Recommendations for pathologic staging (pTNM) of cancer of the esophagus and esophagogastric junction for the 8th edition AJCC/UICC staging manuals

CT-based delta-radiomics nomogram to predict pathological complete response after neoadjuvant chemoradiotherapy in esophageal squamous cell carcinoma patients

BACKGROUND

This study developed a nomogram model using CT-based delta-radiomics features and clinical factors to predict pathological complete response (pCR) in esophageal squamous cell carcinoma (ESCC) patients receiving neoadjuvant chemoradiotherapy (nCRT).

METHODS

The study retrospectively analyzed 232 ESCC patients who underwent pretreatment and post-treatment CT scans. Patients were divided into training (n = 186) and validation (n = 46) sets through fivefold cross-validation. 837 radiomics features were extracted from regions of interest (ROIs) delineations on CT images before and after nCRT to calculate delta values. The LASSO algorithm selected delta-radiomics features (DRF) based on classification performance. Logistic regression constructed a nomogram incorporating DRFs and clinical factors. Receiver operating characteristic (ROC) and area under the curve (AUC) analyses evaluated nomogram performance for predicting pCR.

RESULTS

No significant differences existed between the training and validation datasets. The 4-feature delta-radiomics signature (DRS) demonstrated good predictive accuracy for pCR, with α-binormal-based and empirical AUCs of 0.871 and 0.869. T-stage (p = 0.001) and differentiation degree (p = 0.018) were independent predictors of pCR. The nomogram combined the DRS and clinical factors improved the classification performance in the training dataset (AUCαbin = 0.933 and AUCemp = 0.941). The validation set showed similar performance with AUCs of 0.958 and 0.962.

CONCLUSIONS

The CT-based delta-radiomics nomogram model with clinical factors provided high predictive accuracy for pCR in ESCC patients after nCRT.

Thoracoscopic salvage esophagectomy with prophylactic mediastinal lymph node dissection after definitive chemoradiotherapy for patients with esophageal cancer

BACKGROUND

Salvage esophagectomy for residual tumor and localized relapses after definitive chemoradiotherapy (dCRT) for patients with esophageal cancer is associated with a high rate of postoperative complications and in-hospital mortality. In addition, there are many controversial issues associated with salvage esophagectomy, such as the acceptability of minimally invasive surgery and the need for prophylactic dissection of mediastinal lymph nodes. The aim of this study was to evaluate the safety and usefulness of thoracoscopic salvage esophagectomy with prophylactic mediastinal lymph node dissection.

METHODS

The study included 31 patients who underwent thoracoscopic salvage esophagectomy with prophylactic mediastinal lymph node dissection after dCRT between 2013 and 2022 (salvage patients) and 610 nonsalvage patients who underwent conventional thoracoscopic esophagectomy during the same time period.

RESULTS

Differences between the median ages and sexes of the 2 patient groups were not significant. The dominant location of tumors in the salvage patients was the upper thoracic esophagus. More salvage patients had clinical T4 disease. The salvage patients had a lower median number of retrieved mediastinal lymph nodes than the nonsalvage patients. The differences between the rates of R0, postoperative complications, and in-hospital deaths in the 2 patient groups were not significant. The 3-year overall survival (OS) rates for the salvage patients were 73%, with 3-year OS rates for R0 vs non-R0 of 81% vs 0%, p < 0.01 and pN0 vs pN1-3 of 89% vs 49%, p < 0.01.

CONCLUSION

Regarding short-term outcomes, prophylactic mediastinal lymph node dissection for patients undergoing thoracoscopic salvage esophagectomy was as safe as prophylactic dissection for patients undergoing conventional thoracoscopic esophagectomy. R0 surgery and pN0 are important factors for long-term survival in patients undergoing thoracoscopic salvage esophagectomy.

Clinical significance of geriatric nutritional risk index in esophageal squamous cell carcinoma receiving neoadjuvant immunotherapy

OBJECTIVE

The geriatric nutritional risk index (GNRI) is a novel nutrition-related indicator designed to predict the risk of clinical outcomes in various cancers. The clinical significance of risk assessment, therapeutic response, and prognostic prediction of GNRI in esophageal squamous cell carcinoma (ESCC) receiving neoadjuvant immunochemotherapy (NICT), a hot point of treatment these days, have not been documented in any research.

METHODS

Two hundred and twenty-four cases with ESCC who underwent radical resection after NICT were retrospectively recruited. Using the calculation formula of GNRI (1.489 × albumin (g/L) + 41.7 × current weight/ideal weight), the cases were split into two cohorts. Analysis was done on the connections between GNRI and clinical outcomes, such as clinical features, postoperative complications, and pathological complete response (pCR). Prognostic factors of overall survival (OS) and disease-free survival (DFS) were also performed.

RESULTS

Patients were then categorized as low (n = 139) or high (n = 85) group based on the threshold. After radical surgery, 67 patients achieved pCR (29.9%). Higher pCR rates were attained by patients in the high GNRI group (41.2% vs. 23.0%, P = 0.004). Lower GNRI patients experienced a considerably higher severe morbidity (36.7% vs. 23.5%, P = 0.040), particularly in the case of respiratory complications (28.8% vs. 14.1%, P = 0.012). Compared to high GNRI patients, lower GNRI cases had inferior 3-year OS (68.5% vs. 87.3%, P = 0.003) and DFS (64.8% vs. 81.5%, P = 0.002). It was also discovered that GNRI was a significant independent variable of both DFS [hazard ratios (HR) = 0.436, P = 0.009] and OS (HR = 0.294, P = 0.012).

CONCLUSION

The GNRI, based on nutrition-related indicators, was independently related to postoperative complications, pCR prediction, and prognostication in ESCC receiving NICT.

Neoadjuvant chemoimmunotherapy followed by robot esophagectomy has no effect on short-term results compared with surgery alone

BACKGROUND

To determine the safety and efficacy of robot-assisted minimally invasive esophagectomy (RAMIE) for locally advanced esophageal squamous cell carcinoma (ESCC) after neoadjuvant chemoimmunotherapy (NCI).

METHODS

Data from patients who underwent RAMIE between January 2020 and June 2022 were retrospectively analyzed. The oncological and operative outcomes of the NCI and surgery-only (S) groups were compared by both unmatched and 1:1 propensity score-matched (PSM) analysis.

RESULTS

A total of 201 patients with ESCC who underwent three-incision RAMIE were included in this study (143 patients in the S group and 58 patients in the NCI group). Of the 58 patients who underwent NCI, a pathologically complete response (pCR) (ypT0N0) was identified in 14 (24.1%) patients. The patients in the NCI group were younger than those in the S group (p = 0.017), and had more advanced cT (p < 0.001) and cN stage diseases (p = 0.002). After 1:1 PSM of the confounders, 55 patients were allocated to each of the NCI and S groups. No significant differences were found in oncological and operative results, including surgical blood loss, operative time, and lymph node harvest (all p > 0.05). However, the NCI group exhibited a lower rate of pulmonary complications than the S group (3.6% vs. 14.5%, p = 0.047). No significant difference between the groups was found for other complications (all p > 0.05).

CONCLUSION

These findings indicate that NCI could result in a high pCR rate without increased complications in locally advanced ESCC. RAMIE is safe and feasible in patients with ESCC after NCI.

Advances in tumor microenvironment and underlying molecular mechanisms of bladder cancer: a systematic review

Bladder cancer is one of the most frequent malignant tumors of the urinary system. The prevalence of bladder cancer among men and women is roughly 5:2, and both its incidence and death have been rising steadily over the past few years. At the moment, metastasis and recurrence of advanced bladder cancer-which are believed to be connected to the malfunction of multigene and multilevel cell signaling network-remain the leading causes of bladder cancer-related death. The therapeutic treatment of bladder cancer will be greatly aided by the elucidation of these mechanisms. New concepts for the treatment of bladder cancer have been made possible by the advancement of research technologies and a number of new treatment options, including immunotherapy and targeted therapy. In this paper, we will extensively review the development of the tumor microenvironment and the possible molecular mechanisms of bladder cancer.

TNF-α-induced down-regulation of type I interferon receptor contributes to acquired resistance of cervical squamous cancer to Cisplatin

We aimed to investigate the effects of tumor necrosis factor (TNF)-α on the expression of interferon α/β receptor subunit 1 (IFNAR1) and cervical squamous cancer (CSCC) resistance to Cisplatin, as well as the underlying mechanisms. Kaplan-Meier analysis was used to plot the overall survival curves. SiHa cells were treated with 20 ng/ml TNF-α to determine cell proliferation in human CSCC cells and the expression of IFNAR1. The effects of TNF-α on the downstream signaling pathway, including casein kinase 1α (CK1α), were investigated using the caspase protease inhibitor FK009, the c-Jun kinase inhibitor SP600125, and the nuclear factor kappa-B inhibitor ammonium pyrrolidinedithiocarbamate (PDTC). TNF-α induced down-regulation of IFNAR1 in human CSCC cells and promoted proliferation of SiHa cells. SiHa cells were transfected with the catalytic inactive mutant CK1α K49A, and the ability of TNF-α to induce down-regulation of IFNAR1 expression was found to be significantly diminished in this context. FK009 and PDTC had no obvious effect on the expression of CK1α, however, SP600125 significantly reduced the expression of CK1α in the presence of TNF-α. SiHa cells treated with TNF-α showed reduced sensitivity to Cisplatin and exhibited higher cell viability, while the sensitivity of SiHa cells to Cisplatin was restored after treatment with CK1α inhibitor D4476. Additionally, we constructed a TNF-α overexpressing SiHa cell line and a transplanted tumor model. The results were similar to those of in vitro efficacy. We demonstrate that TNF-α-induced down-regulation of type I interferon receptor contributes to acquired resistance of cervical squamous cancer to Cisplatin.

A Comparison of Clinicopathologic Outcomes and Patterns of Lymphatic Spread Across Neoadjuvant Chemotherapy, Neoadjuvant Chemoradiotherapy, and Neoadjuvant Immunochemotherapy in Locally Advanced Esophageal Squamous Cell Carcinoma

BACKGROUND

Neoadjuvant chemoradiotherapy (NCRT) is recommended as the treatment standard for locally advanced esophageal squamous cell carcinoma (ESCC). The use of immunotherapy in the neoadjuvant setting has gained attention. Multiple, clinical trials have explored the efficacy and safety of neoadjuvant immunochemotherapy (NICT). We evaluated the differences in clinicopathologic outcomes and the patterns of lymphatic spread among patients receiving neoadjuvant chemotherapy (NCT), NCRT, and NICT before esophagectomy for locally advanced ESCC.

