versus 44.4% in patients with complications (P = 0.011). Anastomotic leakage occurred in 18.4% (n = 226), and in 208 matched pairs, it was shown that the 5-year overall survival was 57.2% in patients without anastomotic leakage versus 44.0% in patients with anastomotic leakage (P = 0.005). Overall cardiopulmonary complication rate was 37.1% (n = 454), and in 363 matched pairs, the 5-year overall survival was 52.1% in patients without cardiopulmonary complications versus 45.3% in patients with cardiopulmonary complications (P = 0.019). Overall postoperative complication rate, anastomotic leakage, and cardiopulmonary complications were associated with a decreased long-term survival after an esophagectomy. Efforts to reduce complications might further improve the overall survival for patients treated for esophageal carcinoma.
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Affiliation(s)
- Laura F C Fransen
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - Rob H A Verhoeven
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
- Department of Medical Oncology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Marc J van Det
- Department of Surgery, ZGT Hospital Group Twente, Almelo, The Netherlands
| | - Suzanne S Gisbertz
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC location Academic Medical Center, Amsterdam, The Netherlands
| | | | - Bastiaan Klarenbeek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark I van Berge Henegouwen
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC location Academic Medical Center, Amsterdam, The Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
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10
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Zhang H, Chen Y, Wu B, Chen Y, He H, Gong L, Zhou L, Li C, Xie J, Lin W. A revamped MIC-McKeown operation without removing azygos vein arch, bronchial artery and vagus nerve trunk. BMC Surg 2023; 23:58. [PMID: 36934218 PMCID: PMC10024825 DOI: 10.1186/s12893-023-01903-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 01/04/2023] [Indexed: 03/20/2023] Open
Abstract
BACKGROUND The purpose of this study was to investigate the effect of our revamped MIE-McKeown operation on postoperative gastrointestinal function recovery. METHODS This revamped MIE-McKeown operation without removing azygos vein arch, bronchial artery and vagus nerve trunk and with the tubular stomach buried throughout esophageal bed and azygos arch, has been implemented from July 2020 to July 2021 by the same medical team of Gaozhou People's Hospital thoracic surgery for 13 times. Preoperative clinical data, main intraoperative indicators and postoperative complications were observed. RESULTS All patients had esophageal malignant tumors at the level of middle and lower thoracic non-azygous venous arch, with preoperative clinical stage CT1-2N0M0 stage i-ii. V-vst test was performed on the 7th postoperative day, and 10 patients were found to have no loss of safety/efficacy. There were 2 cases with impaired efficacy and no impaired safety, 1 case with impaired safety. There were 1 cases of pulmonary infection, 1 cases of anastomotic fistula combined with pleural and gastric fistula, 2 cases of hoarseness, 2 cases of arrhythmia, 10 cases of swallowing function were grade i, 2 cases of swallowing function were grade iii, 1 case of swallowing function was grade iv in watian drinking water test one month after operation. CONCLUSIONS Merit of this revamped MIE-McKeown operation is well preserving the integrity of azygos arch of vagus nerve and bronchial artery, and it is technically safe and feasible. No postoperative mechanical obstruction of thoracostomach, huge thoracostomach and gastrointestinal dysfunction occurs.
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Affiliation(s)
- Hai Zhang
- grid.478001.aDepartment of Thoracic Surgery, Gaozhou People’s Hospital, Affiliated to Guangdong Medical University, Guangdong Esophageal Cancer Institute Gaozhou Branch, 89 Xiguan Road, Gaozhou, 525200 Guangdong People’s Republic of China
| | - Ying Chen
- grid.478001.aDepartment of Thoracic Surgery, Gaozhou People’s Hospital, Affiliated to Guangdong Medical University, Guangdong Esophageal Cancer Institute Gaozhou Branch, 89 Xiguan Road, Gaozhou, 525200 Guangdong People’s Republic of China
| | - Bomeng Wu
- grid.478001.aDepartment of Thoracic Surgery, Gaozhou People’s Hospital, Affiliated to Guangdong Medical University, Guangdong Esophageal Cancer Institute Gaozhou Branch, 89 Xiguan Road, Gaozhou, 525200 Guangdong People’s Republic of China
| | - Ying Chen
- grid.478001.aDepartment of Thoracic Surgery, Gaozhou People’s Hospital, Affiliated to Guangdong Medical University, Guangdong Esophageal Cancer Institute Gaozhou Branch, 89 Xiguan Road, Gaozhou, 525200 Guangdong People’s Republic of China
| | - Haiquan He
- grid.478001.aDepartment of Thoracic Surgery, Gaozhou People’s Hospital, Affiliated to Guangdong Medical University, Guangdong Esophageal Cancer Institute Gaozhou Branch, 89 Xiguan Road, Gaozhou, 525200 Guangdong People’s Republic of China
| | - Lanjuan Gong
- grid.478001.aDepartment of Thoracic Surgery, Gaozhou People’s Hospital, Affiliated to Guangdong Medical University, Guangdong Esophageal Cancer Institute Gaozhou Branch, 89 Xiguan Road, Gaozhou, 525200 Guangdong People’s Republic of China
| | - Linrong Zhou
- grid.478001.aDepartment of Thoracic Surgery, Gaozhou People’s Hospital, Affiliated to Guangdong Medical University, Guangdong Esophageal Cancer Institute Gaozhou Branch, 89 Xiguan Road, Gaozhou, 525200 Guangdong People’s Republic of China
| | - Cui Li
- grid.478001.aDepartment of Thoracic Surgery, Gaozhou People’s Hospital, Affiliated to Guangdong Medical University, Guangdong Esophageal Cancer Institute Gaozhou Branch, 89 Xiguan Road, Gaozhou, 525200 Guangdong People’s Republic of China
| | - Jing Xie
- grid.478001.aDepartment of Thoracic Surgery, Gaozhou People’s Hospital, Affiliated to Guangdong Medical University, Guangdong Esophageal Cancer Institute Gaozhou Branch, 89 Xiguan Road, Gaozhou, 525200 Guangdong People’s Republic of China
| | - Wanli Lin
- grid.478001.aDepartment of Thoracic Surgery, Gaozhou People’s Hospital, Affiliated to Guangdong Medical University, Guangdong Esophageal Cancer Institute Gaozhou Branch, 89 Xiguan Road, Gaozhou, 525200 Guangdong People’s Republic of China
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11
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Risk Factors for Tumor Positive Resection Margins After Neoadjuvant Chemoradiotherapy for Esophageal Cancer: Results From the Dutch Upper GI Cancer Audit: A Nationwide Population-Based Study. Ann Surg 2023; 277:e313-e319. [PMID: 34334634 PMCID: PMC9831046 DOI: 10.1097/sla.0000000000005112] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To identify risk factors for tumor positive resection margins after neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy for esophageal cancer. SUMMARY BACKGROUND DATA Esophagectomy after nCRT is associated with tumor positive resection margins in 4% to 9% of patients. This study evaluates potential risk factors for positive resection margins after nCRT followed by esophagectomy. METHODS All patients who underwent an elective esophagectomy following nCRT in 2011 to 2017 in the Netherlands were included. A multivariable logistic regression was performed to assess the association between potential risk factors and tumor positive resection margins. RESULTS In total, 3900 patients were included. Tumor positive resection margins were observed in 150 (4%) patients. Risk factors for tumor positive resection margins included tumor length (in centimeters, OR: 1.1, 95% CI: 1.0-1.1), cT4-stage (OR: 3.0, 95% CI: 1.2-6.7), and an Ivor Lewis esophagectomy (OR: 1.6, 95% CI: 1.0-2.6). Predictors associated with a lower risk of tumor positive resection margins were squamous cell carcinoma (OR: 0.4, 95% CI: 0.2-0.7), distal tumors (OR: 0.5, 95% CI: 0.3-1.0), minimally invasive surgery (OR: 0.6, 95% CI: 0.4-0.9), and a hospital volume of >60 esophagectomies per year (OR: 0.6, 95% CI: 0.4-1.0). CONCLUSIONS In this nationwide cohort study, tumor and surgical related factors (tumor length, histology, cT-stage, tumor location, surgical procedure, surgical approach, hospital volume) were identified as risk factors for tumor positive resection margins after nCRT for esophageal cancer. These results can be used to improve the radical resection rate by careful selection of patients and surgical approach and are a plea for centralization of esophageal cancer care.
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12
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Muir D, Antonowicz S, Whiting J, Low D, Maynard N. Implementation of the Esophagectomy Complication Consensus Group definitions: the benefits of speaking the same language. Dis Esophagus 2022; 35:6603615. [PMID: 35673848 DOI: 10.1093/dote/doac022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/17/2022] [Indexed: 12/24/2022]
Abstract
In 2015 the Esophagectomy Complication Consensus Group (ECCG) reported consensus definitions for complications after esophagectomy. This aimed to reduce variation in complication reporting, attributed to heterogeneous definitions. This systematic review aimed to describe the implementation of this definition set, including the effect on complication frequency and variation. A systematic literature review was performed, identifying all observational and randomized studies reporting complication frequencies after esophagectomy since the ECCG publication. Recruitment periods before and subsequent to the index ECCG publication date were included. Coefficients of variance were calculated to assess outcome heterogeneity. Of 144 studies which met inclusion criteria, 70 (48.6%) used ECCG definitions. The median number of separately reported complication types was five per study; only one study reported all ECCG complications. The coefficients of variance of the reported frequencies of eight of the 10 most common complications were reduced in studies which used the ECCG definitions compared with those that did not (P = 0.036). Among ECCG studies, the frequencies of postoperative pneumothorax, reintubation, and pulmonary emboli were significantly reduced in 2020-2021, compared with 2015-2019 (P = 0.006, 0.034, and 0.037 respectively). The ECCG definition set has reduced variation in esophagectomy morbidity reporting. This adds greater confidence to the observed gradual improvement in outcomes with time, and its ongoing use and wider dissemination should be encouraged. However, only a handful of outcomes are widely reported, and only rarely is it used in its entirety.
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Affiliation(s)
- Duncan Muir
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Stefan Antonowicz
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Jack Whiting
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Donald Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Nick Maynard
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
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13
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Xu SJ, Lin LQ, Chen TY, You CX, Chen C, Chen RQ, Chen SC. Nomogram for prognosis of patients with esophageal squamous cell cancer after minimally invasive esophagectomy established based on non-textbook outcome. Surg Endosc 2022; 36:8326-8339. [PMID: 35556169 DOI: 10.1007/s00464-022-09290-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/18/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Non-textbook outcome (non-TO) represents a new prognostic evaluation index for surgical oncology. The present study aimed to develop new nomograms based on non-TO to predict the mortality and recurrence rate in patients with esophageal squamous cell cancer (ESCC) after minimally invasive esophagectomy (MIE). METHODS The study involved a retrospective analysis of 613 ESCC patients, from the prospectively maintained database from January 2011 to December 2018. All the included ESCC patients underwent MIE, and they were randomly (1:1) assigned to the training cohort (307 patients) and the validation cohort (306 patients). Kaplan-Meier survival analysis was used to analyze the differences recorded between overall survival (OS) and disease-free survival (DFS). In the case of the training cohort, the nomograms based on non-TO were developed using Cox regression, and the performance of these nomograms was calibrated and evaluated in the validation cohort. RESULTS Significant differences were recorded for 5-year OS and DFS between non-TO and TO groups (p < 0.05). Multivariate cox analysis revealed that non-TO, intraoperative bleeding, T stage, and N stage acted as independent risk factors that affected OS and DFS (p < 0.05). The results for multivariate regression were used to build non-TO-based nomograms to predict OS and DFS of patients with ESCC, the t-AUC curve analysis showed that the nomograms predicting OS and DFS were more accurate as compared to TNM staging, during the follow-up period in the training cohort and validation cohort. Further, the nomogram score was used to divide ESCC patients into low-, middle-, and high-risk groups and significant differences were recorded for OS and DFS between these three groups (p < 0.001). CONCLUSIONS Non-TO was identified as an independent prognostic factor for ESCC patients. The nomograms based on non-TO could availably predict OS and DFS in ESCC patients after MIE.
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Affiliation(s)
- Shao-Jun Xu
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29 Xin quan Road, Fuzhou, 350001, Fujian Province, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China
- Fujian Provincial Key Laboratory of Cardiothoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Lan-Qin Lin
- Department of Operation, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Ting-Yu Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29 Xin quan Road, Fuzhou, 350001, Fujian Province, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China
- Fujian Provincial Key Laboratory of Cardiothoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Cheng-Xiong You
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29 Xin quan Road, Fuzhou, 350001, Fujian Province, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China
- Fujian Provincial Key Laboratory of Cardiothoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Chao Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29 Xin quan Road, Fuzhou, 350001, Fujian Province, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China
- Fujian Provincial Key Laboratory of Cardiothoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Rui-Qin Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29 Xin quan Road, Fuzhou, 350001, Fujian Province, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China
- Fujian Provincial Key Laboratory of Cardiothoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Shu-Chen Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29 Xin quan Road, Fuzhou, 350001, Fujian Province, China.