METHODS

A total of 702 patients with ESCC who completed transthoracic esophagectomy followed neoadjuvant therapy were included. Pathological characteristics, including pathologic complete response (pCR), tumor regression grade (TRG) score and patterns of lymphatic spread, were evaluated.

RESULTS

Compared with the NCT group, the NCRT group and NICT group had an advantage in pathological response (P < 0.05). The pCR rate was 8.1% in the NCT group, 29.9% in the NCRT group, and 23.6% in the NICT group. The TRG score (P < 0.05) and pathologic T stage (P < 0.05) in the NCT group were significantly higher. Compared with NICT, NCRT can significantly reduce the rate of lymph node metastasis rate in station 1R (0 vs. 3.4%, P < 0.05) and 2R (1.1% vs. 6.8%, P < 0.05). Subgroup analysis according to the tumor location distribution showed that NICT group had higher lymph node metastasis rate in station 2R (9.1%) in middle thoracic cases (P < 0.05) and in station 18 (7.5%) (P < 0.05) in lower thoracic cases.

CONCLUSIONS

NCRT or NICT followed by surgery may result in a promising pCR rate and show a better performance in therapeutic response of primary lesion. For patients with lymph node metastasis in station 1R and 2R, NCRT should be the optimal preoperative treatment strategy.

Clinical significance of preoperative CALLY index for prognostication in patients with esophageal squamous cell carcinoma undergoing surgery

The C-reactive protein-albumin-lymphocyte (CALLY) index has been identified as a useful and sensitive predictive tool for stratification in cancers. This investigation aimed to validate the prognostic ability of CALLY in esophageal squamous cell carcinoma (ESCC). Clinical characteristics of 318 patients with ESCC who underwent radical excision were gathered and analyzed retrospectively. A restricted cubic spline (RCS) model was used to determine an ideal threshold of CALLY due to the non-linear relation. To investigate the predictors, Cox hazard regression analysis was used. The recursive partitioning analysis (RPA), a method of risk categorization, was also developed for prognostic prediction. The receiver operating characteristic (ROC) curves and decision curve analysis (DCA) curves were used to distinguish from the traditional TNM stage. Patients were compared by groups according to the optimal threshold of CALLY index, which was depicted by the non-linear relation between the cancer-specific survival (CSS) and CALLY index (P < 0.0001). Compared to those with high CALLY index, patients with low CALLY index experienced significantly worse 5-year CSS (21.8% vs. 62.6%, P < 0.001). At different TNM stages, patients with high CALLY index also had better 5-year CSS (I: P = 0.029; II: P < 0.001; III: P < 0.001) in subgroup analyses. The hazard ratio for CSS was 0.368 and CALLY index was an independent predictive factor (P < 0.001). Using TNM stage and CALLY-based RPA algorithms, a new staging was created. The RPA model considerably outperformed the TNM classification for prognostication using ROC (P < 0.001). The DCA also demonstrated that the new model outperformed the TNM stage with significantly improved accuracy for CSS. The prognostic value of CALLY in ESCC undergoing radical resection was initially determined in this study. CALLY was substantially related to prognosis and might be utilized in conjunction with TNM to evaluate ESCC prior to surgery.

Lymph node ratio is a prognostic indicator for locally advanced esophageal squamous cell carcinoma after neoadjuvant immunochemotherapy

The lymph node ratio (LNR) is regarded as a prognostic indicator in esophageal cancer (EC), but its applicability to neoadjuvant immunochemotherapy (NICT) in esophageal squamous cell carcinoma (ESCC) remains unexplored. This retrospective study, conducted between 2019 and 2021, analyzed ESCC patients who underwent radical esophagectomy following NICT. Patients were divided into two groups based on their LNR values according to the X-tile software: Low-LNR group (LNR 0-10%) and High-LNR group (LNR 10-100%). The association between LNR and clinical outcomes in ESCC after NICT were analyzed. A total of 212 ESCC patients who underwent surgery after NICT were included in this study, among which, 169 (79.7%) and 43 (20.3%) cases were allocated to the Low- and High-LNR groups, respectively. Pathologic complete response (PCR) was observed in 28.3% (60/212) of the overall cohort. Patients in the Low-LNR group demonstrated a significantly improved 3-year overall survival (OS) (81.7% vs 55.3%; P < 0.001) and disease-free survival (DFS) (79.9% vs 37.4%; P < 0.001). These findings were consistent among those with non-PCR (3-year DFS was 73.7% vs 37.4%; P < 0.001, and the 3-year OS was 78.9% vs 55.3%; P < 0.001, respectively). High LNR was associated with a 4.013-fold increased risk of relapse and a 7.026-fold elevated risk of death. Compared to the post-neoadjuvant therapy pathologic lymph nodes staging (ypN), LNR exhibited similar prognostic capabilities for DFS and OS. To the best of our knowledge, this study is the first to investigate the prognostic value of LNR in ESCC after NICT, suggesting that LNR may serve as a viable alternative to the ypN stage for prognostication in ESCC patients treated with NICT.

Pretreatment Pan-Immune-Inflammation Value (PIV) in Predicting Therapeutic Response and Clinical Outcomes of Neoadjuvant Immunochemotherapy for Esophageal Squamous Cell Carcinoma

PURPOSE

The pan-immune-inflammation value (PIV), which reflects the balance between the host immune and inflammatory status, is a readily available index for evaluating cancer outcomes. Until now, however, no study has demonstrated the clinical response of PIV to neoadjuvant immunochemotherapy (NICT) in esophageal squamous cell carcinoma (ESCC).

METHODS

This retrospective study included 218 patients with ESCC who underwent NICT. The relationship between PIV and therapeutic response (pathological complete response [PCR]) and clinical outcomes (overall survival [OS] and disease-free survival [DFS]) was examined. Cox proportional, hazard-regression analyses and the Kaplan-Meier method were used for survival analyses. Recursive partitioning analysis (RPA) was used to establish a novel risk stratification model.

RESULTS

Sixty-six patients (30.3%) achieved PCR after NICT. Using PCR as the endpoint of interest, patients were compared in groups based on the optimal threshold. PIV was closely related to PCR (odds ratio [OR] 0.311, 95% confidence interval [CI] 0.140-0.690, P = 0.004). Compared with patients in the low PIV cohort, patients with high PIV had worse 3-year OS (58.7% vs. 83.6%, P < 0.001) and DFS (51.9% vs. 79.1%, P < 0.001). PIV was an independent predictor of OS (hazard ratio [HR] 2.364, 95% CI 1.183-4.724, P = 0.015) and DFS (HR 1.729, 95% CI 1.026-2.913, P = 0.040). Three risk groups with varied DFS and OS were staged by using an RPA method, and the prognostication accuracy was considerably improved.

CONCLUSIONS

Pretreatment PIV can predict the therapeutic efficacy of NICT for ESCC. Because of better prognostic stratification, pretreatment PIV is a novel, sensitive, and effective indicator in ESCC receiving NICT. The prognostic results of PIV need to be verified in additional prospective studies.

Impact of retention index on the neoadjuvant chemotherapy effect and the prognosis in oesophageal cancer

OBJECTIVE

The relationship between retention index calculated from dual-time point 18F-fluorodeoxyglucose positron emission tomography-computed tomography and oesophageal cancer prognosis remains unknown. This study aimed to determine usefulness of retention index as a predictor of long-term prognosis of oesophageal cancer and neoadjuvant chemotherapy efficacy.

METHODS

A total of 151 patients with oesophageal cancer who underwent esophagectomy were evaluated retrospectively in this study. We acquired positron emission tomography scans 60 and 120 min (SUVmax1 and SUVmax2, respectively) after the intravenous administration of 3.7 Mbq/kg 18F-fluorodeoxyglucose. The patients were divided into two groups: high-retention index (retention index ≥29%, 107 patients) and low-retention index (retention index <29%, 44 patients). Retention index was calculated as follows: retention index (%) = [(SUVmax2 - SUVmax1)/SUVmax1] × 100.

RESULTS

The overall survival and relapse-free survival rates in the high-retention index group were significantly lower than those in the low-retention index group (P < 0.001). Our multivariate analysis identified that the high-retention index group contained independent risk factors for overall survival (hazard ratio: 2.44, P = 0.009) and relapse-free survival (hazard ratio: 2.61, P = 0.002). The high-retention index group exhibited a lower partial response rate to neoadjuvant chemotherapy evaluated by computed tomography (P < 0.001) and a lower pathological therapeutic effect in the resected specimen (P = 0.019) than the low-retention index group.

CONCLUSIONS

The retention index was associated with neoadjuvant chemotherapy responses and long-term prognosis for oesophageal cancer.

Comparison of TNM AJCC/UICC 8th with JES 11th staging systems for prognostic prediction in patients with esophageal squamous cell carcinoma who underwent radical (chemo) radiotherapy in China

OBJECTIVE

The aim of the study was to compare the prognostic prediction performances of the American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) 8th staging system and the Japan Esophageal Society (JES) 11th staging system for patients with esophageal squamous cell carcinoma who underwent radical (chemo) radiotherapy.

METHODS

In total, 574 patients were enrolled and categorized according to the tumor, node metastasis (TNM) AJCC/UICC 8th and JES 11th editions. Survival rates and disease-free survival were computed using the Kaplan-Meier technique. The log-rank test was used for survival difference analysis.

RESULTS

(1) The 8th AJCC/UICC N staging exhibited significant stratification for overall survival (OS) and progression-free survival (PFS). JES 11th showed significant OS stratification, but PFS was not well-stratified for N2-N4. (2) Both staging systems demonstrated significant stratification for OS and PFS. (3) AJCC/UICC 8th TNM staging yielded significantly well-stratified OS and PFS in the differing staging group. JES 11th failed to stratify OS and PFS for stages III and IVA. (4) AJCC/UICC 8th TNM stratified OS and PFS significantly well for lower and middle region tumors, whereas JES 11th inadequately stratified stages III and IVA. (5) Significant multivariable analysis results indicated that AJCC/UICC 8th independently predicted poor OS and PFS.

CONCLUSIONS

In Chinese patients with esophageal squamous cell carcinoma who underwent radical (chemo) radiotherapy, the AJCC/UICC 8th edition exhibited superior prognostic prediction capabilities compared with the JES 11th edition.

CT radiomics in the identification of preoperative understaging in patients with clinical stage T1-2N0 esophageal squamous cell carcinoma

Background

Predicting preoperative understaging in patients with clinical stage T1-2N0 (cT1-2N0) esophageal squamous cell carcinoma (ESCC) is critical to customizing patient treatment. Radiomics analysis can provide additional information that reflects potential biological heterogeneity based on computed tomography (CT) images. However, to the best of our knowledge, no studies have focused on identifying CT radiomics features to predict preoperative understaging in patients with cT1-2N0 ESCC. Thus, we sought to develop a CT-based radiomics model to predict preoperative understaging in patients with cT1-2N0 esophageal cancer, and to explore the value of the model in disease-free survival (DFS) prediction.

Methods

A total of 196 patients who underwent radical surgery for cT1-2N0 ESCC were retrospectively recruited from two hospitals. Among the 196 patients, 134 from Peking University Cancer Hospital were included in the training cohort, and 62 from Henan Cancer Hospital were included in the external validation cohort. Radiomics features were extracted from patients' CT images. Least absolute shrinkage and selection operator (LASSO) regression was used for feature selection and model construction. A clinical model was also built based on clinical characteristics, and the tumor size [the length, thickness and the thickness-to-length ratio (TLR)] was evaluated on the CT images. A radiomics nomogram was established based on multivariate logistic regression. The diagnostic performance of the models in predicting preoperative understaging was assessed by the area under the receiver operating characteristic curve (AUC). Kaplan-Meier curves with the log-rank test were employed to analyze the correlation between the nomogram and DFS.

Results

Of the patients, 50.0% (67/134) and 51.6% (32/62) were understaged in the training and validation groups, respectively. The radiomics scores and the TLRs of the tumors were included in the nomogram. The AUCs of the nomogram for predicting preoperative understaging were 0.874 [95% confidence interval (CI): 0.815-0.933] in the training cohort and 0.812 (95% CI: 0.703-0.912) in the external validation cohort. The diagnostic performance of the nomogram was superior to that of the clinical model (P<0.05). The nomogram was an independent predictor of DFS in patients with cT1-2N0 ESCC.

Conclusions

The proposed CT-based radiomics model could be used to predict preoperative understaging in patients with cT1-2N0 ESCC who have undergone radical surgery.

A novel immune-nutritional score predicts response to neoadjuvant immunochemotherapy after minimally invasive esophagectomy for esophageal squamous cell carcinoma

Background

The role of neoadjuvant immunochemotherapy (NICT) has gradually attracted attention in recent years. To date, sensitive and reliable blood indicators to forecast the therapeutic response are still lacking. This study aimed to conduct a novel predictive score based on a variety of peripheral hematological immune-nutritional indicators to predict the therapeutic response in esophageal squamous cell carcinoma (ESCC) receiving NICT.

Methods

There were 206 ESCC patients receiving NICT retrospectively recruited. With pathological complete response (pCR) as the dependent variable, independent risk variables of various peripheral blood immune-nutritional indexes were screened by logistic regression analyses to establish an integrative score.

Results

By logical regression analyses, lymphocyte to monocyte ratio (LMR) and body mass index (BMI) were independent risk factors among all immune-nutritional indices. Then, an integrative score named BMI-LMR score (BLS) was established. Compared with BMI or LMR, BLS was related to complications, especially for respiratory complication (P=0.012) and vocal cord paralysis (P=0.021). Among all patients, 61 patients (29.6%) achieved pCR after NICT. BLS was significantly related to pCR [odds ratio (OR)=0.269, P<0.001)]. Patients in high BLS cohort demonstrated higher 3-year overall survival (OS) (89.9% vs. 67.9%, P=0.001) and disease-free survival (DFS) (81.2% vs. 62.1%, P=0.001). BLS served as an independent factor of DFS [hazard ratio (HR) =2.044, P =0.020) and OS (HR =2.960, P =0.019).

Conclusion

The BLS, based on immune-nutritional indicators of BMI and LMR, employed as a straightforward, accurate, and useful indicator of pCR and prognostic prediction in ESCC patients undergoing NICT.

Deep Learning in Barrett's Esophagus Diagnosis: Current Status and Future Directions

Barrett's esophagus (BE) represents a pre-malignant condition characterized by abnormal cellular proliferation in the distal esophagus. A timely and accurate diagnosis of BE is imperative to prevent its progression to esophageal adenocarcinoma, a malignancy associated with a significantly reduced survival rate. In this digital age, deep learning (DL) has emerged as a powerful tool for medical image analysis and diagnostic applications, showcasing vast potential across various medical disciplines. In this comprehensive review, we meticulously assess 33 primary studies employing varied DL techniques, predominantly featuring convolutional neural networks (CNNs), for the diagnosis and understanding of BE. Our primary focus revolves around evaluating the current applications of DL in BE diagnosis, encompassing tasks such as image segmentation and classification, as well as their potential impact and implications in real-world clinical settings. While the applications of DL in BE diagnosis exhibit promising results, they are not without challenges, such as dataset issues and the "black box" nature of models. We discuss these challenges in the concluding section. Essentially, while DL holds tremendous potential to revolutionize BE diagnosis, addressing these challenges is paramount to harnessing its full capacity and ensuring its widespread application in clinical practice.

Third Eye? The Assistance of Artificial Intelligence (AI) in the Endoscopy of Gastrointestinal Neoplasms

Gastrointestinal cancers are characterized by high incidence and mortality. However, there are well-established methods of screening. The endoscopy exam provides the macroscopical image and enables harvesting the tissue samples for further histopathological diagnosis. The efficiency of endoscopies relies not only on proper patient preparation, but also on the skills of the personnel conducting the exam. In recent years, a number of reports concerning the application of artificial intelligence (AI) in medicine have arisen. Numerous studies aimed to assess the utility of deep learning/ neural network systems supporting endoscopies. In this review, we summarized the most recent reports and randomized clinical trials regarding the application of AI in screening and surveillance of gastrointestinal cancers among patients suffering from esophageal, gastric, and colorectal cancer, along with the advantages, limitations, and controversies of those novel solutions.

Preoperative prediction of clinical and pathological stages for patients with esophageal cancer using PET/CT radiomics

BACKGROUND

Preoperative stratification is critical for the management of patients with esophageal cancer (EC). To investigate the feasibility and accuracy of PET-CT-based radiomics in preoperative prediction of clinical and pathological stages for patients with EC.

METHODS

Histologically confirmed 100 EC patients with preoperative PET-CT images were enrolled retrospectively and randomly divided into training and validation cohorts at a ratio of 7:3. The maximum relevance minimum redundancy (mRMR) was applied to select optimal radiomics features from PET, CT, and fused PET-CT images, respectively. Logistic regression (LR) was applied to classify the T stage (T1,2 vs. T3,4), lymph node metastasis (LNM) (LNM(-) vs. LNM(+)), and pathological state (pstage) (I-II vs. III-IV) with features from CT (CT_LR_Score), PET (PET_LR_Score), fused PET/CT (Fused_LR_Score), and combined CT and PET features (CT + PET_LR_Score), respectively.

RESULTS

Seven, 10, and 7 CT features; 7, 8, and 7 PET features; and 3, 6, and 3 fused PET/CT features were selected using mRMR for the prediction of T stage, LNM, and pstage, respectively. The area under curves (AUCs) for T stage, LNM, and pstage prediction in the validation cohorts were 0.846, 0.756, 0.665, and 0.815; 0.769, 0.760, 0.665, and 0.824; and 0.727, 0.785, 0.689, and 0.837 for models of CT_LR_Score, PET_ LR_Score, Fused_ LR_Score, and CT + PET_ LR_Score, respectively.

CONCLUSIONS

Accurate prediction ability was observed with combined PET and CT radiomics in the prediction of T stage, LNM, and pstage for EC patients.

CRITICAL RELEVANCE STATEMENT

PET/CT radiomics is feasible and promising to stratify stages for esophageal cancer preoperatively.

KEY POINTS

• PET-CT radiomics achieved the best performance for Node and pathological stage prediction. • CT radiomics achieved the best AUC for T stage prediction. • PET-CT radiomics is feasible and promising to stratify stages for EC preoperatively.

Milestones in the History of Esophagectomy: From Torek to Minimally Invasive Approaches

The history of esophagectomy reflects a journey of dedication, collaboration, and technical innovation, with ongoing endeavors aimed at optimizing outcomes and reducing complications. From its early attempts to modern minimally invasive approaches, the journey has been marked by perseverance and innovation. Franz J. A. Torek's 1913 successful esophageal resection marked a milestone, demonstrating the feasibility of transthoracic esophagectomy and the potential for esophageal cancer cure. However, its high mortality rate posed challenges, and it took almost two decades for similar successes to emerge. Surgical techniques evolved with the left thoracotomy, right thoracotomy, and transhiatal approaches, expanding the indications for resection. Mechanical staplers introduced in the early 20th century transformed anastomosis, reducing complications. The advent of minimally invasive techniques in the 1990s aimed to minimize complications while maintaining oncological efficacy. Robot-assisted esophagectomy further pushed the boundaries of minimally invasive surgery. Collaborative efforts, particularly from the Worldwide Esophageal Cancer Collaboration and the Esophageal Complications Consensus Group, standardized reporting and advanced the understanding of outcomes. The introduction of risk prediction models aids in making informed decisions. Despite significant improvements in survival rates and postoperative mortality, anastomotic leaks remain a concern, with recent rates showing an increase. Prevention strategies include microvascular anastomosis and ischemic preconditioning, yet challenges persist.

Implementation of Staging Guidelines in Early Esophageal Cancer: A Study of the Society of Thoracic Surgeons General Thoracic Surgery Database

OBJECTIVE

To evaluate the adoption and clinical impact of endoscopic resection (ER) in early esophageal cancer.

BACKGROUND

Staging for early esophageal cancer is largely inaccurate. Assessment of the impact of ER on staging accuracy is unknown, as is the implementation of ER.

METHODS

We retrospectively reviewed 2608 patients captured in the Society of Thoracic Surgeons General Thoracic Surgery Database between 2015 and 2020. Patients with clinical T1 and T2 esophageal cancer without nodal involvement (N0) who were treated with upfront esophagectomy were included. Staging accuracy was assessed by clinical-pathologic concordance among patients staged with and without ER. We also sought to measure adherence to National Comprehensive Cancer Network staging guidelines for esophageal cancer staging, specifically the implementation of ER.