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China.
- Fujian Provincial Key Laboratory of Cardiothoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.
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14
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Okuda S, Ohuchida K, Shindo K, Moriyama T, Kawata J, Tamura K, Sada M, Nagayoshi K, Mizuuchi Y, Ikenaga N, Nakata K, Oda Y, Nakamura M. Clinical impact of remnant lymphatic invasion on the recurrence of esophageal squamous cell carcinoma after esophagectomy with neoadjuvant chemotherapy. Oncol Lett 2022; 24:337. [PMID: 36039060 PMCID: PMC9404688 DOI: 10.3892/ol.2022.13457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/26/2022] [Indexed: 12/09/2022] Open
Abstract
For stage II and III esophageal squamous cell carcinoma (ESCC), neoadjuvant chemotherapy (NAC) followed by esophagectomy is recommended in the Japanese guidelines for the diagnosis and treatment of esophageal cancer. However, recurrence of ESCC is common regardless of the NAC regimen and surgical method, and NAC demonstrates limited efficacy against recurrence. Therefore, the present study was conducted to identify risk factors of recurrence of ESCC with surgery after NAC. The outcomes of 51 patients who underwent esophagectomy for ESCC after NAC from 2010 to 2017 at Kyushu University Hospital were retrospectively analyzed. A total of 52 patients with ESCC without NAC followed by esophagectomy from 2001 to 2017 were selected for comparison. Among patients who underwent NAC followed by surgery, only lymphatic invasion (LY; hazard ratio, 2.761; 95% CI, 1.86-6.43, P=0.018) was an independent factor significantly associated with 3-year recurrence-free survival in the multivariate analysis. In patients with pathologic lymph node metastasis (pN) and no LY after NAC, there was significantly less recurrence compared with patients with pN and LY (P=0.0085), whereas in patients without LY after NAC, the presence of pN was not significantly associated with recurrence (P=0.2401). There were significantly fewer LY (+) patients in the NAC (+) group (P=0.0158) compared with those in the NAC (−) group. The presence of LY was an independent risk factor for recurrence of ESCC after esophagectomy following NAC. Overall, adjuvant treatment after surgery may be required in cases with remnant LY after NAC.
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Affiliation(s)
- Sho Okuda
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812‑8582, Japan
| | - Kenoki Ohuchida
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812‑8582, Japan
| | - Koji Shindo
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812‑8582, Japan
| | - Taiki Moriyama
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812‑8582, Japan
| | - Jun Kawata
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812‑8582, Japan
| | - Koji Tamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812‑8582, Japan
| | - Masafumi Sada
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812‑8582, Japan
| | - Kinuko Nagayoshi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812‑8582, Japan
| | - Yusuke Mizuuchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812‑8582, Japan
| | - Naoki Ikenaga
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812‑8582, Japan
| | - Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812‑8582, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812‑8582, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812‑8582, Japan
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15
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Esagian SM, Ziogas IA, Skarentzos K, Katsaros I, Tsoulfas G, Molena D, Karamouzis MV, Rouvelas I, Nilsson M, Schizas D. Robot-Assisted Minimally Invasive Esophagectomy versus Open Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14133177. [PMID: 35804949 PMCID: PMC9264782 DOI: 10.3390/cancers14133177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/12/2022] [Accepted: 06/23/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Robot-assisted minimally invasive esophagectomy (RAMIE) constitutes a newly developed surgical technique for the treatment of resectable esophageal cancer, aiming to further improve the high morbidity and mortality associated with open esophagectomy. We performed a systematic review of the literature and compared the outcomes of RAMIE and open esophagectomy. RAMIE is a safe and feasible procedure, resulting in decreased cardiopulmonary morbidity, wound infections, blood loss, and hospital stays compared to open esophagectomy. Abstract Robot-assisted minimally invasive esophagectomy (RAMIE) was introduced as a further development of the conventional minimally invasive esophagectomy, aiming to further improve the high morbidity and mortality associated with open esophagectomy. We aimed to compare the outcomes between RAMIE and open esophagectomy, which remains a popular approach for resectable esophageal cancer. Ten studies meeting our inclusion criteria were identified, including five retrospective cohort, four prospective cohort, and one randomized controlled trial. RAMIE was associated with significantly lower rates of overall pulmonary complications (odds ratio (OR): 0.38, 95% confidence interval (CI): [0.26, 0.56]), pneumonia (OR: 0.39, 95% CI: [0.26, 0.57]), atrial fibrillation (OR: 0.53, 95% CI: [0.29, 0.98]), and wound infections (OR: 0.20, 95% CI: [0.07, 0.57]) and resulted in less blood loss (weighted mean difference (WMD): −187.08 mL, 95% CI: [−283.81, −90.35]) and shorter hospital stays (WMD: −9.22 days, 95% CI: [−14.39, −4.06]) but longer operative times (WMD: 69.45 min, 95% CI: [34.39, 104.42]). No other statistically significant difference was observed regarding surgical and short-term oncological outcomes. Similar findings were observed when comparing totally robotic procedures only to OE. RAMIE is a safe and feasible procedure, resulting in decreased cardiopulmonary morbidity, wound infections, blood loss, and shorter hospital stays compared to open esophagectomy.
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Affiliation(s)
- Stepan M. Esagian
- Surgery Working Group, Society of Junior Doctors, 151-23 Athens, Greece; (S.M.E.); (I.A.Z.); (K.S.); (I.K.)
| | - Ioannis A. Ziogas
- Surgery Working Group, Society of Junior Doctors, 151-23 Athens, Greece; (S.M.E.); (I.A.Z.); (K.S.); (I.K.)
| | - Konstantinos Skarentzos
- Surgery Working Group, Society of Junior Doctors, 151-23 Athens, Greece; (S.M.E.); (I.A.Z.); (K.S.); (I.K.)
| | - Ioannis Katsaros
- Surgery Working Group, Society of Junior Doctors, 151-23 Athens, Greece; (S.M.E.); (I.A.Z.); (K.S.); (I.K.)
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 115-27 Athens, Greece
| | - Georgios Tsoulfas
- First Department of Surgery, Aristotle University of Thessaloniki, 541-24 Thessaloniki, Greece;
| | - Daniela Molena
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA;
| | - Michalis V. Karamouzis
- Molecular Oncology Unit, Department of Biological Chemistry, National and Kapodistrian University of Athens, 115-27 Athens, Greece;
| | - Ioannis Rouvelas
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, 141-86 Stockholm, Sweden; (I.R.); (M.N.)
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 171-77 Stockholm, Sweden
| | - Magnus Nilsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, 141-86 Stockholm, Sweden; (I.R.); (M.N.)
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 171-77 Stockholm, Sweden
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 115-27 Athens, Greece
- Correspondence:
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16
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Hélène M, Vincent N, Christophe Z, Jacques E, Jean-Philippe R, Slimane D, Jérôme G. Transhiatal esophagectomy as a treatment for locally advanced adenocarcinoma of the gastroesophageal junction: postoperative and oncologic results of a single-center cohort THE for locally advanced GEJC. World J Surg Oncol 2022; 20:70. [PMID: 35249555 PMCID: PMC8898468 DOI: 10.1186/s12957-022-02537-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/21/2022] [Indexed: 12/12/2022] Open
Abstract
Background and purpose To report the postoperative and oncological outcomes of transhiatal esophagectomy for locally advanced cancer of the gastroesophageal junction. Methods Medical records of 120 consecutive patients who underwent transhiatal esophagectomy for locally advanced cancer of the gastroesophageal junction with curative intent after neoadjuvant treatment between February 2006 and December 2018 at our center were reviewed. Results All patients received either chemotherapy (46.7%) or chemoradiation (53.3%). The 90-day mortality and overall morbidity rates were 0.8% and 56.7%, respectively. Respiratory complications were the most common (30.8%). Anastomotic leakage occurred in 19 patients (15.8%), who were treated by local wound care (n = 13) or surgical drainage (n = 6). Recurrent laryngeal nerve injury occurred in 12 patients (9.9%). The median length of hospital stay was 15.5 days. The rate of R0 resection was 95.8%, and the median number of nodes removed was 17.5. Over a median follow-up of 77 months, the rate of recurrence was 40.8%, and the overall survival rates at 1, 3, and 5 years were 91%, 75%, and 65%, respectively. The median survival time was not reached. In multivariate analysis, disease stage was the only independent significant prognostic factor. Conclusions Transhiatal esophagectomy is a safe and effective procedure with good long-term oncological outcomes for locally advanced tumors after neo-adjuvant treatment. It can be recommended for all patients with cancer of the gastroesophageal junction, regardless of the Siewert classification, tumor stage, and comorbidities.
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17
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Wu J, Hu Y, Xu L. Positive circumferential resection margin in locally advanced esophageal cancer: an updated systematic review and meta-analysis. Updates Surg 2022; 74:1187-1197. [PMID: 35212980 DOI: 10.1007/s13304-022-01256-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/10/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The impact of positive circumferential resection margin on prognosis in esophageal cancer is under controversy. Previous systematic reviews and meta-analyses had limitations. This updated systematic review and meta-analysis aimed to assess the prognostic impact of positive circumferential resection margin in esophageal cancer.PubMed and Web of Science were searched for studies investigating the association between circumferential resection margin status and prognosis in esophageal cancer. Study population were focused on T3 and/or T4a patients. Study selection was based on availability of survival information (Kaplan-Meier curves and adjusted analysis). Random-effects models were used to summarize hazard ratios for overall survival and disease-free survival.According to College of American Pathologists criteria, circumferential resection margin-positive patients had shorter median overall survival (P < 0.0001) and shorter median disease-free survival (P < 0.0001) compared with circumferential resection margin-negative patients. The pooled hazard ratios for overall survival and disease-free survival were 2.06 (95% confidence interval, 1.68-2.53; P < 0.0001) and 2.00 (95% confidence interval, 1.41-2.84; P < 0.0001), respectively. According to the Royal College of Pathologists criteria, circumferential resection margin-positive patients had shorter median overall survival (P < 0.0001) and shorter median disease-free survival (P < 0.0001) compared with circumferential resection margin-negative patients. The pooled hazard ratios for overall survival and disease-free survival were 1.31 (95% confidence interval, 1.16-1.48; P < 0.0001) and 1.31 (95% confidence interval, 1.09-1.57; P < 0.0001), respectively.ompared with negative circumferential resection margin, positive circumferential resection margin is associated with worse survival outcomes in esophageal cancer.
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Affiliation(s)
- Jie Wu
- Department of Thoracic Surgery, Institute of Basic Medicine and Cancer (IBMC), The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Chinese Academy of Sciences, 1 East Banshan Rd, Hangzhou, 310022, China.
- Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Beijing, China.
| | - Yuqian Hu
- Department of Thoracic Surgery, Institute of Basic Medicine and Cancer (IBMC), The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Chinese Academy of Sciences, 1 East Banshan Rd, Hangzhou, 310022, China
- Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Beijing, China
| | - Liwei Xu
- Department of Thoracic Surgery, Institute of Basic Medicine and Cancer (IBMC), The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Chinese Academy of Sciences, 1 East Banshan Rd, Hangzhou, 310022, China
- Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Beijing, China
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18
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Levy J, Gupta V, Amirazodi E, Allen-Ayodabo C, Jivraj N, Jeong Y, Davis LE, Mahar AL, De Mestral C, Saarela O, Coburn NG. Textbook Outcome and Survival in Patients With Gastric Cancer: An Analysis of the Population Registry of Esophageal and Stomach Tumours in Ontario (PRESTO). Ann Surg 2022; 275:140-148. [PMID: 32149825 DOI: 10.1097/sla.0000000000003849] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the association between Textbook Outcome (TO)-a new composite quality measurement-and long-term survival in gastric cancer surgery. BACKGROUND Single-quality indicators do not sufficiently reflect the complex and multifaceted nature of perioperative care in patients with gastric adenocarcinoma. METHODS All patients undergoing gastrectomy for nonmetastatic gastric adenocarcinoma registered in the Population Registry of Esophageal and Stomach Tumours of Ontario (PRESTO) between 2004 and 2015 were included. TO was defined according to negative margins; >15 lymph nodes sampled; no severe complications; no re-interventions; no unplanned ICU admission; length of stay ≤21 days; no 30-day readmission; and no 30-day mortality. Three-year survival was estimated using the Kaplan-Meier method. A marginal multivariable Cox proportional-hazards model was used to estimate the association between achieving TO metrics and long-term survival. E-value methodology was used to assess for risk of residual confounding. RESULTS Of the 1836 patients included in this study, 402 (22%) achieved all TO metrics. TO patients had a higher 3-year survival rate compared to non-TO patients (75% vs 55%, log-rank P < 0.001). After adjustments for covariates and clustering within hospitals, TO was associated with a 41% reduction in mortality (adjusted hazards ratio 0.59, 95% confidence interval 0.48, 0.72, P < 0.001). These results were robust to potential residual confounding. CONCLUSIONS Achieving TO is strongly associated with improved long-term survival in gastric cancer patients and merits further focus in surgical quality improvement efforts.