RESULTS

For early esophageal cancer, computed tomography/positron emission tomography/endoscopic ultrasound (CT/PET/EUS) accurately predicts the pathologic tumor (T) stage 58.5% of the time. The addition of ER to staging was related to a decrease in upstaging from 17.6% to 10.8% ( P =0.01). Adherence to staging guidelines with CT/PET/EUS improved from 58.2% between 2012 and 2014 to 77.9% between 2015 and 2020. However, when ER was added as a staging criterion, adherence decreased to 23.3%. Increased volume of esophagectomies within an institution was associated with increased staging adherence with ER ( P =0.008).

CONCLUSIONS

The use of CT/PET/EUS for the staging of early esophageal cancer is accurate in only 56.3% of patients. ER may increase staging accuracy as it is related to a decrease in upstaging. ER is poorly utilized in staging of early esophageal cancer. Barriers to the implementation of ER as a staging modality should be identified and corrected.

Clinical utility of preoperative pan-immune-inflammation value (PIV) for prognostication in patients with esophageal squamous cell carcinoma

BACKGROUND

Several researches have shown that pan-immune-inflammation value (PIV) is related to cancer prognosis in recent years. In esophageal squamous cell carcinoma (ESCC), nevertheless, the prognostic impact of PIV remains unclear. The present study sought to investigate the prognostic impact of preoperative PIV in ESCC with radical resection.

METHODS

The data of 294 ESCC patients who received radical resection were retrospectively analyzed. Based on analyzing the non-linear relationship between PIV and cancer-specific survival (CSS), the optimal cutoff value for PIV was calculated by the restricted cubic spline (RCS) model. Cox proportional hazards regression was carried out to identify the prognostic factors. A risk stratification model was established by recursive partitioning analysis (RPA). The performance of the RPA-based model was assessed by the decision curve analysis (DCA) and receiver operating characteristic (ROC).

RESULTS

The RCS visualized the non-linear relationship between PIV and CSS (P < 0.0001). Then patients were then divided into high and low groups based on the optimal threshold of 308.2. The 5-year CSS (17.7 % vs. 48.3 %, P < 0.001) was significantly worse in patients with high PIV than those in the low group. Subgroup analyses confirmed that patients with low PIV also achieved better 5-year survival at different pathological tumor node metastasis (pTNM) stages (pTNM I: P = 0.022; pTNM II: P = 0.001; pTNM III: P = 0.011). PIV served as an independent prognostic factor of CSS (hazard ratio = 1.983, P < 0.001). A new staging involving three risk groups with significantly different CSS was developed using RPA algorithms based on pTNM and PIV. Compared with the pTNM classification, the RPA-based model exhibited significantly superior performance for prognostication.

CONCLUSION

The present study confirmed the prognostic impact of PIV in ESCC who treated with radical resection. PIV was associated with the tumor stage and prognosis, which might be useful in the preoperative assessment of ESCC.

Stratification of lymph node metastasis improves diagnostic efficiency in thoracic esophageal squamous cell carcinoma

INTRODUCTION

Difference of the short diameter of lymph nodes in the main regions of esophageal squamous cell carcinoma (ESCC) and its value in the diagnosis of lymph nodes need to explore.

METHODS

The clinical data of patients with thoracic ESCC who underwent surgical treatment in our hospital were collected. The short diameters of the largest lymph node in each region of the patient were measured by preoperative enhanced computed tomography (CT) and were compared with the postoperative pathology.

RESULTS

A total of 477 patients with thoracic ESCC who did not receive neoadjuvant therapy were enrolled in this study. The receiver operating characteristic curve suggested that the short diameters of the paracardial nodes, the left gastric nodes, the right recurrent laryngeal nerve nodes, and the left recurrent laryngeal nerve nodes could well predict the postoperative pathology of the lymph nodes, with area under curve (AUC) of 0.958, 0.937, 0.931, and 0.915, the corresponding cut-off values of 5.7 mm, 5.7 mm, 5.5 mm, and 4.8 mm, the corresponding sensitivities of 94.7%, 85.4%, 88.7%, and 79.4%, and the corresponding specificities of 93.7%, 96.3%, 86.2%, and 95.0%, respectively. The AUC of the thoracic paraesophageal lymph nodes, the subcarinal nodes and all regional lymph nodes were 0.845, 0.688, and 0.776, respectively.

CONCLUSION

Region-based criterion for lymph node metastasis of thoracic ESCC is beneficial to improve the diagnostic efficiency of preoperative CT.

Adjuvant Therapy After Neoadjuvant Therapy for Esophageal Cancer: Who Needs It?

OBJECTIVE

We hypothesized that, on average, patients do not benefit from additional adjuvant therapy after neoadjuvant therapy for locally advanced esophageal cancer, although subsets of patients might. Therefore, we sought to identify profiles of patients predicted to receive the most survival benefit or greatest detriment from adding adjuvant therapy.

BACKGROUND

Although neoadjuvant therapy has become the treatment of choice for locally advanced esophageal cancer, the value of adding adjuvant therapy is unknown.

METHODS

From 1970 to 2014, 22,123 patients were treated for esophageal cancer at 33 centers on 6 continents (Worldwide Esophageal Cancer Collaboration), of whom 7731 with adenocarcinoma or squamous cell carcinoma received neoadjuvant therapy; 1348 received additional adjuvant therapy. Random forests for survival and virtual-twin analyses were performed for all-cause mortality.

RESULTS

Patients received a small survival benefit from adjuvant therapy (3.2±10 months over the subsequent 10 years for adenocarcinoma, 1.8±11 for squamous cell carcinoma). Consistent benefit occurred in ypT3-4 patients without nodal involvement and those with ypN2-3 disease. The small subset of patients receiving most benefit had high nodal burden, ypT4, and positive margins. Patients with ypT1-2N0 cancers had either no benefit or a detriment in survival.

CONCLUSIONS

Adjuvant therapy after neoadjuvant therapy has value primarily for patients with more advanced esophageal cancer. Because the benefit is often small, patients considering adjuvant therapy should be counseled on benefits versus morbidity. In addition, given that the overall benefit was meaningful in a small number of patients, emerging modalities such as immunotherapy may hold more promise in the adjuvant setting.

Systematic meta-analysis of computer-aided detection to detect early esophageal cancer using hyperspectral imaging

One of the leading causes of cancer deaths is esophageal cancer (EC) because identifying it in early stage is challenging. Computer-aided diagnosis (CAD) could detect the early stages of EC have been developed in recent years. Therefore, in this study, complete meta-analysis of selected studies that only uses hyperspectral imaging to detect EC is evaluated in terms of their diagnostic test accuracy (DTA). Eight studies are chosen based on the Quadas-2 tool results for systematic DTA analysis, and each of the methods developed in these studies is classified based on the nationality of the data, artificial intelligence, the type of image, the type of cancer detected, and the year of publishing. Deeks' funnel plot, forest plot, and accuracy charts were made. The methods studied in these articles show the automatic diagnosis of EC has a high accuracy, but external validation, which is a prerequisite for real-time clinical applications, is lacking.

Comprehensive nutritional index predicts clinical outcomes for esophageal squamous cell carcinoma receiving neoadjuvant immunotherapy combined with chemotherapy

OBJECTIVE

No study has reported the clinical outcomes of comprehensive nutritional index (CNI) in esophageal squamous cell carcinoma (ESCC) receiving neoadjuvant immunotherapy combined with chemotherapy (nICT).

METHODS

This retrospective study involved 233 ESCC patients who underwent nICT. Principal component analysis was performed to establish the CNI based on 5 indexes including body mass index, usual body weight percentage, total lymphocyte count, albumin and hemoglobin. The relationships between the CNI and therapeutic response, postoperative complications and prognosis were analyzed.

RESULTS

One hundred and forty-nine and 84 patients were assigned to the high and low CNI group, respectively. The incidences of respiratory complications (33.3% vs. 18.8%, P = 0.013) and vocal cord paralysis (17.9% vs. 8.1%, P = 0.025) in low CNI were significantly higher than those in high group, respectively. Seventy (30.0%) patients achieved pathological complete response (pCR). High CNI patients achieved a better pCR rate than those with low CNI (41.6% vs. 9.5%, P < 0.001). The CNI served as an independent pCR predictor [odds ratio (OR) = 0.167, 95% confidence interval (CI) = 0.074-0.377, P < 0.001)]. High CNI patients had better 3-year disease-free survival (DFS) (85.4% vs. 52.6%, P < 0.001) and overall survival (OS) (85.5% vs. 64.5%, P < 0.001) than those with low CNI, respectively. The CNI served as an independent prognostic score regarding DFS [hazard ratio (HR) = 3.878, 95% CI = 2.214-6.792, P < 0.001)] and OS (HR = 4.386, 95% CI = 2.006-9.590, P < 0.001).

CONCLUSION

Based on nutrition-related indicators, the pretreatment CNI serves as a sensitive and effective predictor of therapeutic response, postoperative complications and prognosis in ESCC receiving nICT.

Prognostic analysis and nomogram establishment in patients with early esophageal cancer receiving endoscopic therapy: a population-based study

Background

The growing numbers of early esophageal cancer (EEC) have increased the demand for endoscopic therapy.

Objectives

To clarify the influential factors for the prognosis of patients with EEC receiving endoscopic surgery, and to construct a nomogram to evaluate the prognostic value of endoscopic therapy.

Design

Prognostic analysis study.

Methods

Clinical data of EEC patients who received endoscopic therapy between 2004 and 2015 were collected from the Surveillance, Epidemiology, and End Results database and used to construct the nomogram. The prognosis was analyzed by R language; the nomogram was constructed by Cox survival analysis; and the accuracy of the nomogram was verified by C index and the receiver operating characteristic (ROC) and calibration curves. X-Tile software was used to stratify the risk of patients.

Results

Our study constructed the nomogram of the prognosis of patients with EEC treated by endoscopic surgery, including 1118 patients and 5 independent prognostic factors of esophageal cancer-specific survival. The C index and the area under the ROC curve (AUC) of the training and verification cohorts were all >0.75. The calibration curve also reflected the good consistency of the model in predicting survival. Significant difference in the risk of patients from different stratifications with the same T staging existed, and the model had a better C index than that of the T staging.

Conclusion

Our study reports potential influential factors affecting the prognosis of EEC patients who received endoscopic therapy and establishes a reliable nomogram to predict the risk and prognosis, which has certain advantages compared with traditional TNM staging system.

Learning Curve of Robot-Assisted Lymph Node Dissection of the Left Recurrent Laryngeal Nerve: A Retrospective Study of 417 Patients

OBJECTIVE

Left recurrent laryngeal nerve (no.106recL) lymph node dissection is a challenging procedure, and robotic-assisted minimally invasive esophagectomy (RAMIE) may have some advantages. This study aimed to determine the learning curve of no.106recL lymph node dissection.

METHODS

The data of 417 patients who underwent McKeown RAMIE between June 2017 and June 2022 were retrospectively analyzed. The lymph node harvest of no.106recL was used to determine the learning curve, and the cumulative sum (CUSUM) method was employed to obtain the inflection point.

RESULTS

A total of 404 patients (404/417, 96.9%) underwent robotic surgery. Based on the number of no.106recL lymph nodes harvested, the CUSUM learning curve was mapped and divided into three phases: phase I (1‒75 cases), phase II (76‒240 cases), and phase III (241‒404 cases). The median (IQR) number of no.106recL lymph node harvests were 1 (4), 3 (6,) and 4 (4) in each phase (p < 0.001). The lymph node dissection rate gradually increased from 62.7% in phase I to 82.9% in phase III (p = 0.001). The total and thoracic lymph node harvest gradually increased (p < 0.001), whereas operation time (p = 0.001) and blood loss gradually decreased (p < 0.001). Moreover, the incidence of total complication (p = 0.020) and recurrent laryngeal nerve injury (p = 0.001) significantly decreased, and the postoperative hospital stay gradually shortened (p < 0.001).

CONCLUSION

Robotic no.106recL lymph node dissection has some advantages for patients with esophageal cancer. In this study, perioperative and clinical outcomes were significantly improved over the learning curve. However, further prospective studies are required to confirm our results.

Role of Lower Esophageal Squamous Cell Carcinoma Margin Location on Abdominal Lymph Node Metastasis Risk

Background: Different sites of esophageal cancer are accompanied by different regional lymph node metastasis (LNM) risks. We aimed to investigate the impact of a lower tumor margin on abdominal LNM risk. Methods: We enrolled patients who underwent esophagectomy for esophageal squamous carcinoma (ESCC) from 2014 to 2017 in West China Hospital. Overall survival (OS) analysis was performed. We measured the distance between the lower tumor margin and esophagogastric junction (LED) with upper gastrointestinal contrast-enhanced X-ray (UGCXR). Multivariate logistic regression analysis and propensity score matching (PSM) were performed to explore the relationship between LED and the risk of abdominal LNM. Abdominal LNM risk in ESCC was stratified based on the location of the lower tumor margin. A model predicting abdominal LNM risk was constructed and presented with a nomogram. Results: The included patients had an abdominal LNM rate of 48.29%. In multivariate logistic regression analysis, LED was identified as a risk factor for abdominal LNM. Subgroup analysis of middle ESCC showed that patients with an LED less than 10 cm had a significantly higher rate of abdominal LNM than those with an LED greater than 10 cm. The abdominal LNM rate in middle ESCC patients with an LED less than 10 cm was 32.2%, while it was 35.1% in lower ESCC patients whose lower tumor margin did not invade the esophagogastric junction (EGJ), which was comparable after PSM. Conclusions: LED could help surgeons evaluate the risk of abdominal LNM preoperatively and better guide dissection of abdominal lymph nodes according to risk level.

Intrathoracic Robotic-Sewn Anastomosis During Ivor Lewis Esophagectomy for Cancer: Back to Basics?

BACKGROUND

To assess the feasibility, clinical utility, and safety of intrathoracic robotic-sewn esophageal anastomosis (IrEA) during Ivor Lewis esophagectomy for adenocarcinoma of the lower third of the esophagus, or cancer at the gastro-esophageal junction type I (Siewert classification).

METHODS

A protocol for completely robotic Ivor Lewis esophagectomy (CrIE) and intrathoracic robotic-sewn anastomosis (IrEA) was established at the authors' institutions from January 2015 through December 2019. Overall surgery-related postoperative complications were analyzed. Overall survival and disease-free survival analysis were performed using standard methods.

RESULTS

The study population consisted of 40 patients. Median operative time was 320 min (sd 62, range 235-500 min), and conversion to open rate was 0%. Anastomotic leak rate was 10%. The mean number of examined lymph nodes (ELN) was 19 (IQR 11-29), and the mean number of positive lymph nodes (PLN) was 3 (IQR 0-5). Short- and long-term surgical and oncological outcomes were comparable at a medium follow-up of 37 months. The median overall survival was 48 months while the mean disease-free survival was 29 months.

CONCLUSION

This pilot series, in which an intrathoracic robotic-sewn anastomosis (IrEA) was performed during CrIE, demonstrated the safety and feasibility of this approach. Compared to the current standard of care at a high-volume center, IrEA was associated with better postoperative surgical outcomes and similar oncological outcomes to those reported worldwide today. These results call for further validation in a prospective and controlled setting to be fully incorporated into clinical practice.

Prediction of pathologic complete response prediction in patients with locally advanced esophageal squamous cell carcinoma treated with neoadjuvant immunochemotherapy: A real-world study

As an emerging hotspot for patients with locally advanced esophageal squamous cell carcinoma (LA-ESCC), neoadjuvant immunochemotherapy (nICT) is safe and feasible. Pathological complete response (pCR) is considered to be an important therapeutic effect of neoadjuvant therapy. However, few studies have explored pCR predictors for nICT in LA-ESCC. The purpose of this study was to predict pCR after nICT in LA-ESCC by pretreatment clinical characteristics and hematological indexes. The primary endpoint was to explore the impacts on the predictors for pCR prediction. Clinical characteristics and hematological indexes including systemic immune-inflammation index (SII), neutrophil lymphocyte ratio (NLR), lymphocyte monocyte ratio (LMR), prognostic nutritional index (PNI) and platelet lymphocyte ratio (PLR) were conducted. A total of 150 LA-ESCC patients were enrolled in the current study. There were 14 (9.3%) female and 136 (90.7%) male patients. Fifty-two patients achieved pCR (34.7%). A higher pCR rate was found in low-NLR group (43.7% vs. 26.6%, P=0.028) and high-LMR group (43.8% vs. 21.3%, P=0.004), respectively. Differentiation [odds ratio (OR) =0.464, 95% confidence interval (CI)=0.259-0.830, P=0.010], LMR (OR=0.309, 95% CI=0.132-0.707, P=0.007) and cTNM (OR=0.225, 95% CI=0.115-0.441, P<0.001) were independent predictors for pCR. The nomogram for pCR prediction based on LMR, differentiation and cTNM stage had good discrimination performance and calibration coordination (C-index=0.779). The results of our study are of great significance for designing therapeutic strategies. Nomogram based on LMR, differentiation and cTNM may accurately and effectively predict pCR.

Prognostic impact of examined lymph-node count for patients with esophageal cancer: development and validation prediction model

Esophageal cancer (EC) is a malignant tumor with high mortality. We aimed to find the optimal examined lymph node (ELN) count threshold and develop a model to predict survival of patients after radical esophagectomy. Two cohorts were analyzed: the training cohort which included 734 EC patients from the Chinese registry and the external testing cohort which included 3208 EC patients from the Surveillance, Epidemiology, and End Results (SEER) registry. Cox proportional hazards regression analysis was used to determine the prognostic value of ELNs. The cut-off point of the ELNs count was determined using R-statistical software. The prediction model was developed using random survival forest (RSF) algorithm. Higher ELNs count was significantly associated with better survival in both cohorts (training cohort: HR = 0.98, CI = 0.97-0.99, P < 0.01; testing cohort: HR = 0.98, CI = 0.98-0.99, P < 0.01) and the cut-off point was 18 (training cohort: P < 0.01; testing cohort: P < 0.01). We developed the RSF model with high prediction accuracy (AUC: training cohort: 87.5; testing cohort: 79.3) and low Brier Score (training cohort: 0.122; testing cohort: 0.152). The ELNs count beyond 18 is associated with better overall survival. The RSF model has preferable clinical capability in terms of individual prognosis assessment in patients after radical esophagectomy.

Fatty acid metabolism is related to the immune microenvironment changes of gastric cancer and RGS2 is a new tumor biomarker

Background

Alterations in lipid metabolism promote tumor progression. However, the role of lipid metabolism in the occurrence and development of gastric cancer have not been fully clarified.

Method

Here, genes that are related to fatty acid metabolism and differentially-expressed between normal and gastric cancer tissues were identified in the TCGA-STAD cohort. The intersection of identified differentially-expressed genes with Geneset was determined to obtain 78 fatty acid metabolism-related genes. The ConsensusClusterPlus R package was used to perform differentially-expressed genes, which yielded divided two gastric cancer subtypes termed cluster 1 and cluster 2.

Results

Patients in cluster 2 was found to display poorer prognosis than patients in cluster 1. Using machine learning method to select 8 differentially expressed genes among subtypes to construct fatty acid prognostic risk score model (FARS), which was found to display good prognostic efficacy. We also identified that certain anticancer drugs, such as bortezomib, elesclomol, GW843682X, and nilotinib, showed significant sensitivity in the high FARS score group. RGS2 was selected as the core gene upon an analysis of the gastric cancer single-cell, and Western blotting and immunofluorescence staining results revealed high level of expression of this gene in gastric cancer cells. The results of immunohistochemical staining showed that a large amount of RGS2 was deposited in the stroma in gastric cancer. A pan-cancer analysis also revealed a significant association of RGS2 with TMB, TIDE, and CD8+ T-cell infiltration in other cancer types as well. RGS2 may thus be studied further as a new target for immunotherapy in future studies on gastric cancer.

Conclusion

In summary, the FARS model developed here enhances our understanding of lipid metabolism in the TME in gastric cancer, and provides a theoretical basis for predicting tumor prognosis and clinical treatment.