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Affiliation(s)
- Jordan Levy
- Division of General Surgery, Department of Surgery and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Vaibhav Gupta
- Division of General Surgery, Department of Surgery and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Elmira Amirazodi
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Naheed Jivraj
- Department of Anesthesia and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Yunni Jeong
- Division of General Surgery, Department of Surgery and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Laura E Davis
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Alyson L Mahar
- Manitoba Centre for Health Policy and Department of Community Health Sciences, University of Manitoba, Canada
| | - Charles De Mestral
- Division of General Surgery, Department of Surgery and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute and St. Michael's Hospital, Toronto, Ontario, Canada
| | - Olli Saarela
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Natalie G Coburn
- Division of General Surgery, Department of Surgery and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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19
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Brac B, Dufour C, Behal H, Vanderbeken M, Labreuche J, Leteurtre E, Mariette C, Eveno C, Piessen G, Renaud F. Is There an Optimal Definition for a Positive Circumferential Resection Margin in Locally Advanced Esophageal Cancer? Ann Surg Oncol 2021; 28:8337-8346. [PMID: 34514523 DOI: 10.1245/s10434-021-10707-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 07/09/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Two definitions of a positive circumferential resection margin (CRM) in esophageal cancer coexist: one by the College of American Pathologists (CAP) (CRM = 0 mm) and another by the Royal College of Pathologists (RCP) (CRM ≤ 1 mm). This study aimed to evaluate the prognostic value of both definitions in esophageal cancer and to identify a new cutoff value for the CRM to predict survival. METHODS Patients who underwent curative esophageal resection for locally advanced (≥ pT3) adenocarcinoma or squamous cell carcinoma were selected from 2007 to 2016. The CRM was reassessed using an ocular micrometer. Overall survival (OS) and disease-free survival were estimated with uni- and multivariate analyses. RESULTS The study enrolled 283 patients: 48 with a positive CRM according to the CAP definition and 171 with a positive CRM according to the RCP definition. In the multivariate analysis, a positive CRM according to both definitions was significantly associated with a poor OS (CAP: hazard ratio [HR], 2.26, p < 0.001; RCP: HR, 1.42, p = 0.035). A CRM of 0 mm was predictive of a worse OS and DFS than a CRM of 1 mm or less (p < 0.0001), whereas no significant difference was found between a CRM greater than 1 mm and a CRM of 1 mm or less, indicating that the CAP definition was more accurate for predicting prognosis and recurrence. New cutoff CRM values of 100 µm in squamous cell carcinoma and 200 µm in adenocarcinoma were optimal for predicting OS. CONCLUSION The CAP definition was more accurate for predicting prognosis and recurrence. The study identified a new cutoff value of CRM according to histologic type.
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Affiliation(s)
- B Brac
- Department of Digestive and Oncological Surgery, University of Lille, Claude Huriez University Hospital, Lille, France
| | - C Dufour
- Institute of Pathology, Lille University Hospital, Lille, Cedex, France.,CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, University of Lille, Lille, France
| | - H Behal
- CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, University of Lille, Lille, France
| | - M Vanderbeken
- Department of Digestive and Oncological Surgery, University of Lille, Claude Huriez University Hospital, Lille, France
| | - J Labreuche
- CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, University of Lille, Lille, France
| | - E Leteurtre
- Institute of Pathology, Lille University Hospital, Lille, Cedex, France.,CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, University of Lille, Lille, France
| | - C Mariette
- Department of Digestive and Oncological Surgery, University of Lille, Claude Huriez University Hospital, Lille, France.,CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, University of Lille, Lille, France
| | - C Eveno
- Department of Digestive and Oncological Surgery, University of Lille, Claude Huriez University Hospital, Lille, France.,CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, University of Lille, Lille, France
| | - G Piessen
- Department of Digestive and Oncological Surgery, University of Lille, Claude Huriez University Hospital, Lille, France.,CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, University of Lille, Lille, France
| | - F Renaud
- Institute of Pathology, Lille University Hospital, Lille, Cedex, France. .,CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, University of Lille, Lille, France.
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20
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Patel DC, Jeffrey Yang CF, He H, Liou DZ, Backhus LM, Lui NS, Shrager JB, Berry MF. Influence of facility volume on long-term survival of patients undergoing esophagectomy for esophageal cancer. J Thorac Cardiovasc Surg 2021; 163:1536-1546.e3. [PMID: 34247867 DOI: 10.1016/j.jtcvs.2021.05.048] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 04/03/2021] [Accepted: 05/25/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE This study investigated the influence of facility volume on long-term survival in patients with esophageal cancer treated with esophagectomy. METHODS Patients treated with esophagectomy for cT1 3N0 3M0 adenocarcinoma or squamous cell carcinoma of the mid-distal esophagus in the National Cancer Database between 2006 and 2013 were stratified by annual facility esophagectomy volume dichotomized as more/less than both 6 and 20. Patient characteristics associated with facility volume were evaluated using logistic regression, and the influence of facility volume on survival was evaluated with Kaplan-Meier curves, Cox proportional hazards methods, and propensity matched analysis. RESULTS Of 11,739 patients who had esophagectomy at 1018 facilities where annual volume ranged from 1 to 47.6 cases, 4262 (36.3%) were treated at 44 facilities with annual esophagectomy volume > 6 and 1515 (12.9%) were treated at 7 facilities with annual volume > 20. Higher volume was associated with significantly better 5-year survival for both annual volume > 6 (47.6% vs 40.2%; P < .001) and annual volume > 20 (47.2% vs 42.3%; P < .001), which persisted in propensity matched analyses as well as Cox multivariable analysis (hazard ratio, 0.81; 95% confidence interval, 0.74-0.89; P < .001 for facility volume > 6 and hazard ratio, 0.78; 95% confidence interval, 0.65-0.95; P = .01 for facility volume > 20). In Cox multivariable analysis that considered facility volume as a continuous variable, higher volume continued to be associated with better survival (hazard ratio, 0.93 per 5 cases; 95% CI, 0.91-0.96; P < .001). CONCLUSIONS Esophageal cancer patients treated with esophagectomy at higher volume facilities have significantly better long-term survival than patients treated at lower volume facilities.
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Affiliation(s)
- Deven C Patel
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Institute, Stanford University Medical Center, Stanford, Calif
| | - Chi-Fu Jeffrey Yang
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Institute, Stanford University Medical Center, Stanford, Calif
| | - Hao He
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Institute, Stanford University Medical Center, Stanford, Calif
| | - Douglas Z Liou
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Institute, Stanford University Medical Center, Stanford, Calif
| | - Leah M Backhus
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Institute, Stanford University Medical Center, Stanford, Calif; VA Palo Alto Health Care System, Palo Alto, Calif
| | - Natalie S Lui
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Institute, Stanford University Medical Center, Stanford, Calif
| | - Joseph B Shrager
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Institute, Stanford University Medical Center, Stanford, Calif; VA Palo Alto Health Care System, Palo Alto, Calif
| | - Mark F Berry
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Institute, Stanford University Medical Center, Stanford, Calif; VA Palo Alto Health Care System, Palo Alto, Calif.
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21
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St-Amour P, Winiker M, Sempoux C, Fasquelle F, Demartines N, Schäfer M, Mantziari S. The "Real R0": A Resection Margin Smaller Than 0.1 cm is Associated with a Poor Prognosis After Oncologic Esophagectomy. Ann Surg Oncol 2021; 28:7095-7106. [PMID: 34041624 PMCID: PMC8519834 DOI: 10.1245/s10434-021-10121-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/21/2021] [Indexed: 12/09/2022]
Abstract
Background Although resection margin (R) status is a widely used prognostic factor after esophagectomy, the definition of positive margins (R1) is not universal. The Royal College of Pathologists considers R1 resection to be a distance less than 0.1 cm, whereas the College of American Pathologists considers it to be a distance of 0.0 cm. This study assessed the predictive value of R status after oncologic esophagectomy, comparing survival and recurrence among patients with R0 resection (> 0.1-cm clearance), R0+ resection (≤ 0.1-cm clearance), and R1 resection (0.0-cm clearance). Methods The study enrolled all eligible patients undergoing curative oncologic esophagectomy between 2012 and 2018. Clinicopathologic features, survival, and recurrence were compared for R0, R0+, and R1 patients. Categorical variables were compared with the chi-square or Fisher’s test, and continuous variables were compared with the analysis of variance (ANOVA) test, whereas the Kaplan-Meier method and Cox regression were used for survival analysis. Results Among the 160 patients included in this study, 113 resections (70.6%) were R0, 34 (21.3%) were R0+, and 13 (8.1%) were R1. The R0 patients had a better overall survival (OS) and disease-free survival (DFS) than the R0+ and R1 patients. The R0+ resection offered a lower long-term recurrence risk than the R1 resection, and the R status was independently associated with DFS, but not OS, in the multivariate analysis. Both the R0+ and R1 patients had significantly more adverse histologic features (lymphovascular and perineural invasion) than the R0 patients and experienced more distant and locoregional recurrence. Conclusions Although R status is an independent predictor of DFS after oncologic esophagectomy, the < 0.1-cm definition for R1 resection seems more appropriate than the 0.0-cm definition as an indicator of poor tumor biology, long-term recurrence, and survival. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10121-y.
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Affiliation(s)
- Penelope St-Amour
- Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Michael Winiker
- Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Christine Sempoux
- Institute of Pathology, University Hospital of Lausanne, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
| | - François Fasquelle
- Institute of Pathology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Markus Schäfer
- Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland. .,Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland.
| | - Styliani Mantziari
- Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
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22
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Hollertz P, Lindblad M, Sandström P, Halldestam I, Edholm D. Outcome of microscopically non-radical oesophagectomy for oesophageal and oesophagogastric junctional cancer: nationwide cohort study. BJS Open 2021; 5:6273342. [PMID: 33972990 PMCID: PMC8110895 DOI: 10.1093/bjsopen/zrab038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/16/2021] [Indexed: 11/14/2022] Open
Abstract
Background Microscopically non-radical (R1) oesophageal cancer resection has been associated with worse survival. The aim of this study was to identify risk factors for R1 resection and to investigate how this affects long-term survival. Methods The Swedish National Register for Oesophageal and Gastric Cancer was used to identify all patients who underwent oesophageal cancer resection with curative intent between 2006 and 2017. Risk factors for R1 resection were assessed by multivariable logistic regression analysis, and factors predicting 5-year survival identified by multivariable Cox regression. Results The study included 1460 patients. Surgical margins were involved microscopically in 142 patients (9.7 per cent). The circumferential resection margin was involved in 114 (7.8 per cent), the proximal margin in 53 (3.6 per cent), and the distal margin in 29 (2.0 per cent). In 30 specimens (2.1 per cent), two or all three margins were involved. Independent risk factors for R1 resection were male sex, low BMI, absence of neoadjuvant treatments, and clinical T4 disease. The 5-year survival rate for the entire cohort was 42.2 per cent, but only 18.0 per cent for those who had an R1 resection. Independent risk factors for death within 5 years of resection were male sex, age above 60 years, normal BMI, ASA fitness grade III, intermediate-level education, R1 resection (hazard ratio 1.80, 95 per cent c.i. 1.40 to 2.32), clinical T3 disease, and clinical lymph node metastasis. Conclusion R1 resection is common and predicts poor 5-year survival. Absence of neoadjuvant treatment is a risk factor for R1 resection.
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Affiliation(s)
- P Hollertz
- Department of Surgery, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Surgery, Västervik Hospital, Västervik, Sweden
| | - M Lindblad
- Division of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - P Sandström
- Department of Surgery, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - I Halldestam
- Department of Surgery, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - D Edholm
- Department of Surgery, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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23
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Otake R, Okamura A, Yamashita K, Imamura Y, Kanamori J, Kozuki R, Takahashi K, Toihata T, Yamamoto N, Asari T, Mine S, Watanabe M. Efficacy of postoperative radiotherapy in esophageal squamous cell carcinoma patients with positive circumferential resection margin. Esophagus 2021; 18:288-295. [PMID: 33108536 DOI: 10.1007/s10388-020-00790-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 10/15/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND The significance of postoperative radiotherapy for residual disease after esophageal cancer surgery remains controversial. The purpose of this study was to elucidate the efficacy of postoperative radiotherapy in esophageal squamous cell carcinoma (ESCC) patients with positive circumferential resection margin (CRM). METHODS We retrospectively analyzed data from 1190 patients who underwent esophagectomy for ESCC at our hospital from 2005 to 2018, of whom 61 (5.1%) patients were diagnosed with positive CRM of ESCC. Overall survival (OS), progression-specific survival (PSS), local progression-specific survival (LPSS), and clinicopathological factors were compared between patients with and without postoperative radiotherapy. The efficacy of additional radiotherapy on patient outcomes was evaluated. RESULTS Among the 61 patients analyzed, 29 (47.5%) underwent radiotherapy (RT group) and 32 (52.5%) did not (NRT group). In the RT group, 22 patients (75.9%) received radiotherapy and 7 patients (24.1%) received chemoradiotherapy. The RT group included younger patients, a greater number of upper-esophageal tumors, and a greater rate of R2 resections than the NRT group. The LPSS and PSS of the RT group were significantly better than those of the NRT group (P = 0.007, P < 0.001, respectively). In multivariate analysis, postoperative radiotherapy was an independent factor for LPSS [P < 0.001; hazard ratio (HR) 0.17; 95% confidence interval (CI) 0.06-0.46] and PSS (P < 0.001; HR 0.31; 95% CI 0.16-0.60). CONCLUSIONS Postoperative radiotherapy contributed to the control of residual tumor and was significantly associated with better LPSS and PSS among patients with positive CRM after esophagectomy for ESCC.
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Affiliation(s)
- Reiko Otake
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akihiko Okamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Kotaro Yamashita
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Jun Kanamori
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Ryotaro Kozuki
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Keita Takahashi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Tasuku Toihata
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Noriko Yamamoto
- Department of Pathology, Cancer Institute, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takao Asari
- Department of Radiotherapy, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shinji Mine
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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24
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Impact of radial margins after esophagectomy for esophageal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 47:2313-2322. [PMID: 33714649 DOI: 10.1016/j.ejso.2021.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 02/01/2021] [Accepted: 02/09/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The prognostic significance of radial margin (RM) involvement in esophagectomy cancer specimens is unclear. Our study investigated survival and recurrence rates between different depths of RM involvement. MATERIALS AND METHODS We retrospectively analyzed 1103 esophagectomies at our institution from 2005 to 2019. Patients were grouped by three-tier stratification: negative RM > 1 mm away, direct RM involvement at 0 mm, and close RM between 0 mm and 1 mm. Survival, loco-regional and distant recurrences were analyzed. RESULTS 1103 esophageal cancer patients were analyzed. 389 patients had recurrence (35.3%). Median survival (13.2 months) and recurrence rates (71%) were worst with direct RM (p < 0.001) as compared to negative RM (median survival not achieved within 5-years from surgery and 30%). Without nodal involvement, RM involvement of <1 mm was associated with decreased overall survival, and overall, loco-regional and distant recurrence-free survival compared to negative RM (log rank p-value <0.05). In those with persistent nodal disease, only direct RM was associated with decreased overall and loco-regional recurrence-free survival as compared to negative margins (p < 0.05). Direct RM tended to do worse compared to close RM in terms of median survival and trended worse for recurrence. Direct RM (baseline negative RM), but not close RM, was an independent RF in a multivariable Cox model for worse overall survival (HR 2.74; p < 0.001), recurrence-free survival (HR 1.96; p = 0.019), and loco-regional recurrence-free survival (HR 3.19; p = 0.011). CONCLUSION RM involvement affects survival and recurrence. Tumor at 0 mm remained an independent RF for worse survival and overall and loco-regional recurrence.
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25
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Pucher PH, Green M, Bateman AC, Underwood TJ, Maynard N, Allum WH, Novelli M, Gossage JA. Variation in histopathological assessment and association with surgical quality indicators following oesophagectomy. Br J Surg 2021; 108:74-79. [PMID: 33640940 DOI: 10.1093/bjs/znaa038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/04/2020] [Accepted: 09/15/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Histopathological outcomes, such as lymph node yield and margin positivity, are used to benchmark and assess surgical centre quality, and are reported annually by the National Oesophago-Gastric Cancer Audit (NOGCA) in England and Wales. The variation in pathological specimen assessment and how this affects these outcomes is not known. METHODS A survey of practice was circulated to all tertiary oesophagogastric cancer centres across England and Wales. Questions captured demographic data, and information on how specimens were prepared and analysed. National performance data were retrieved from the NOGCA. Survey results were compared for tertiles of lymph node yield, and circumferential and longitudinal margins. RESULTS Survey responses were received from 32 of 37 units (86 per cent response rate), accounting for 93.1 per cent of the total oesophagectomy volume in England and Wales. Only 5 of 32 units met or exceeded current guidelines on specimen preparation according to the Royal College of Pathologists guidelines. There was wide variation in how centres defined positive (R1) margins, and how margins and lymph nodes were assessed. Centres with the highest nodal yield were more likely to use systematic fat blocking, and to re-examine specimens when the initial load was low. Systematic blocking of lesser curve fat resulted in significantly higher rates of patients with at least 15 lymph nodes examined (91.4 versus 86.5 per cent; P = 0.027). CONCLUSION Preparation and histopathological assessment of specimens varies significantly across institutions. This challenges the validity of currently used surgical quality metrics for oesophageal and other tumours.
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Affiliation(s)
- P H Pucher
- Department of General Surgery, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - M Green
- Department of Histopathology, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - A C Bateman
- Department of Histopathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - T J Underwood
- Department of General Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - N Maynard
- Department of General Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - W H Allum
- Department of General Surgery, Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - M Novelli
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, UK
| | - J A Gossage
- Department of General Surgery, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
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Failure to Cure in Patients Undergoing Surgery for Esophageal Carcinoma: Hospital of Surgery Influences Prospects for Cure: A Nation-wide Cohort Study. Ann Surg 2020; 272:744-750. [PMID: 32657922 DOI: 10.1097/sla.0000000000004178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE This study aimed to describe failure to cure in terms of incidence, hospital variation, and as an outcome parameter for salvage esophagectomy. SUMMARY BACKGROUND DATA Failure to cure is a composite outcome measure that could be used for hospital comparison in esophageal carcinoma care. METHODS All patients registered in the Dutch Upper GI Cancer Audit who underwent potentially curative esophageal carcinoma surgery in 2011 to 2018, were included in this nationwide cohort study. Failure to cure was defined as: 1) no surgical resection due to intraoperative metastasis or locally irresectable tumor, 2) macroscopically or microscopically incomplete resection, or 3) 30-day/in-hospital mortality. Association of baseline characteristics with failure to cure was analyzed using multivariable logistic regression in the total population and in salvage patients. RESULTS Some 5894 patients from 22 hospitals were included, of whom 630 (10.7%) had failure to cure (hospital variation [5.5%-19.1%]). Higher age, preoperative weight loss, higher ASA-score, higher N-stage, neoadjuvant chemotherapy, or no neoadjuvant therapy (compared with neoadjuvant chemoradiotherapy), open surgery, and resection before 2014 were associated with failure to cure. After case-mix correction, 2 hospitals had statistically significant higher failure to cure percentages, whereas 2 had lower percentages. Of 151 salvage esophagectomy patients, 32.5% had failure to cure. The failure to cure rate after salvage surgery was 27.6% in high-volume hospitals and 47.6% in medium-volume hospitals. CONCLUSIONS The incidence of failure to cure was 10.7%. Given the significant hospital variation in the percentage of failure to cure, improvement is needed. Since salvage procedures are more often successful in high-volume hospitals, further centralization of this procedure is warranted.
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Abstract
Summary
Background
In the surgical treatment of esophageal cancer, complete tumor resection is the most important factor and determines long-term survival. With an increase in robotic expertise in other fields of surgery, robotic-assisted minimally invasive esophagectomy (RAMIE) was born. Currently, there is a lack of convincing data on the extent of expected benefits (perioperative and oncologic outcomes and/or quality of life). Some evidence exists that patients’ overall quality of life and physical function improves, with less fatigue and pain 3 months after surgery. We aimed to review the available literature regarding robotic esophagectomy, compare perioperative, oncologic, and quality of life outcomes with open and minimally invasive approaches, and give a brief overview of our standardized four-arm RAMIE technique and explore future directions.
Methods
A Medline (PubMed) search was conducted including the following key words: esophagectomy, minimally invasive esophagectomy, robotic esophagectomy, Ivor Lewis and McKeown. We present the history, different techniques used, outcomes, and the standardization of robotic esophagectomy.
Results
Robotic esophagectomy offers a steeper learning curve with fewer complications but comparable oncological results compared to conventional minimally invasive esophagectomy.
Conclusions
Available studies suggest that RAMIE is associated with benefits regarding length of stay, clinical outcomes, and quality of life—if patients are treated in an experienced center with a standardized technique for robotic esophagectomy—making it a potentially beneficial tool in the treatment of esophageal cancer. However, center-wide standardization and prospective data collection will be a necessity to prove superiority of robotic esophagectomy.
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Patterns of Failure After Trimodal Treatment in Esophageal Squamous Cell Carcinoma: Initial Experiences from a High-Risk Endemic Area. Indian J Surg Oncol 2020; 11:360-366. [PMID: 33013111 DOI: 10.1007/s13193-020-01164-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 07/07/2020] [Indexed: 12/24/2022] Open
Abstract
Recurrence is a significant problem faced in patients with esophageal cancer even after treatment with trimodal approach. We report patterns of failure in our patients of esophageal squamous cell cancer (ESCC) treated with trimodal approach. This is a single-institution retrospective analysis of 46 patients of locally advanced ESCC (treated between 2013 and 2017) managed by trimodal treatment approach. Variables were summarized using descriptive statistics. Survival statistics were estimated using Kaplan-Meier method. With a median follow-up of about 28 months, we noted an overall recurrence rate of 37% (17/46), with most of the failures being distant, with or without locoregional recurrence (4 isolated distant and 6 combined distant and locoregional). Median RFS was 34 months and median OS was yet to be reached at the last follow-up. To conclude, optimization of treatment approaches in ESCC is of utmost importance and need of the hour to further improve outcomes in these patients.
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Siaw‐Acheampong K, Kamarajah SK, Gujjuri R, Bundred JR, Singh P, Griffiths EA. Minimally invasive techniques for transthoracic oesophagectomy for oesophageal cancer: systematic review and network meta-analysis. BJS Open 2020; 4:787-803. [PMID: 32894001 PMCID: PMC7528517 DOI: 10.1002/bjs5.50330] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/24/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Oesophagectomy is a demanding operation that can be performed by different approaches including open surgery or a combination of minimal access techniques. This systematic review and network meta-analysis aimed to evaluate the clinical outcomes of open, minimally invasive and robotic oesophagectomy techniques for oesophageal cancer. METHODS A systematic literature search was conducted for studies reporting open oesophagectomy, laparoscopically assisted oesophagectomy (LAO), thoracoscopically assisted oesophagectomy (TAO), totally minimally invasive oesophagectomy (MIO) or robotic MIO (RAMIO) for oesophagectomy. A network meta-analysis of intraoperative (operating time, blood loss), postoperative (overall complications, anastomotic leaks, chyle leak, duration of hospital stay) and oncological (R0 resection, lymphadenectomy) outcomes, and survival was performed. RESULTS Ninety-eight studies involving 32 315 patients were included in the network meta-analysis (open 17 824, 55·2 per cent; LAO 1576, 4·9 per cent; TAO 2421 7·5 per cent; MIO 9558, 29·6 per cent; RAMIO 917, 2·8 per cent). Compared with open oesophagectomy, both MIO and RAMIO were associated with less blood loss, significantly lower rates of pulmonary complications, shorter duration of stay and higher lymph node yield. There were no significant differences between surgical techniques in surgical-site infections, chyle leak, and 30- and 90-day mortality. MIO and RAMIO had better 1- and 5-year survival rates respectively compared with open surgery. CONCLUSION Minimally invasive and robotic techniques for oesophagectomy are associated with reduced perioperative morbidity and duration of hospital stay, with no compromise of oncological outcomes but no improvement in perioperative mortality.