Effect of Adjuvant Radiation Dose on Survival in Patients with Esophageal Squamous Cell Carcinoma

Background: For patients with esophageal squamous cell carcinoma (ESCC) treated with surgery alone, the incidence of local-regional recurrence remains unfavorable. Postoperative radiotherapy (PORT) has been associated with increased local-regional recurrence-free survival (LRFS), although its application is limited by concerns of PORT-related toxicities. Methods: Among 3591 patients with ESCC analyzed in this study, 2765 patients with T3-4N0 and T1-4N1-3 lesions and specific local-regional status information were analyzed in a subsequent analysis of adjuvant radiation dose (aRTD) effect. Application of the restricted cubic spline regression model revealed a non-linear relationship between aRTD and survival/radiotoxicity. Linear regression analysis (LRA) was performed to evaluate correlations between LRFS and overall survival (OS)/ disease-free survival (DFS). Results: For patients staged T1−2N0, T1−2N1−3, T3−4N0, and T3−4N1−3, 5-year OS in PORT and non-PORT groups were 77.38% vs. 72.91%, p = 0.919, 52.35% vs. 46.60%, p = 0.032, 73.41% vs. 61.19%, p = 0.005 and 38.30% vs. 25.97%, p < 0.001. With aRTD escalation, hazard ratios (HRs) of OS/DFS declined until aRTD exceeded 50Gy, then increased, whereas that of LRFS declined until aRTD exceeded 50 Gy, then remained steady. HR of treatment-related mortality was stable until aRTD exceeded 50 Gy, then increased. LRA revealed strong correlations between LRFS and OS/DFS (r = 0.984 and r = 0.952, respectively). An absolute 1% advancement in LRFS resulted in 0.32% and 0.34% improvements in OS and DFS. Conclusions: An aRTD of 50Gy was well-tolerated, with favorable survival resulting from PORT-related LRFS improvement in patients staged T3−4N0 or T1-4N1−3. Further stratification analyses based on tumor burden would help determine potential PORT-beneficiaries.

The usefulness of pretreatment controlling nutritional status score for predicting recurrence in patients with esophageal squamous cell carcinoma undergoing neoadjuvant immunochemotherapy: A real-world study

Background

The controlling nutritional status (CONUT) score, as an immune-nutritional index, has been reported to be related to prognosis in several cancers. Neoadjuvant immunochemotherapy (nICT) is an emerging pattern for cancer treatment in recent years. However, the usefulness of CONUT in esophageal squamous cell carcinoma (ESCC) with nICT has not been reported so far. This study attempted to clarify the usefulness of CONUT in predicting disease-free survival (DFS) in ESCC with nICT.

Methods

Two hundred sixteen ESCC patients receiving nICT between 2019 and 2021 were retrospectively enrolled. Based on CONUT, the patients were divided into two groups: low groups (score ≤ 2) and high (score ≥ 3) groups. The relationships between CONUT and clinical characteristics were estimated. Cox regression analyses with hazard ratios (HRs) and 95% confidence intervals (CIs) were also performed to evaluate the prognostic factors of DFS.

Results

Fifty-nine (27.3%) patients achieved pathologic complete response (pCR), and 30 (13.9%) cases had a recurrence. There were 150 cases (69.4%) in low CONUT group and 66 cases (30.6%) in high CONUT group, respectively. The results revealed that vessel invasion (P = 0.037), postoperative pneumonia (P = 0.001), advanced ypT stage (P = 0.011), cTNM stage (P = 0.007), and ypTNM stage (P < 0.001) were significantly related to patients with a high CONUT score. A high pCR rate was found in patients with a low CONUT score (33.3% vs. 13.6%, P = 0.003), and a high recurrence rate was found in patients with a high CONUT score (24.2% vs. 9.3%, P = 0.004), respectively. Patients with a low CONUT score had a better 1-year DFS than those with a high CONUT score (90.7% vs. 75.8%, P = 0.004). Multivariate analyses indicated that the pretreatment CONUT score was an independent predictor regarding DFS (HR = 2.221, 95% CI: 1.067-4.625, P = 0.033).

Conclusion

A better response and a lower recurrence were found in ESCC patients with a lower pretreatment CONUT. As a useful index for immune-nutritional status, the CONUT might be a reliable prognostic indicator in ESCC patients with nICT.

Serum insulin-like growth factor binding protein 3 as a promising diagnostic and prognostic biomarker in esophagogastric junction adenocarcinoma

BACKGROUND

Esophagogastric junction adenocarcinoma (EJA) lacks serum biomarkers to assist in diagnosis and prognosis. Here, we aimed to evaluate the diagnostic and prognostic value of serum insulin-like growth factor binding protein 3 (IGFBP3) in EJA patients.

METHODS

320 participants were recruited from November 2016 to January 2020, who were randomly divided into a training cohort (112 normal controls and 102 EJA patients including 24 early-stage patients) and a validation cohort (56 normal controls and 50 EJA patients including 12 early-stage patients). We used receiver operating characteristics curve (ROC) to evaluate diagnostic value. The predictive performance of the nomogram was evaluated by the concordance index (C-index).

RESULTS

Serum IGFBP3 levels were significantly lower in early-stage EJA or EJA patients than those in controls (P < 0.01). Measurement of serum IGFBP3 demonstrated an area under curve of 0.819, specificity 90.18% and sensitivity 43.14% in training cohort. Similar results were observed in validation cohort (0.804, 87.50%, 42.00%). Importantly, serum IGFBP3 had a satisfactory diagnostic value for early-stage EJA (0.822, 90.18%, 45.83% and 0.811, 84.48%, 50.00% in training and validation cohorts, respectively). Furthermore, survival analysis demonstrated that lower serum IGFBP3 level was related to poor prognosis (P < 0.05). Cox multivariate analysis revealed that serum IGFBP3 was an independent prognostic factor (HR = 0.468, P = 0.005). Compared with TNM stage, a nomogram based on serum IGFBP3, tumor size and TNM stage indicated an improved C-index in prognostic prediction (0.625 vs. 0.735, P = 0.001).

CONCLUSIONS

We found that serum IGFBP3 was a potential diagnostic and prognostic marker of EJA. Meanwhile, the nomogram might predict the prognosis of EJA more accurately and efficiently.

Prognostic prediction by a novel integrative inflammatory and nutritional score based on least absolute shrinkage and selection operator in esophageal squamous cell carcinoma

BACKGROUND

This study aimed to establish and validate a novel predictive model named integrative inflammatory and nutritional score (IINS) for prognostic prediction in esophageal squamous cell carcinoma (ESCC).

MATERIALS AND METHODS

We retrospectively recruited 494 pathologically confirmed ESCC patients with surgery and randomized them into training (n = 346) or validation group (n = 148). The least absolute shrinkage and selection operator (LASSO) Cox proportional hazards (PH) regression analysis was initially used to construct a novel predictive model of IINS. The clinical features and prognostic factors with hazard ratio (HRs) and 95% confidence intervals (CIs) grouped by IINS were analyzed. Nomogram was also established to verify the prognostic value of IINS.

RESULTS

According to the LASSO Cox PH regression analysis, a novel score of IINS was initially constructed based on 10 inflammatory and nutritional indicators with the optimal cut-off level of 2.35. The areas under the curve (AUCs) of IINS regarding prognostic ability in 1-year, 3-years, and 5-years prediction were 0.814 (95% CI: 0.769-0.854), 0.748 (95% CI: 0.698-0.793), and 0.792 (95% CI: 0.745-0.833) in the training cohort and 0.802 (95% CI: 0.733-0.866), 0.702 (95% CI: 0.621-0.774), and 0.748 (95% CI: 0.670-0.816) in the validation cohort, respectively. IINS had the largest AUCs in the two cohorts compared with other prognostic indicators, indicating a higher predictive ability. A better 5-years cancer-specific survival (CSS) was found in patients with IINS ≤ 2.35 compared with those with IINS > 2.35 in both training cohort (54.3% vs. 11.1%, P < 0.001) and validation cohort (53.7% vs. 18.2%, P < 0.001). The IINS was then confirmed as a useful independent factor (training cohort: HR: 3.000, 95% CI: 2.254-3.992, P < 0.001; validation cohort: HR: 2.609, 95% CI: 1.693-4.020, P < 0.001). Finally, an IINS-based predictive nomogram model was established and validated the CSS prediction (training set: C-index = 0.71 and validation set: C-index = 0.69, respectively).

CONCLUSION

Preoperative IINS is an independent predictor of CSS in ESCC. The nomogram based on IINS may be used as a potential risk stratification to predict individual CSS and guide treatment in ESCC with radical resection.

Single-Cell Transcriptomics of Endothelial Cells in Upper and Lower Human Esophageal Squamous Cell Carcinoma

Esophageal squamous cell carcinoma (ESCC) is a type of progressive and distant metastatic tumor. Targeting anti-angiogenic genes could effectively hinder ESCC development and metastasis, whereas ESCC locating on the upper or the lower esophagus showed different response to the same clinical treatment, suggesting ESCC location should be taken into account when exploring new therapeutic targets. In the current study, to find novel anti-angiogenic therapeutic targets, we identified endothelial cell subsets in upper and lower human ESCC using single-cell RNA sequencing (scRNA-seq), screened differentially expressed genes (DEGs), and performed gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis. The results showed that common DEGs shared in the upper and the lower endothelial cells mainly are involved in vessel development, angiogenesis, and cell motility of endothelial cells by regulating PI3K-AKT, Rap1, Ras, TGF-beta, and Apelin signaling pathways. The critical regulatory genes were identified as ITGB1, Col4A1, Col4A2, ITGA6, LAMA4, LAMB1, LAMC1, VWF, ITGA5, THBS1, PDGFB, PGF, RHOC, and CTNNB1. Cell metabolism-relevant genes, e.g., MGST3, PNP, UPP1, and HYAL2 might be the prospective therapeutic targets. Furthermore, we found that DEGs only in the upper endothelial cells, such as MAPK3, STAT3, RHOA, MAPK11, HIF1A, FGFR1, GNG5, GNB1, and ARHGEF12, mainly regulated cell adhesion, structure morphogenesis, and motility through Phospholipase D, Apelin, and VEGF signaling pathways. Moreover, DEGs only in the lower endothelial cells, for instance PLCG2, EFNA1, CALM1, and RALA, mainly regulated cell apoptosis and survival by targeting calcium ion transport through Rap1, Ras, cAMP, Phospholipase D, and Phosphatidylinositol signaling pathways. In addition, the upper endothelial cells showed significant functional diversity such as cytokine-responsive, migratory, and proliferative capacity, presenting a better angiogenic capacity and making it more sensitive to anti-angiogenic therapy compared with the lower endothelial cells. Our study has identified the potential targeted genes for anti-angiogenic therapy for both upper and lower ESCC, and further indicated that anti-angiogenic therapy might be more effective for upper ESCC, which still need to be further examined in the future.

Severe radiation-induced lymphopenia during postoperative radiotherapy or chemoradiotherapy has poor prognosis in patients with stage IIB-III after radical esophagectomy: A post hoc analysis of a randomized controlled trial

Objective

To investigate whether radiation-induced lymphopenia (RIL) affects survival and identify the predictors of RIL in postoperative esophageal cancer.