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Affiliation(s)
| | - S. K. Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman HospitalNewcastle University NHS Foundation Trust HospitalsNewcastle upon TyneUK
- Institute of Cellular MedicineUniversity of NewcastleNewcastle upon TyneUK
| | - R. Gujjuri
- College of Medical and Dental SciencesNewcastle upon TyneUK
| | - J. R. Bundred
- College of Medical and Dental SciencesNewcastle upon TyneUK
| | - P. Singh
- Regional Oesophago‐Gastric UnitRoyal Surrey County Hospital NHS Foundation TrustGuildfordUK
| | - E. A. Griffiths
- Institute of Cancer and Genomic Sciences, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Department of Upper Gastrointestinal SurgeryUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
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30
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Liu CY, Hsu PK, Hsu HS, Wu YC, Chuang CY, Lin CH, Hsu CP. Prognostic impact of circumferential resection margin in esophageal cancer with or without neoadjuvant chemoradiotherapy. Dis Esophagus 2020; 33:5739288. [PMID: 32065226 DOI: 10.1093/dote/doz114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/09/2019] [Accepted: 01/02/2020] [Indexed: 12/11/2022]
Abstract
The prognostic impact of circumferential resection margin (CRM) in surgically resected esophageal squamous cell carcinoma (ESCC) has been controversial. This investigation assessed the prognostic impact of CRM in surgically resected pathologic T3 ESCC patients with or without neoadjuvant chemoradiotherapy (nCRT). We reviewed consecutive p/yp T3 ESCC patients undergoing esophagectomy from two medical centers between January 2009 and December 2016. The cohort was divided into two groups: upfront esophagectomy (upfront surgery) and nCRT followed by esophagectomy (nCRT + surgery). CRM status was assessed and divided into CRM > 1 mm, 0 < CRM < 1 mm, and tumor at CRM. A total of 217 p/yp T3 ESCC patients undergoing esophagectomy (138 patients in the upfront surgery group and 79 in the nCRT + surgery group) were enrolled. In the upfront surgery group, patients with 0 < CRM < 1 mm showed equivalent overall survival to those with CRM > 1 mm (log-rank P = 0.817) and significantly outlived those with tumor at CRM (log-rank P < 0.001). However, in the nCRT + surgery group, CRM > 1 mm failed to show survival superiority to CRM between 0 and 1 mm or involved by cancer (log-rank P = 0.390). In conclusion, a negative CRM, even though being <1 mm, is adequate for pT3 ESCC patients undergoing upfront esophagectomy. In contrast, the CRM status is less prognostic in ypT3 ESCC patients undergoing nCRT followed by esophagectomy.
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Affiliation(s)
- C-Y Liu
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Thoracic Surgery, Department of Surgery, Far-Eastern Memorial Hospital, New Taipei City, Taiwan
| | - P-K Hsu
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - H-S Hsu
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Y-C Wu
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - C-Y Chuang
- Division of Thoracic Surgery, Department Thoracic Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - C-H Lin
- Division of Thoracic Surgery, Department Thoracic Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - C-P Hsu
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Thoracic Surgery, Department of Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
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31
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Raman V, Jawitz OK, Voigt SL, Yang CFJ, D'Amico TA, Harpole DH. The Role of Adjuvant Therapy in Patients With Margin-Positive (R1) Esophagectomy: A National Analysis. J Surg Res 2020; 249:82-90. [PMID: 31926400 PMCID: PMC7275192 DOI: 10.1016/j.jss.2019.11.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 11/17/2019] [Accepted: 11/23/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND We performed a nationwide analysis to assess the impact of adjuvant therapy on survival after a microscopically margin-positive (R1) resection for esophageal cancer. METHODS The National Cancer Database was used to identify patients with R1 resection for esophageal cancer (2004-2015). Patients were grouped by type of adjuvant therapy. Patients who had other margin status, M1 disease, neoadjuvant chemotherapy and radiation, missing survival, and no or unknown treatment were excluded. The primary outcome was overall survival. A 1:1 propensity score-matched sensitivity analysis was also performed comparing patients who received no adjuvant therapy with those who received adjuvant chemoradiation. RESULTS Of 546 patients, 279 (51%) received adjuvant therapy and 267 (49%) did not. Patients receiving adjuvant therapy were more likely to be younger, have more advanced pathologic stage, have nonsquamous histology, and have shorter hospitalization. In multivariable analysis, adjuvant chemotherapy, radiation, and chemoradiation were all associated with improved survival compared with no adjuvant therapy. In a propensity score-matched analysis of 123 patient pairs, adjuvant chemoradiation was associated with improved survival compared with no adjuvant therapy (adjusted HR: 0.30; 95% CI: [0.22, 0.40]). CONCLUSIONS Adjuvant therapy is associated with improved survival compared with no adjuvant therapy in patients with R1 resection for esophageal cancer even after adjustment for pathologic stage. Adjuvant therapy should be considered in patients with incompletely resected esophageal cancer in concordance with national guidelines.
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Affiliation(s)
- Vignesh Raman
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Oliver K Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Soraya L Voigt
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Chi-Fu J Yang
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Palo Alto, California
| | - Thomas A D'Amico
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - David H Harpole
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Ma LX, Espin-Garcia O, Lim CH, Jiang DM, Sim HW, Natori A, Chan BA, Suzuki C, Chen EX, Liu G, Brar SS, Swallow CJ, Yeung JC, Darling GE, Wong RK, Kalimuthu SN, Conner J, Elimova E, Jang RW. Impact of adjuvant therapy in patients with a microscopically positive margin after resection for gastric and esophageal cancers. J Gastrointest Oncol 2020; 11:356-365. [PMID: 32399276 DOI: 10.21037/jgo.2020.03.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background A microscopically positive (R1) resection margin following resection for gastric and esophageal cancers has been documented to be a poor prognostic factor. The optimal strategy and impact of different modalities of adjuvant treatment for an R1 resection margin remain unclear. Methods A retrospective analysis was performed for patients with gastric and esophageal adenocarcinoma treated at the Princess Margaret Cancer Centre (PMCC) from 2006-2016. Electronic medical records of all patients with an R1 resection margin were reviewed. Kaplan-Meier and Cox proportional hazards methods were used to analyze recurrence free survival (RFS) and overall survival (OS) with stage and neoadjuvant treatment as covariates in the multivariate analysis. Results We identified 69 gastric and esophageal adenocarcinoma patients with a R1 resection. Neoadjuvant chemoradiation was used in 13% of patients, neoadjuvant chemotherapy in 12%, surgery alone in 75%. Margins involved included proximal in 30%, distal in 14%, radial in 52% and multiple margins in 3% of patients. Pathological staging showed 3% with stage I disease, 20% stage II and 74% stage III. Adjuvant therapy was given in 52% of R1 pts (28% CRT, 20% chemotherapy alone, 3% radiation alone, 1% reoperation). Median RFS was 14.1 months [95% confidence interval (CI), 11.1-17.2]. The site of first recurrence was 72% distant, 12% mixed, 16% locoregional alone. Median OS was 34.5 months (95% CI, 23.3-57.9) for all patients. There was no significant difference in RFS (adjusted P=0.26) or OS (adjusted P=0.83) comparing modality of adjuvant therapy. Conclusions Most patients with positive margins after resection for gastric and esophageal cancer had advanced pathologic stage and prognosis was poor. Our study did not find improved RFS or OS with adjuvant treatment and only one patient had reresection. The main failure pattern was distant recurrence, suggesting that patients being considered for adjuvant radiotherapy (RT) should be carefully selected. Further studies are required to determine factors to select patients with good prognosis despite a positive margin, or those who may benefit from adjuvant treatment.
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Affiliation(s)
- Lucy X Ma
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Osvaldo Espin-Garcia
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Charles H Lim
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Di M Jiang
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Hao-Wen Sim
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Akina Natori
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada.,Department of Medical Oncology, University of Miami, Miami, FL, USA
| | - Bryan A Chan
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Chihiro Suzuki
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Eric X Chen
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Geoffrey Liu
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Savtaj S Brar
- Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and Sinai Health System, University of Toronto, Toronto, Canada
| | - Carol J Swallow
- Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and Sinai Health System, University of Toronto, Toronto, Canada
| | - Jonathan C Yeung
- Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Gail E Darling
- Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Rebecca K Wong
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Sangeetha N Kalimuthu
- Department of Pathology, Laboratory Medicine Program, University Health Network, University of Toronto, Toronto, Canada
| | - James Conner
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Elena Elimova
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Raymond W Jang
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
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33
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Schlick CJR, Bentrem DJ. ASO Author Reflections: Margin Positivity Following Esophageal Cancer Resection is Associated with Treatment Decisions. Ann Surg Oncol 2020; 27:1508-1509. [PMID: 32078715 DOI: 10.1245/s10434-019-08180-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Cary Jo R Schlick
- Department of Surgery, Feinberg School of Medicine, Surgical Outcomes and Quality Improvement Center, Northwestern University, Chicago, USA
| | - David J Bentrem
- Department of Surgery, Feinberg School of Medicine, Surgical Outcomes and Quality Improvement Center, Northwestern University, Chicago, USA. .,Surgery Service, Jesse Brown VA Medical Center, Chicago, IL, USA.
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34
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Schlick CJR, Khorfan R, Odell DD, Merkow RP, Bentrem DJ. Margin Positivity in Resectable Esophageal Cancer: Are there Modifiable Risk Factors? Ann Surg Oncol 2020; 27:1496-1507. [PMID: 31933223 DOI: 10.1245/s10434-019-08176-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients with esophageal cancer have poor overall survival, with positive resection margins worsening survival. Margin positivity rates are used as quality measures in other malignancies, but modifiable risk factors are necessary to develop actionable targets for improvement. Our objectives were to (1) evaluate trends in esophageal cancer margin positivity, and (2) identify modifiable patient/hospital factors associated with margin positivity. METHODS Patients who underwent esophagectomy from 2004 to 2015 were identified from the National Cancer Database. Trends in margin positivity by time and hospital volume were evaluated using Cochrane-Armitage tests. Associations between patient/hospital factors and margin positivity were assessed by multivariable logistic regression. RESULTS Among 29,706 patients who underwent esophagectomy for cancer, 9.37% had positive margins. Margin positivity rates decreased over time (10.62% in 2004 to 8.61% in 2015; p < 0.001). Older patients (≥ 75 years) were more likely to have positive margins [odds ratio (OR) 2.04, 95% confidence interval (CI) 1.42-2.92], as were patients with a Charlson-Deyo Index ≥ 3 (OR 1.84, 95% CI 1.08-3.12). Patients who received neoadjuvant therapy were less likely to have positive margins (OR 0.37, 95% CI 0.29-0.47), while laparoscopic surgical approach was associated with increased margin positivity (OR 1.70, 95% CI 1.40-2.06). As the hospital annual esophagectomy volume increased, margin positivity rates decreased (7.76% in the fourth quartile vs. 11.39% in the first quartile; OR 0.70, 95% CI 0.49-0.99). CONCLUSIONS Use of neoadjuvant therapy, surgical approach, and hospital volume are modifiable risk factors for margin positivity in esophageal cancer. These factors should be considered in treatment planning, and margin positivity rates could be considered as a quality measure in esophageal cancer.
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Affiliation(s)
- Cary Jo R Schlick
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Rhami Khorfan
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - David D Odell
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ryan P Merkow
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - David J Bentrem
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. .,Surgery Service, Jesse Brown VA Medical Center, Chicago, IL, USA.