Materials and methods

Post hoc analysis was conducted on data from 116 patients with esophageal cancer from a randomized controlled trial comparing adjuvant therapy with surgery alone. Doses of 54 Gy in 27 fractions was delivered in the postoperative radiotherapy (PORT) group and 50.4 Gy in 28 fractions combined with chemotherapy was delivered in postoperative concurrent chemoradiotherapy (POCRT) group. Blood counts were obtained before, during, and at first follow-up after treatment. Lymphopenia was graded per version 4.03 of the Common Terminology Criteria for Adverse Events. Disease-free survival (DFS) and overall survival (OS) were analyzed using the Kaplan-Meier method, and compared between groups using the log-rank test. Receiver operating characteristic curves identified thresholds for preventing grade 4 (G4) lymphopenia.

Results

Median follow-up duration was 56.0 months. During treatment, 16 patients (13.8%) had G4 lymphopenia. All cases of G4 lymphopenia occurred in group PORT (30.2% vs 0.0%, p<0.001). Baseline absolute lymphocyte count was comparable between G1-3 and G4 patients (2.0 ± 0.8 *10⁹/L vs 1.7 ± 0.5 *10⁹/L; p=0.101). The 3-year DFS was significantly lower in group G4 lymphopenia than that in group G1-3 (31.3% vs 57.6%, p=0.036). The 3-year OS was comparable between both groups (50.0% vs 66.5%, p=0.095). Logistic regression analysis revealed that exposed more thoracic marrow (TM V20 ≥75%; TVB V20 ≥71%), heart (V15 ≥40%) and PTV (volume ≥507 ml) were associated with G4 lymphopenia (p<0.05).

Conclusions

G4 RIL had poor disease-free survival, which may be related to more dose exposure of thoracic marrow and heart due to larger PTV. Reasonably reducing the radiation field combined with concurrent chemotherapy, or radiation dose constraints for these normal tissues may be sufficient to decrease the incidence of G4 lymphopenia, but further prospective trials are needed to verify the results.

Clinical Trial Registration

clinicaltrials.gov, identifier NCT02279134

A modified survival model for patients with esophageal squamous cell carcinoma based on lymph nodes: A study based on SEER database and external validation

Background

The counts of examined lymph nodes (ELNs) in predicting the prognosis of patients with esophageal squamous cell carcinoma (ESCC) is a controversial issue. We conducted a retrospective study to develop an ELNs-based model to individualize ESCC prognosis.

Methods

Patients with ESCC from the SEER database and our center were strictly screened. The optimal threshold value was determine by the X-tile software. A prognostic model for ESCC patients was developed and validated with R. The model’s efficacy was evaluated by C-index, ROC curve, and decision curve analysis (DCA).

Results

3,629 cases and 286 cases were screened from the SEER database and our center, respectively. The optimal cut-off value of ELNs was 10. Based on this, we constructed a model with a favorable C-index (training group: 0.708; external group 1: 0.687; external group 2: 0.652). The model performance evaluated with ROC curve is still reliable among the groups. 1-year AUC for nomogram in three groups (i.e., 0.753, 0.761, and 0.686) were superior to that of the TNM stage (P < 0.05). Similarly, the 3-year AUC and the 5-year AUC results for the model were also higher than that of the 8th TNM stage. By contrast, DCA showed the benefit of this model was better in the same follow-up period.

Conclusion

More than 10 ELNs are helpful to evaluate the survival of ESCC patients. Based on this, an improved model for predicting the prognosis of ESCC patients was proposed.

The effect of histologic grade on neoadjuvant treatment outcomes in esophageal cancer

BACKGROUND AND OBJECTIVES

The gold standard for locoregional esophageal cancer (LEC) treatment includes preoperative chemoradiation and surgical resection, with possible perioperative or adjuvant systemic therapy. With few data associating histologic grade and prognosis in LEC patients receiving neoadjuvant chemoradiation followed by resection, we seek to evaluate this association.

METHODS

Our institutional esophagectomy database between 1999 and 2019 was queried, selecting esophageal adenocarcinoma patients who completed neoadjuvant therapy (NAT), followed by esophagectomy. Propensity-score matching of low- and high-histologic grade groups was performed to assess survival metrics using initial clinical grade (cG) and final pathologic grade (pG). We performed a multivariable logistic regression to study predictors of pathologic complete response as a secondary objective.

RESULTS

A total of 518 patients met the inclusion criteria. Kaplan-Meier analysis of the matched dataset showed no difference in initial or 5-year recurrence-free survival or overall survival (OS) between cG1 and cG2 versus cG3 based on original grade. When matched according to pG, cG1-2 had improved median survival parameters compared to cG3, with 5-year OS for cG1-2 of 45% versus 27% (p = 0.001). Higher pG, pathologic N stage, and poor response to NAT are predictors of poor survival.

CONCLUSION

Patients with post-NAT pG1-2 demonstrated improved survival. Integrating histologic grade into postneoadjuvant staging may be warranted.

Recent advances in multidisciplinary therapy for adenocarcinoma of the esophagus and esophagogastric junction

Esophageal adenocarcinoma (EAC) and adenocarcinoma of the esophagogastric junction (EGJA) have long been associated with poor prognosis. With changes in the spectrum of the disease caused by economic development and demographic changes, the incidence of EAC and EGJA continues to increase, making them worthy of more attention from clinicians. For a long time, surgery has been the mainstay treatment for EAC and EGJA. With advanced techniques, endoscopic therapy, radiotherapy, chemotherapy, and other treatment methods have been developed, providing additional treatment options for patients with EAC and EGJA. In recent decades, the emergence of multidisciplinary therapy (MDT) has enabled the comprehensive treatment of tumors and made the treatment more flexible and diversified, which is conducive to achieving standardized and individualized treatment of EAC and EGJA to obtain a better prognosis. This review discusses recent advances in EAC and EGJA treatment in the surgical-centered MDT mode in recent years.

Development and validation of a novel prognostic model for patients with surgically resected esophageal squamous cell carcinoma

Background and objectives

Esophageal squamous cell carcinoma (ESCC) is the most common pathological type of esophageal malignancy in most regions of the world. The study aimed to identify risk factors and develop a predictive model for ESCC following surgical resection.

Patients and methods

A total of 533 ESCC patients who underwent surgical resection from Suining Central Hospital were enrolled in the study. Cox proportional hazards regression and Least Absolute Shrinkage and Selection Operator (LASSO) regression were performed to identify significant prognostic factors. A prognostic model was constructed, and the receiver operating characteristic (ROC) curve, concordance index (C-index), and decision cure analysis (DCA) were used to evaluate the discrimination and calibration of the prognostic model. Subsequently, we built a nomogram for overall survival (OS) incorporating the prognostic factors, and a calibration plot was employed to assess the consistency between the predicted survival and the observed survival. Based on the model risk score, we split the patients into two subgroups, low-risk and high-risk, and we analyzed the survival time of these two groups using Kaplan–Meier (K-M) survival plots.

Results

Five independent prognosis factors were identified as independent risk factors for OS in ESCC patients who underwent surgical resection. The C-index, ROC curve, and DCA showed that the prognostic model had good predictive accuracy and discriminatory power in the training cohort and validation cohort than other clinical features. A nomogram consisting of prognosis factors showed some superior net benefit. K-M survival plots showed significant differences in OS between the low-risk and high-risk groups. Similar results were observed in the subgroup analysis based on age, grade, and stage. Univariate and multivariate Cox regression analyses revealed that both risk score and risk group are independent prognostic factors in the patient cohort.

Conclusions

This study put forward a novel prognostic model based on clinical features; biopsy data and blood biomarkers may represent a promising tool for estimating OS in ESCC patients.

SIRGs score may be a predictor of prognosis and immunotherapy response for esophagogastric junction adenocarcinoma

Background

Esophagogastric junction adenocarcinoma (EGJA) is a special malignant tumor with unknown biological behavior. PD-1 checkpoint inhibitors have been recommended as first-line treatment for advanced EGJA patients. However, the biomarkers for predicting immunotherapy response remain controversial.

Methods

We identified stromal immune-related genes (SIRGs) by ESTIMATE from the TCGA-EGJA dataset and constructed a signature score. In addition, survival analysis was performed in both the TCGA cohort and GEO cohort. Subsequently, we explored the differences in tumor-infiltrating immune cells, immune subtypes, immune-related functions, tumor mutation burden (TMB), immune checkpoint gene expression, immunophenoscore (IPS) between the high SIRGs score and low SIRGs score groups. Finally, two validation cohorts of patients who had accepted immunotherapy was used to verify the value of SIRGs score in predicting immunotherapy response.

Results

Eight of the SIRGs were selected by LASSO regression to construct a signature score (SIRGs score). Univariate and multivariate analyses in the TCGA and GEO cohort suggested that SIRGs score was an independent risk factor for the overall survival (OS) and it could increase the accuracy of clinical prediction models for survival. However, in the high SIRGs score group, patients had more immune cell infiltration, more active immune-related functions, higher immune checkpoint gene expression and higher IPS-PD1 and IPS-PD1-CTLA4 scores, which indicate a better response to immunotherapy. The external validation illustrated that high SIRGs score was significantly associated with immunotherapy response and immune checkpoint inhibitors (ICIs) can improve OS in patients with high SIRGs score.

Conclusion

The SIRGs score may be a predictor of the prognosis and immune-therapy response for esophagogastric junction adenocarcinoma.

Development and validation of a deep learning model to predict survival of patients with esophageal cancer

Objective

To compare the performance of a deep learning survival network with the tumor, node, and metastasis (TNM) staging system in survival prediction and test the reliability of individual treatment recommendations provided by the network.

Methods

In this population-based cohort study, we developed and validated a deep learning survival model using consecutive cases of newly diagnosed stage I to IV esophageal cancer between January 2004 and December 2015 in a Surveillance, Epidemiology, and End Results (SEER) database. The model was externally validated in an independent cohort from Fujian Provincial Hospital. The C statistic was used to compare the performance of the deep learning survival model and TNM staging system. Two other deep learning risk prediction models were trained for treatment recommendations. A Kaplan–Meier survival curve was used to compare survival between the population that followed the recommended therapy and those who did not.

Results

A total of 9069 patients were included in this study. The deep learning network showed more promising results in predicting esophageal cancer-specific survival than the TNM stage in the internal test dataset (C-index=0.753 vs. 0.638) and external validation dataset (C-index=0.687 vs. 0.643). The population who received the recommended treatments had superior survival compared to those who did not, based on the internal test dataset (hazard ratio, 0.753; 95% CI, 0.556-0.987; P=0.042) and the external validation dataset (hazard ratio, 0.633; 95% CI, 0.459-0.834; P=0.0003).

Conclusion

Deep learning neural networks have potential advantages over traditional linear models in prognostic assessment and treatment recommendations. This novel analytical approach may provide reliable information on individual survival and treatment recommendations for patients with esophageal cancer.

Adjuvant Chemotherapy for Pathological Node-Positive Disease in Squamous Cell Carcinoma of the Esophagus after Neoadjuvant Chemoradiotherapy Plus Surgery

Purpose: The purpose of the present study is to determine the impact on survival using adjuvant chemotherapy on patients with locally advanced esophageal cancer. Materials and Methods: From 2007 to 2016, we enrolled 127 locally advanced esophageal squamous cell carcinoma patients treated with combined neoadjuvant chemoradiotherapy (nCRT) and surgery. For patients with the pathological residual primary disease (pT+) and/or residual node disease (pN+) after nCRT, adjuvant chemotherapy was also given after consideration of the toxicity of nCRT, patient performance, and/or comorbidity. The regimen of adjuvant chemotherapy was cisplatin 20 mg/m²/day and 5-fluorouracil 800 mg/m²/day on days 1 through 4 and 22 through 25. The primary endpoint was overall survival (OS). Results: From a total of 127 patients, 26 of them (20.5%) received adjuvant chemotherapy. In the multivariate analysis, pN+ diseases were independently associated with poor OS (hazard ratio (HR): 4.117, 95% confidence interval (CI): 1.366–12.404; p = 0.012). For those with pN+ diseases, their 5-year OS was 36.4% in the follow-up arm compared with 45.8% in the adjuvant chemotherapy arm (p = 0.094). Conclusions: Pathologic node-positive disease is associated with poor OS in locally advanced esophagus cancer patients after combined treatments with nCRT and surgery. Adjuvant chemotherapy appeared to have improved OS in pathologic node-positive diseases.

Pathologic Complete Response Prediction to Neoadjuvant Immunotherapy Combined with Chemotherapy in Resectable Locally Advanced Esophageal Squamous Cell Carcinoma: Real-World Evidence from Integrative Inflammatory and Nutritional Scores

Purpose

Neoadjuvant immunotherapy and chemotherapy (nICT) is an emerging hotspot that has been shown to be safe and feasible for locally advanced esophageal squamous cell carcinoma (LA-ESCC). This real-world study aimed to develop and validate a novel predictive model [integrative inflammatory and nutritional score (IINS)] in LA-ESCC patients receiving nICT to predict the pathologic complete response (pCR).

Patients and Methods

Patients with LA-ESCC who received nICT followed by surgery from Jun 2019 to Dec 2021 were enrolled and randomly divided into two sets (7:3). Using least absolute shrinkage and selection operator (LASSO) logistic regression analysis, the IINS was constructed in LA-ESCC patients received nICT to predict pCR. A nomogram based on IINS for pCR prediction was generated in the training cohort and verified in the validation cohort.

Results

Of the 285 enrolled LA-ESCC patients received nICT followed by radical resection, 84 (29.5%) patients achieved pCR. A predictive index of IINS based on 8 inflammatory and nutritional indicators was constructed using the LASSO model. According to the cutoff finder, patients were then stratified into two groups (high and low). The pCR rates were significantly higher in high-IINS group than in low-IINS group in both the training cohort (44.7% vs 17.4%, P < 0.001) and validation cohort (50.0% vs 13.3%, P < 0.001). The IINS [odds ratio (OR) = 0.237, 95% confidence interval (CI) = 0.117–0.480, P < 0.001] was an independent significant predictor for pCR in multivariate logistic analyses. The IINS-based nomogram showed an excellent discrimination for pCR prediction (C-indexes = 0.759 and 0.812 for training and validation cohorts, respectively).

Conclusion

Pretreatment IINS is an independent predictor for pCR in LA-ESCC patients who are treated with nICT. To our knowledge, the IINS-based nomogram is the first model for pCR prediction and may serve as a simple and potential risk stratification model in LA-ESCC who are treated with nICT.

Skeletonizing En Bloc Esophagectomy Revisited: Oncologic Outcome in Association with the Presence of Thoracic Duct Lymph Nodes

BACKGROUND

Skeletonizing en bloc esophagectomy (SEBE) involves the removal of the esophagus en bloc with locoregional soft tissues and lymph nodes, including the thoracic duct (TD); however, its oncologic benefits remain unclear. We evaluated the impact of SEBE on oncologic outcomes in patients with esophageal squamous cell carcinoma.

METHODS

Patients undergoing McKeown esophagectomy without neoadjuvant therapy between 2013 and 2019 were evaluated. Outcomes after SEBE were compared with those after conventional esophagectomy (CE) using propensity score-matched analysis.

RESULTS

Overall, 232 patients were identified, including 133 patients with SEBE and 99 patients with CE. Lymph node metastasis along the TD was identified in 7.5% (10/133) of the SEBE group, and the incidence was closely related with the tumor invasion depth (2.2% in pT1 and 19.0% in pT2-3). Based on the propensity score, 180 patients (90 pairs) were analyzed. Tumor recurrence was identified in 24.4% and 12.2% of CE and SEBE cases, respectively (p = 0.036). The observed difference was due to the higher incidence of locoregional recurrence in CE (10.5% vs. 2.2%; p = 0.024), while the incidence of systemic recurrence was similar (18.6% vs. 12.2%; p = 0.240). The 5-year disease-free survival rate was 83.6% and 62.4% in the SEBE and CE groups, respectively (p = 0.022). Multivariate analysis revealed that SEBE could significantly reduce the risk of recurrence or death in patients with pT2-3 tumors (hazard ratio 0.173, 95% confidence interval 0.048-0.628; p = 0.008).

CONCLUSIONS

SEBE could identify and eradicate lymphatic metastasis along the TD and positively impact disease-free survival, particularly in patients with pT2-3 tumors.

Novel pathological staging for patients with locally advanced esophageal squamous cell carcinoma undergoing neoadjuvant chemotherapy followed by surgery

BACKGROUND

The aim of the present study was to clarify an appropriate staging system for patients with locally advanced esophageal squamous cell carcinoma (LAESCC) after neoadjuvant chemotherapy (NAC) prior to surgery.

METHODS

A total of 388 patients with clinical stage II or III LAESCC who had undergone NAC followed by an esophagectomy with three-field lymphadenectomy were retrospectively reviewed.

RESULTS

The relapse-free survival (RFS) curves plotted using ypN grading and ypTNM staging both monotonically decreased as the classification number increased, and the groups were more clearly separated than when the Japanese Classification (JC) was applied. A multivariate analysis of relapse free survival (RFS) suggested that ypN (HR = 2.911, P < 0.001), lymphovascular invasion (LVI) (HR = 2.608, P < 0.001) were independent factors associated with OS. The LVI+/ypN+ group had a significantly poorer outcome than the other groups (P < 0.001). The 5-year RFS rates for patients with ypStage IIIA or higher among the LVI-negative cases and ypStage II or higher among the LVI-positive cases were around 0.6 or under. The novel pathological staging which was based on the present results was proposed and RFS curves of each novel stage suggested the suitability of these staging for our cohort.

CONCLUSIONS

The present results suggest that a novel pathological staging system using the ypTNM classification, in which the supraclavicular lymph node was regarded as a regional lymph node and the presence of LVI was included as a category, was appropriate for patients with LAESCC after NAC prior to surgery.

Clinical significance of Osaka prognostic score based on nutritional and inflammatory status in patients with esophageal squamous cell carcinoma

Background

It has been reported that Osaka prognostic score (OPS), based on C-reactive protein (CRP), total lymphocyte counts (TLC) and albumin (ALB), was relevant to prognosis in colorectal cancer. However, the role of OPS regarding prognosis in patients with esophageal squamous cell carcinoma (ESCC) has not been reported. The current study aimed to explore the clinical outcome of OPS and establish and validate a nomogram for survival prediction in ESCC after radical resection.

Methods

This retrospective study included 395 consecutive ESCC patients with radical resection. Then patients were randomly divided into two cohorts: training cohort (276) and validation cohort (119). The OPS, based on TLC, CRP and ALB, was constructed to verify the prognostic value by Kaplan-Meier curves and Cox analyses. A nomogram model for prognosis prediction of cancer-specific survival (CSS) was developed and validated in two cohorts.

Results

Kaplan-Meier curves regarding the 5-year CSS for the groups of OPS 0, 1, 2 and 3 were 55.3, 30.6, 17.3 and 6.7% (P < 0.001) in the training cohort and 52.6, 33.3, 15.8 and 9.1% (P < 0.001) in the validation cohort, respectively. Then the OPS score in multivariate Cox analysis was confirmed to be a useful independent score. Finally, a predictive OPS-based nomogram was developed and validated with a C-index of 0.68 in the training cohort and 0.67 in the validation cohort, respectively. All above results indicated that the OPS-based nomogram can accurately and effectively predict survival in ESCC after radical resection.

Conclusion

The OPS serves as a novel, convenient and effective predictor in ESCC after radical resection. The OPS-based nomogram has potential independent prognostic value, which can accurately and effectively predict individual CSS in ESCC after radical resection.

Diagnosis of Esophageal Lesions by Multi-Classification and Segmentation Using an Improved Multi-Task Deep Learning Model

It is challenging for endoscopists to accurately detect esophageal lesions during gastrointestinal endoscopic screening due to visual similarities among different lesions in terms of shape, size, and texture among patients. Additionally, endoscopists are busy fighting esophageal lesions every day, hence the need to develop a computer-aided diagnostic tool to classify and segment the lesions at endoscopic images to reduce their burden. Therefore, we propose a multi-task classification and segmentation (MTCS) model, including the Esophageal Lesions Classification Network (ELCNet) and Esophageal Lesions Segmentation Network (ELSNet). The ELCNet was used to classify types of esophageal lesions, and the ELSNet was used to identify lesion regions. We created a dataset by collecting 805 esophageal images from 255 patients and 198 images from 64 patients to train and evaluate the MTCS model. Compared with other methods, the proposed not only achieved a high accuracy (93.43%) in classification but achieved a dice similarity coefficient (77.84%) in segmentation. In conclusion, the MTCS model can boost the performance of endoscopists in the detection of esophageal lesions as it can accurately multi-classify and segment the lesions and is a potential assistant for endoscopists to reduce the risk of oversight.