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35
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Fountoulakis A, Souglakos J, Vini L, Douridas GN, Koumarianou A, Kountourakis P, Agalianos C, Alexandrou A, Dervenis C, Gourtsoyianni S, Gouvas N, Kalogeridi MA, Levidou G, Liakakos T, Sgouros J, Sgouros SN, Triantopoulou C, Xynos E. Consensus statement of the Hellenic and Cypriot Oesophageal Cancer Study Group on the diagnosis, staging and management of oesophageal cancer. Updates Surg 2019; 71:599-624. [DOI: 10.1007/s13304-019-00696-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/26/2019] [Indexed: 12/13/2022]
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36
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Knight WRC, Yip C, Wulaningsih W, Jacques A, Griffin N, Zylstra J, Van Hemelrijck M, Maisey N, Gaya A, Baker CR, Kelly M, Gossage JA, Lagergren J, Landau D, Goh V, Davies AR, Ngan S, Qureshi A, Deere H, Green M, Chang F, Mahadeva U, Gill‐Barman B, George S, Dunn J, Zeki S, Meenan J, Hynes O, Tham G, Iezzi C. Prediction of a positive circumferential resection margin at surgery following neoadjuvant chemotherapy for adenocarcinoma of the oesophagus. BJS Open 2019; 3:767-776. [PMID: 31832583 PMCID: PMC6887675 DOI: 10.1002/bjs5.50211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 06/24/2019] [Indexed: 02/06/2023] Open
Abstract
Background A positive circumferential resection margin (CRM) has been associated with higher rates of locoregional recurrence and worse survival in oesophageal cancer. The aim of this study was to establish if clinicopathological and radiological variables might predict CRM positivity in patients who received neoadjuvant chemotherapy before surgery for oesophageal adenocarcinoma. Methods Multivariable analysis of clinicopathological and CT imaging characteristics considered potentially predictive of CRM was performed at initial staging and following neoadjuvant chemotherapy. Prediction models were constructed. The area under the curve (AUC) with 95% confidence intervals (c.i.) from 1000 bootstrapping was assessed. Results A total of 223 patients were included in the study. Poor differentiation (odds ratio (OR) 2·84, 95 per cent c.i. 1·39 to 6·01) and advanced clinical tumour status (T3-4) (OR 2·93, 1·03 to 9·48) were independently associated with an increased CRM risk at diagnosis. CT-assessed lack of response (stable or progressive disease) following chemotherapy independently corresponded with an increased risk of CRM positivity (OR 3·38, 1·43 to 8·50). Additional CT evidence of local invasion and higher CT tumour volume (14 cm3) improved the performance of a prediction model, including all the above parameters, with an AUC (c-index) of 0·76 (0·67 to 0·83). Variables associated with significantly higher rates of locoregional recurrence were pN status (P = 0·020), lymphovascular invasion (P = 0·007) and poor response to chemotherapy (Mandard score 4-5) (P = 0·006). CRM positivity was associated with a higher locoregional recurrence rate, but this was not statistically significant (P = 0·092). Conclusion The presence of advanced cT status, poor tumour differentiation, and CT-assessed lack of response to chemotherapy, higher tumour volume and local invasion can be used to identify patients at risk of a positive CRM following neoadjuvant chemotherapy.
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Affiliation(s)
- W. R. C. Knight
- Department of Surgery, Guy's and St Thomas' Oesophago‐Gastric Centre, King's College London
- School of Cancer and Pharmaceutical Sciences, King's College London
| | - C. Yip
- School of Biomedical Engineering and Imaging Sciences, King's College London
| | - W. Wulaningsih
- Cancer Epidemiology and Population Health Associated Research Group, King's College London
| | - A. Jacques
- Department of Radiology, Guy's and St Thomas' Hospital, London, UK
| | - N. Griffin
- Department of Radiology, Guy's and St Thomas' Hospital, London, UK
| | - J. Zylstra
- Department of Surgery, Guy's and St Thomas' Oesophago‐Gastric Centre, King's College London
| | - M. Van Hemelrijck
- Cancer Epidemiology and Population Health Associated Research Group, King's College London
| | - N. Maisey
- Department of Oncology, Guy's and St Thomas' Hospital, London, UK
| | - A. Gaya
- Department of Oncology, Guy's and St Thomas' Hospital, London, UK
| | - C. R. Baker
- Department of Surgery, Guy's and St Thomas' Oesophago‐Gastric Centre, King's College London
| | - M. Kelly
- Department of Surgery, Guy's and St Thomas' Oesophago‐Gastric Centre, King's College London
| | - J. A. Gossage
- Department of Surgery, Guy's and St Thomas' Oesophago‐Gastric Centre, King's College London
- School of Cancer and Pharmaceutical Sciences, King's College London
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - J. Lagergren
- Department of Surgery, Guy's and St Thomas' Oesophago‐Gastric Centre, King's College London
- School of Cancer and Pharmaceutical Sciences, King's College London
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - D. Landau
- Department of Oncology, Guy's and St Thomas' Hospital, London, UK
| | - V. Goh
- School of Biomedical Engineering and Imaging Sciences, King's College London
- Cancer Epidemiology and Population Health Associated Research Group, King's College London
| | - A. R. Davies
- Department of Surgery, Guy's and St Thomas' Oesophago‐Gastric Centre, King's College London
- School of Cancer and Pharmaceutical Sciences, King's College London
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Papaxoinis G, Kamposioras K, Weaver JMJ, Kordatou Z, Stamatopoulou S, Germetaki T, Nasralla M, Owen-Holt V, Anthoney A, Mansoor W. The Role of Continuing Perioperative Chemotherapy Post Surgery in Patients with Esophageal or Gastroesophageal Junction Adenocarcinoma: a Multicenter Cohort Study. J Gastrointest Surg 2019; 23:1729-1741. [PMID: 30671799 DOI: 10.1007/s11605-018-04087-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 12/16/2018] [Indexed: 01/31/2023]
Abstract
PURPOSE The aim of this cohort study was to assess the benefit that patients with lower esophageal or gastroesophageal junction (E/GEJ) adenocarcinoma receive by continuing perioperative chemotherapy post-surgery. METHODS Three hundred twelve patients underwent radical tumor surgical resection after preoperative chemotherapy. Chemotherapy was mainly ECX (epirubicin, cisplatin, capecitabine). Propensity score matching (PSM) was used to compare continuation of chemotherapy post-surgery vs. no postoperative treatment. RESULTS Two hundred ten patients (67.3%) had GEJ and 102 (32.7%) lower esophageal adenocarcinoma. Microscopically clear surgical margins (R0), according to the Royal College of Pathologists, were achieved in 208 patients (66.7%). In total, 225 patients (72.1%) continued perioperative chemotherapy post-surgery. PSM was used to create two patient groups, well-balanced for basic epidemiological, clinical, and histopathological characteristics. The first included 148 patients who continued perioperative chemotherapy after surgery and the second 86, who did not receive postoperative treatment. The first group had non-significantly different median time-to-relapse (TTR 22.2 vs. 25.7 months, p = 0.627), overall survival (OS 46.1 vs. 36.7 months, p = 0.199), and post-relapse survival (15.3 vs. 8.7 months, p = 0.122). Subgroup analysis showed that only patients with microscopically residual disease after surgery (R1 resection) benefited from continuation of chemotherapy post-surgery for both TTR (hazard ratio [HR] 0.556, 95% CI 0.330-0.936, p = 0.027) and OS (HR 0.530, 95% CI 0.313-0.898, p = 0.018). CONCLUSIONS Continuation of perioperative chemotherapy post-surgery was not associated with improved outcome in patients with E/GEJ adenocarcinoma. Patients with microscopically residual disease post-surgery might receive a potential benefit from adjuvant chemotherapy.
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Affiliation(s)
- George Papaxoinis
- Department of Medical Oncology, The Christie NHS Foundation Trust, 550 Wilmslow Road, Manchester, M20 4BX, UK
| | | | - Jamie M J Weaver
- Department of Medical Oncology, The Christie NHS Foundation Trust, 550 Wilmslow Road, Manchester, M20 4BX, UK
| | - Zoe Kordatou
- Department of Medical Oncology, The Christie NHS Foundation Trust, 550 Wilmslow Road, Manchester, M20 4BX, UK
| | - Sofia Stamatopoulou
- Department of Medical Oncology, The Christie NHS Foundation Trust, 550 Wilmslow Road, Manchester, M20 4BX, UK
| | - Theodora Germetaki
- Department of Medical Oncology, The Christie NHS Foundation Trust, 550 Wilmslow Road, Manchester, M20 4BX, UK
| | - Magdy Nasralla
- Department of Medical Oncology, The Christie NHS Foundation Trust, 550 Wilmslow Road, Manchester, M20 4BX, UK
| | - Vikki Owen-Holt
- Department of Medical Oncology, The Christie NHS Foundation Trust, 550 Wilmslow Road, Manchester, M20 4BX, UK
| | - Alan Anthoney
- Department of Medical Oncology, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Wasat Mansoor
- Department of Medical Oncology, The Christie NHS Foundation Trust, 550 Wilmslow Road, Manchester, M20 4BX, UK.
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Vadhwana B, Zosimas D, Lykoudis PM, Phen HM, Martinou M, Amalesh T, Khoo D. Adjuvant radiotherapy in oesophageal cancer with positive circumferential resection margins-recurrence and survival outcomes. J Gastrointest Oncol 2019; 10:483-491. [PMID: 31183198 DOI: 10.21037/jgo.2019.01.26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background The role of adjuvant radiotherapy in patients with microscopically positive circumferential resection margins (CRM), R1 specimen, in oesophageal resections for cancer with curative intent remains unclear. However, R1 specimens are associated with poorer survival outcomes. The aim was to assess the benefit of adjuvant radiotherapy on recurrence and survival in these patients. Methods Patients were identified in a single centre between July 2000 and December 2016. Patient demographics, tumour characteristics and survival outcomes were assimilated and compared between those who received adjuvant therapy and those who did not. Results Sixty-eight patients were included in the study; 57 (83.8%) male and 11 (16.2%) female with a median age of 67 years. The adjuvant radiotherapy regimen used was 40-50 Gy in 25 fractions over 5 weeks. Median follow-up was 13 months (interquartile range, 6-27 months). Twenty-five (36.8%) patients received adjuvant radiotherapy. There was no statistically significant correlation between administration of adjuvant radiotherapy and local recurrence (P=0.148), distant metastases (P=0.605), overall disease progression (P=0.561), progression-free survival (P=0.663) and overall survival (P=0.538). Conclusions This study detects no benefit to oncological outcomes with the use of adjuvant radiotherapy in patients with microscopically positive CRM. Larger randomized studies are needed to further confirm these results.
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Affiliation(s)
- Bhamini Vadhwana
- Department of General Surgery, Queens Hospital, Rom Valley Way, Romford, UK
| | - Dimitrios Zosimas
- Department of General Surgery, Queens Hospital, Rom Valley Way, Romford, UK
| | - Panagis M Lykoudis
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Huan Ming Phen
- Department of General Surgery, Queens Hospital, Rom Valley Way, Romford, UK
| | - Maria Martinou
- Department of Oncology, Queens Hospital, Rom Valley Way, Romford, UK
| | | | - David Khoo
- Department of General Surgery, Queens Hospital, Rom Valley Way, Romford, UK
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Lin JB, Hung LC, Cheng CY, Chien YA, Lee CH, Huang CC, Chou TW, Ko MH, Lai YC, Liu MT, Chang TH, Lee J, Chen YJ. Prognostic significance of lung radiation dose in patients with esophageal cancer treated with neoadjuvant chemoradiotherapy. Radiat Oncol 2019; 14:85. [PMID: 31126307 PMCID: PMC6534831 DOI: 10.1186/s13014-019-1283-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 04/25/2019] [Indexed: 12/13/2022] Open
Abstract
Background The prognostic significance of radiation dose to the lung or heart is unknown in esophageal cancer patients receiving neoadjuvant chemoradiotherapy followed by surgery (trimodal therapy). This study aimed to determine the association between lung and heart radiation dose volumes and prognosis of esophageal cancer after trimodal therapy. Methods This study reviewed 123 esophageal cancer patients treated with trimodal therapy in two tertiary institutions between 2010 and 2015. The dose-volume histogram parameter of Vx was defined as the percentage of total organ volume receiving a radiation dose of x (Gy) or more. Predictors of overall survival (OS) were identified using Cox regression models. Receiver-operating characteristic curves were used to select cut-off values for dose-volume. Results Median follow-up was 28.3 months (range: 4.7–92.8 months). Median OS and progression-free survival were 34.0 months (95% confidence interval [CI]: 27.4–40.6 months) and 24.8 months (95% CI, 18.9–30.7 months), respectively. Multivariate analyses showed that lung V20 (hazard ratio, 1.09; 95% CI: 1.04–1.14; p < 0.001) and lung V5 (hazard ratio, 1.02; 95% CI: 1.00–1.05; p = 0.03) were associated with OS when adjusting for surgical margin and pathological treatment response. The 5-year OS for patients with lung V20 ≤ 23% vs. patients with lung V20 > 23% was 54.4% vs. 5% (p < 0.001) whereas that for patients with lung V5 ≤ 56% vs. patients with lung V5 > 56% was 81.5% vs. 23.4% (p < 0.001). Mean heart dose showed no association with survival outcomes. Conclusions Lung radiation dose was independently associated with survival outcomes in esophageal cancer patients treated with neoadjuvant chemoradiotherapy and surgery. Electronic supplementary material The online version of this article (10.1186/s13014-019-1283-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jhen-Bin Lin
- Department of Radiation Oncology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua City, 50006, Taiwan
| | - Li-Chung Hung
- Department of Radiation Oncology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua City, 50006, Taiwan
| | - Ching-Yuan Cheng
- Department of Thoracic Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Yu-An Chien
- Department of Radiation Oncology, Changhua Christian Hospital Yunlin Branch, Yunlin, Taiwan
| | - Chou-Hsien Lee
- Department of Radiation Oncology, E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Chia-Chun Huang
- Department of Radiation Oncology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua City, 50006, Taiwan
| | - Tsai-Wei Chou
- Department of Radiation Oncology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua City, 50006, Taiwan
| | - Ming-Huei Ko
- Division of Medical Physics, Department of Radiation Oncology, Changhua Christian Hospital, Changhua, Taiwan
| | - Yuan-Chun Lai
- Division of Medical Physics, Department of Radiation Oncology, Changhua Christian Hospital, Changhua, Taiwan
| | - Mu-Tai Liu
- Department of Radiation Oncology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua City, 50006, Taiwan.,Department of Medical Imaging and Radiological Technology, Yuanpei University of Science and Technology, Hsinchu, Taiwan
| | - Tung-Hao Chang
- Department of Radiation Oncology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua City, 50006, Taiwan. .,Department of Medical Imaging and Radiological Technology, Yuanpei University of Science and Technology, Hsinchu, Taiwan.
| | - Jie Lee
- Department of Radiation Oncology, MacKay Memorial Hospital, 92, Section 2, Chung Shan North Road, Taipei, 10449, Taiwan. .,Department of Medicine, MacKay Medical College, New Taipei city, Taiwan.
| | - Yu-Jen Chen
- Department of Radiation Oncology, MacKay Memorial Hospital, 92, Section 2, Chung Shan North Road, Taipei, 10449, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei city, Taiwan
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40
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Chen YH, Yeh CJ, Wen YW, Chuang WY, Chao YK. Do dysplastic proximal resection margins predict the risk of anastomotic recurrence and overall survival in patients with esophageal squamous cell carcinoma? Dis Esophagus 2019; 32:5098583. [PMID: 30239640 DOI: 10.1093/dote/doy090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 07/23/2018] [Accepted: 08/21/2018] [Indexed: 12/11/2022]
Abstract
Positive proximal resection margins are strongly associated with anastomotic recurrence in esophageal cancer. However, the prognostic significance of dysplastic proximal resection margins remains unclear. The aim of this study is to investigate whether the dysplastic proximal resection margin can predict anastomotic recurrence and overall survival in patients with esophageal squamous cell carcinoma. Between 2000 and 2014, patients with esophageal squamous cell carcinoma who received a nonpalliative resection and survived the perioperative period were included. Two expert pathologists independently reviewed the proximal resection margin status, which was classified as negative, dysplastic, or positive. The kappa statistic was used to test interobserver reliability. Anastomotic recurrence and overall survival served as the main outcome measures. The study cohort consisted of 469 patients (445 males and 27 females). There was an excellent interobserver agreement for negative (kappa = 0.88), dysplastic (kappa = 0.88), and positive (kappa = 1) proximal resection margins-which were identified in 418 (89.1%), 37 (7.9%), and 14 (3.0%) patients, respectively. After a median follow-up of 21.6 months, 30 (6.4%) patients developed an anastomotic recurrence. Compared with patients with negative proximal resection margins (24/418, 5.7%), the occurrence of anastomotic recurrence was more commonly observed in those with positive proximal resection margins (3/14, 21.4%, P = 0.017) but not in those with dysplastic proximal resection margins (3/37, 8.1%, P = 0.56). Multivariable Cox regression analysis identified positive proximal resection margins (hazard ratio: 5.93, P = 0.010) and advanced clinical stage (hazard ratio: 12.04, P = 0.023) as independent risk factors for anastomotic recurrence. Dysplastic proximal resection margins were not retained in the model as an independent predictor (hazard ratio: 1.38, P = 0.602). The 5-year overall survival rates of patients with negative (38.2%) and dysplastic margins (27.0%) were similar (P = 0.814), and significantly higher than that observed in those with positive proximal resection margins (9.5%, P = 0.015). In conclusion, dysplastic proximal resection margins can be identified in at least 7.9% of patients with esophageal squamous cell carcinoma, but neither they are associated with an increased risk of anastomotic recurrence nor they portend a poor overall survival.
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Affiliation(s)
- Y-H Chen
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, College of Medicine, Taoyuan, Taiwan
| | - C-J Yeh
- Department of Pathology, Chang Gung Memorial Hospital-Linkou, College of Medicine, Taoyuan, Taiwan
| | - Y-W Wen
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, College of Medicine, Taoyuan, Taiwan.,Department of Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan
| | - W-Y Chuang
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, College of Medicine, Taoyuan, Taiwan
| | - Y-K Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, College of Medicine, Taoyuan, Taiwan
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Radiation With Neoadjuvant Chemotherapy Does Not Improve Outcomes in Esophageal Squamous Cell Cancer. J Surg Res 2019; 236:259-265. [PMID: 30694764 PMCID: PMC10005325 DOI: 10.1016/j.jss.2018.11.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 10/25/2018] [Accepted: 11/26/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND Neoadjuvant treatment improves survival for patients undergoing esophagectomy for esophageal cancer. Recent evidence suggests that neoadjuvant chemoradiation offers no advantage over chemotherapy alone before surgical resection for adenocarcinoma histology. We sought to examine if this applies to patients with squamous cell histology. MATERIALS AND METHODS The National Cancer Database was queried for patients who underwent treatment for squamous cell carcinoma of the esophagus from 2004 to 2012. Patients who underwent neoadjuvant chemotherapy before esophagectomy were compared with those undergoing chemotherapy and radiation before surgical resection. Associations between potential covariates and treatment were analyzed using the Pearson chi-square test for categorical variables and Wilcoxon rank sum test for continuous variables. Univariate and multivariate proportional hazards modeling results were used to assess the effect of treatment on overall survival. Relative prognosis was summarized using estimates and 95% confidence limits for the hazard ratio. Unadjusted differences in overall survival and disease-specific survival between the treatment are shown using Kaplan-Meier methods. RESULTS A total of 902 patients underwent neoadjuvant therapy before surgical resection during the study period, with 827 receiving chemotherapy and radiation, and 75 receiving chemotherapy alone preoperatively. The 30- and 90-d mortality for patients undergoing neoadjuvant chemotherapy and radiation followed by surgery were 5.4% and 10.4% compared to 5.5% and 11.1% for patients who received chemotherapy alone preoperatively (P = 0.963 and P = 0.856), respectively. Median overall survival for patients receiving chemotherapy and radiation was 36.0 mo versus 40.8 mo for chemotherapy alone. The 5-y survival was 39% for the chemotherapy and radiation group and 43% for the chemotherapy group (logrank P = 0.7212). CONCLUSIONS For patients undergoing neoadjuvant treatment before planned surgical resection of squamous cell carcinoma of the esophagus, the addition of radiation to neoadjuvant chemotherapy did not improve long-term survival and did not appear to impact short-term outcomes postoperatively. Further study with a randomized phase III trial is needed.
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42
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Patrão AS, Papaxoinis G, Kordatou Z, Weaver JMJ, Owen-Holt V, Alkhaffaf B, Galloway S, Mansoor W. Prognostic significance of positive circumferential resection margin post neoadjuvant chemotherapy in patients with esophageal or gastro-esophageal junction adenocarcinoma. Eur J Surg Oncol 2019; 45:439-445. [DOI: 10.1016/j.ejso.2018.10.530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 10/02/2018] [Accepted: 10/22/2018] [Indexed: 12/20/2022] Open
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Wong I, Law S. The management of mid & proximal oesophageal squamous cell carcinoma. Best Pract Res Clin Gastroenterol 2018; 36-37:85-90. [PMID: 30551861 DOI: 10.1016/j.bpg.2018.11.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 01/31/2023]
Abstract
Despite the rise in incidence of adenocarcinoma, squamous cell cancer of the oesophagus remains the commonest cell type worldwide and is predominant in the East. Except for very early tumours where endoscopic therapy can be performed with curative intent, in more advanced but potentially curative cancers, treatment for mid and upper third tumours is primarily surgery with extended lymphadenectomy, together with multimodal therapies such as preoperative chemotherapy or chemoradiotherapy. Definitive chemoradiotherapy is utilized in those who decline surgery or in those who are unfit for major procedures. For cervical oesophageal cancer, the anatomical proximity to the larynx influences the choice of treatment and surgical options. Definitive chemoradiation with the aim of laryngeal preservation has become the treatment of choice; long-term prognosis is believed to be comparable to radical pharyngo-laryngo-oesophagectomy. Selected patients with residual disease or disease recurrence can consider salvage surgery. The decision to operate is a major undertaking as salvage surgery carries high morbidity and even mortality risks. Careful patient selection, choice of treatment, meticulous operative technique and postoperative care are the cornerstones of success.
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Affiliation(s)
- Ian Wong
- Division of Esophageal and Upper Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong.
| | - Simon Law
- Division of Esophageal and Upper Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong.
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44
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Vendrely V, Launay V, Najah H, Smith D, Collet D, Gronnier C. Prognostic factors in esophageal cancer treated with curative intent. Dig Liver Dis 2018; 50:991-996. [PMID: 30166221 DOI: 10.1016/j.dld.2018.08.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/31/2018] [Accepted: 08/02/2018] [Indexed: 02/06/2023]
Abstract
The overall prognosis of patients with esophageal cancer has improved in recent decades due to surgical and medical progress, but overall survival remains poor. Better patient selection and tailored treatment are needed. Different prognostic factors linked with the patient, tumoral characteristics and treatment with curative intent have been identified and are the purpose of this review. Tumor detection at an earlier stage, the advent of new molecules and therapeutic combinations, and the centralization of management in high-volume centers should help to improve the prognosis of esophageal cancer. Improved imaging techniques and a better prediction strategy should guide future treatments.
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Affiliation(s)
- Véronique Vendrely
- Bordeaux University of Medicine, Bordeaux, France; Department of Radiation Oncology, Haut-Lévêque Hospital, Pessac, France; INSERM UMR1035 University of Bordeaux, Bordeaux, France
| | - Vincent Launay
- Esophageal and Endocrine Surgery Unit, Visceral Surgery Department, Magellan Center, Bordeaux University Hospital, Pessac, France
| | - Haythem Najah
- Esophageal and Endocrine Surgery Unit, Visceral Surgery Department, Magellan Center, Bordeaux University Hospital, Pessac, France
| | - Denis Smith
- Department of Hepatogastroenterology, Magellan Center, Bordeaux University Hospital, Pessac, France
| | - Denis Collet
- Bordeaux University of Medicine, Bordeaux, France; Esophageal and Endocrine Surgery Unit, Visceral Surgery Department, Magellan Center, Bordeaux University Hospital, Pessac, France
| | - Caroline Gronnier
- Bordeaux University of Medicine, Bordeaux, France; Esophageal and Endocrine Surgery Unit, Visceral Surgery Department, Magellan Center, Bordeaux University Hospital, Pessac, France; INSERM, UMR1053 Bordeaux Research in Translational Oncology, BaRITOn, University of Bordeaux, Bordeaux, France.
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45
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Alieva M, van Rheenen J, Broekman MLD. Potential impact of invasive surgical procedures on primary tumor growth and metastasis. Clin Exp Metastasis 2018; 35:319-331. [PMID: 29728948 PMCID: PMC6063335 DOI: 10.1007/s10585-018-9896-8] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 04/30/2018] [Indexed: 02/08/2023]
Abstract
Surgical procedures such as tumor resection and biopsy are still the gold standard for diagnosis and (determination of) treatment of solid tumors, and are prognostically beneficial for patients. However, growing evidence suggests that even a minor surgical trauma can influence several (patho) physiological processes that might promote postoperative metastatic spread and tumor recurrence. Local effects include tumor seeding and a wound healing response that can promote tumor cell migration, proliferation, differentiation, extracellular matrix remodeling, angiogenesis and extravasation. In addition, local and systemic immunosuppression impairs antitumor immunity and contributes to tumor cell survival. Surgical manipulation of the tumor can result in cancer cell release into the circulation, thus increasing the chance of tumor cell dissemination. To prevent these undesired effects of surgical interventions, therapeutic strategies targeting immune response exacerbation or alteration have been proposed. This review summarizes the current literature regarding these local, systemic and secondary site effects of surgical interventions on tumor progression and dissemination, and discusses studies that aimed to identify potential therapeutic approaches to prevent these effects in order to further increase the clinical benefit from surgical procedures.
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Affiliation(s)
- Maria Alieva
- Princess Máxima Center for Pediatric Oncology, Uppsalalaan 8, 3584 CT, Utrecht, The Netherlands.
| | - Jacco van Rheenen
- Department of Molecular Pathology, Oncode Institute, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Marike L D Broekman
- Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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46
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Knight WRC, Zylstra J, Wulaningsih W, Van Hemelrijck M, Landau D, Maisey N, Gaya A, Baker CR, Gossage JA, Largergren J, Davies AR. Impact of incremental circumferential resection margin distance on overall survival and recurrence in oesophageal adenocarcinoma. BJS Open 2018; 2:229-237. [PMID: 30079392 PMCID: PMC6069345 DOI: 10.1002/bjs5.65] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 03/02/2018] [Indexed: 01/04/2023] Open
Abstract
Background Previous analyses of the oesophageal circumferential resection margin (CRM) have focused on the prognostic validity of two different definitions of a positive CRM, that of the College of American Pathologists (tumour at margin) and that of the Royal College of Pathologists (tumour within 1 mm). This study aimed to analyse the validity of these definitions and explore the risk of recurrence and survival with incremental tumour distances from the CRM. Methods This cohort study included patients who underwent resection for adenocarcinoma of the oesophagus between 2000 and 2014. Kaplan-Meier and Cox regression analyses were performed to determine the hazard ratio (HR) with 95 per cent confidence intervals for recurrence and mortality in CRM increments: tumour at the cut margin, extending to within 0·1-0·9, 1·0-1·9, 2·0-4·9 mm, and 5·0 mm or more from the margin. Results A total of 444 patients were included in the study. Kaplan-Meier and unadjusted analyses showed a significant incremental improvement in overall survival (P < 0·001) and recurrence (P for trend < 0·001) rates with increasing distance from the CRM. Tumour distance of 2·0 mm or more remained a significant predictor of survival on multivariable analysis (HR for risk of death 0·66, 95 per cent c.i. 0·44 to 1·00). Multivariable analysis of overall survival demonstrated a significant difference between a positive and negative CRM with the Royal College of Pathologists' definition (HR 1·37, 1·01 to 1·85), but not with the College of American Pathologists' definition (HR 1·22, 0·90 to 1·65). Conclusion This study demonstrated an incremental improvement in survival and recurrence rates with increasing tumour distance from the CRM.
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Affiliation(s)
- W R C Knight
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK.,Division of Cancer Studies, King's College London, London, UK
| | - J Zylstra
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | - W Wulaningsih
- Medical Research Council Unit for Lifelong Health and Ageing, University College London, London, UK
| | - M Van Hemelrijck
- Cancer Epidemiology and Population Health Associated Research Group, King's College London, London, UK
| | - D Landau
- Department of Oncology, Guy's and St Thomas' Hospital, London, UK
| | - N Maisey
- Department of Oncology, Guy's and St Thomas' Hospital, London, UK
| | - A Gaya
- Department of Oncology, Guy's and St Thomas' Hospital, London, UK
| | - C R Baker
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | - J A Gossage
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK.,Division of Cancer Studies, King's College London, London, UK.,Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - J Largergren
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK.,Division of Cancer Studies, King's College London, London, UK.,Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - A R Davies
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK.,Division of Cancer Studies, King's College London, London, UK.,Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Depypere L, Moons J, Lerut T, De Hertogh G, Peters C, Sagaert X, Coosemans W, Van Veer H, Nafteux P. Prognostic value of the circumferential resection margin and its definitions in esophageal cancer patients after neoadjuvant chemoradiotherapy. Dis Esophagus 2018; 31:4259165. [PMID: 29036407 DOI: 10.1093/dote/dox117] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 08/29/2017] [Indexed: 12/11/2022]
Abstract
The accepted importance of a positive circumferential resection margin (CRM) (defined as R1 in the TNM classification) is based on histopathology of the resection specimen obtained after primary surgery in esophageal cancer patients. The aim of this study is to look for the prognostic value of CRM after neoadjuvant chemoradiotherapy and to compare the clinical significance of a histologically CRM < 1 mm from the cut margin (Royal College of Pathologists definition of R1) to a positive cut margin (College of American Pathologists definition of R1) and to ≥1 mm margin (R0) resections in patients with ypT3-esophageal tumors after neoadjuvant chemoradiotherapy. Between 2000 and 2014, 458 patients who received esophagectomy after neoadjuvant chemoradiation therapy were selected. Overall (OS) and disease-free survival (DFS) were calculated by means of Kaplan-Meier curves and compared by Cox regression analysis. There were 163 (35.9%) patients who had a ypT3 tumor; in 118 (72.4%) resection was complete (R0). In 37 (22.7%) patients a CRM < 1 mm was found and 8 (4.9%) had a circumferential R1-resection. CRM involvement was inversely correlated with tumor regression grading, lymph node capsular involvement, and number of positive lymph nodes. On univariate analysis, no statistically significant difference was found between R0-resection and CRM < 1 mm (P = 0.103) for OS, but DFS showed a significant difference (P = 0.025). Circumferential R1-resections showed a significant difference compared to R0-resections for OS and DFS (both P = 0.002). In multivariate analysis, extracapsular lymph node involvement and circumferential R1-resection were withheld as independent prognosticators for OS, whereas extracapsular lymph node involvement, absence of regression on the primary tumor and circumferential R1-resection were withheld for DFS. After correcting for different variables in the multivariate model, CRM < 1 mm showed no statistical difference compared to R0-resections neither for OS nor for DFS. After neoadjuvant chemoradiotherapy, CRM is correlated with biological behavior of the tumor and with therapy response. Furthermore it is an independent prognosticator for OS and DFS. However CRM < 1 mm itself is no independent prognosticator for OS nor DFS survival in multivariable analysis. These results suggest that the definition of R1-resection should be limited to true invasion of the section plane.
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Affiliation(s)
| | - J Moons
- Department of Thoracic Surgery
| | - T Lerut
- Department of Thoracic Surgery
| | - G De Hertogh
- Department of Pathology, University Hospital Leuven, Leuven, Belgium
| | | | - X Sagaert
- Department of Pathology, University Hospital Leuven, Leuven, Belgium
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48
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Kauppila JH, Wahlin K, Lagergren P, Lagergren J. Neoadjuvant therapy in relation to lymphadenectomy and resection margins during surgery for oesophageal cancer. Sci Rep 2018; 8:446. [PMID: 29323261 PMCID: PMC5765051 DOI: 10.1038/s41598-017-18879-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 12/18/2017] [Indexed: 12/23/2022] Open
Abstract
Differences in lymph node yield and tumour-involved resection margins comparing neoadjuvant therapy plus surgery with surgery alone for oesophageal cancer are unclear. Patients who underwent oesophageal cancer surgery in Sweden in 1987–2010 were included. Patients treated with neoadjuvant therapy were compared with those who underwent surgery alone. Outcomes were the number of examined lymph nodes (main outcome), number metastatic lymph nodes, and resection margin status. Rate ratios (RRs) and 95% CIs of lymph node yield were calculated by Poisson regression, and odds ratios (ORs) and 95% CIs of resection margin status by multivariable logistic regression, both adjusted for confounders. Among 1818 patients, 587 (32%) had received neoadjuvant therapy and 1231 (68%) had not. Lymph node yield was lower in the neoadjuvant therapy group (median 6 versus 8; adjusted RR 0.75, 0.73–0.78). Fewer metastatic nodes were identified following neoadjuvant therapy (median 0 versus 1; adjusted RR 0.76, 0.69–0.84). Neoadjuvant therapy associated to decreased risk of tumour-involved resection margins when adjusted for confounders except T-stage (OR 0.52, 0.38–0.70), but the association did not remain after adjustment for T-stage (OR 0.91, 0.64–1.29). Neoadjuvant therapy seems to decrease the lymph node yield and decrease the risk of tumour-involved resection margins by shrinking primary tumour.
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Affiliation(s)
- Joonas H Kauppila
- Upper Gastrointestinal Surgery, Department of Molecular medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 17176, Stockholm, Sweden. .,Cancer and Translational Medicine Research Unit, Medical Research Center, University of Oulu and Oulu University Hospital, 90014, Oulu, Finland.
| | - Karl Wahlin
- Upper Gastrointestinal Surgery, Department of Molecular medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 17176, Stockholm, Sweden
| | - Pernilla Lagergren
- Surgical Care Science, Department of Molecular medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 17176, Stockholm, Sweden
| | - Jesper Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 17176, Stockholm, Sweden.,Division of Cancer Studies, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, England
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49
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Gao SJ, Park HS, Corso CD, Rutter CE, Khan SA, Johung KL. Post-operative radiotherapy is associated with improved survival in esophageal cancer with positive surgical margins. J Gastrointest Oncol 2018; 8:953-961. [PMID: 29299354 DOI: 10.21037/jgo.2017.08.12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background The optimal treatment for early-stage esophageal cancer with positive surgical margins after an upfront esophagectomy is not well-defined. This study investigates the effect of post-operative radiotherapy (PORT) on overall survival (OS) in clinical stage I-II patients with positive margins. Methods We identified patients diagnosed between 2004 and 2012 with clinical stage I-II esophageal carcinoma from the National Cancer Data Base (NCDB) who underwent an upfront esophagectomy. For those patients with positive margins, administration of PORT was recorded, and OS was compared by the Kaplan-Meier estimator and log-rank test. Multivariable Cox regression analysis was performed to identify variables associated with improved survival. Results Among the 3,490 patients identified, 209 (5.8%) had positive margins. One hundred forty-two (67.9%) patients did not receive PORT while 67 (32.1%) did receive PORT. Compared to those receiving PORT, patients who did not receive PORT were significantly older (68.5 vs. 64.0 years, P=0.003), more likely to have pN0 disease (50.7% vs. 35.4%, P=0.026), and less likely to receive postoperative chemotherapy (21.1% vs. 86.6%, P<0.001). On multivariable logistic regression, only receipt of chemotherapy predicted for receipt of PORT (OR: 25.6, 95% CI: 9.9-65.8, P<0.001). OS was significantly higher for patients receiving PORT compared to those who did not (median OS: 32.2 vs. 16.9 months, log-rank P=0.008). Multivariable analysis confirmed an association with PORT and improved OS (HR: 0.39, 95% CI: 0.27-0.60, P<0.001). Subset analysis demonstrated that the OS benefit of PORT persisted in those patients who received adjuvant chemotherapy (HR: 0.33, 95% CI: 0.19-0.57, P<0.001). Conclusions PORT is associated with improved OS in clinical stage I-II esophageal cancer patients after an upfront esophagectomy with positive margins. In the absence of prospective randomized data, our findings suggest that PORT should be strongly considered in the setting of early-stage esophageal cancer resected with positive margins.
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Affiliation(s)
- Sarah J Gao
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, USA
| | - Henry S Park
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, USA
| | - Christopher D Corso
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, USA
| | - Charles E Rutter
- Department of Radiation Oncology, Hartford Hospital, Hartford, USA
| | - Sajid A Khan
- Department of Surgery, Section of Surgical Oncology, Yale University School of Medicine, New Haven, USA
| | - Kimberly L Johung
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, USA
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50
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Mine S, Watanabe M, Imamura Y, Okamura A, Kurogochi T, Sano T. Clinical Significance of the Pre-therapeutic Nodal Size in Patients Undergoing Neo-Adjuvant Treatment Followed by Esophagectomy for Esophageal Squamous Cell Carcinoma. World J Surg 2017; 41:184-190. [PMID: 27468743 DOI: 10.1007/s00268-016-3675-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The clinical significance of pre-therapeutic nodal size in patients with esophageal squamous cell carcinoma (ESCC) is not clear. We investigated whether nodal size was correlated with survival in patients undergoing neo-adjuvant treatment followed by esophagectomy for ESCC. METHODS In 2009-2013, 222 patients who underwent neo-adjuvant treatment followed by esophagectomy for ESCC were enrolled in this retrospective study. Nodal size was measured along the short axis of the largest node using pre-therapeutic CT images. Patients were then stratified based on this short axis, and nodal size was correlated with clinicopathological factors and survival. RESULTS Patients with larger nodes were likely to have deeper cT, higher cN status, and poorer survival. Among the clinical factors cT, cN, cM, and nodal size, only cT and nodal size were independent prognostic factors in multivariate analysis [hazard ratio (HR) 2.0, 95 % confidence interval (CI) 1.1-3.5, p = 0.025 and HR 1.5, 95 % CI 1-2.3, p = 0.036, respectively]. In addition, nodal size was significantly associated with hematological recurrence (p = 0.007), but not lymphatic relapse (p = 0.272). CONCLUSIONS The short axis of the largest node before neo-adjuvant treatment in patients with ESCC is a prognostic factor.
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Affiliation(s)
- Shinji Mine
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan. .,Department of Esophageal and Gastroenterological Surgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akihiko Okamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takanori Kurogochi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takeshi Sano
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
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