Margin Positivity in Resectable Esophageal Cancer: Are there Modifiable Risk Factors?

Robotic-assisted esophagectomy with total mesoesophageal excision enhances R0-resection in patients with esophageal cancer: A single-center experience

BACKGROUND

The focus of this research is to examine the growing use of robotic-assisted minimally invasive esophagectomy. Specifically, it evaluates the immediate clinical and cancer-related results of combining robotic-assisted minimally invasive esophagectomy with a systematic approach to total mesoesophageal excision, as opposed to traditional open transthoracic esophagectomy methods that do not employ a structured total mesoesophageal excision protocol.

METHODS

A propensity score-matched analysis of 185 robotic-assisted minimally invasive esophagectomies and 223 open transthoracic esophagectomies after standardized Ivor Lewis esophagectomy was performed. After 1:1 nearest neighbor matching to account for confounding by covariates, outcomes of 181 robotic-assisted minimally invasive esophagectomy and 181 open transthoracic esophagectomy were compared.

RESULTS

The patient characteristics showed significant differences in the age distribution and in comorbidities such as coronary heart disease, arterial hypertension, and anticoagulant intake. The R0-resection rate of robotic-assisted minimally invasive esophagectomy (96.7%) was significantly higher than open transthoracic esophagectomy (89.0%, P = .004). Thirty-day mortality and hospital mortality showed no significant differences. Postoperative pneumonia rate after robotic-assisted minimally invasive esophagectomy (12.7%) was significantly reduced (open transthoracic esophagectomy 28.7%, P < .001). Robotic-assisted minimally invasive esophagectomy had a significantly shorter intensive care unit stay (P < .001) and shorter hospital stay (P < .001).

CONCLUSION

This single-center, retrospective study employing propensity score matching found that combining robotic-assisted minimally invasive esophagectomy with structured total mesoesophageal excision results in better short-term clinical and oncologic outcomes than open transthoracic esophagectomy. This finding is significant because the increased rate of R0 resection could indicate a higher likelihood of improved long-term survival. Additionally, enhanced overall postoperative recovery may contribute to better risk management in esophagectomy procedures.

Application of near-infrared fluorescence imaging in theranostics of gastrointestinal tumors

Gastrointestinal cancers have become an important cause of cancer-related death in humans. Improving the early diagnosis rate of gastrointestinal tumors and improving the effect of surgical treatment can significantly improve the survival rate of patients. The conventional diagnostic method is high-definition white-light endoscopy, which often leads to missed diagnosis. For surgical treatment, intraoperative tumor localization and post-operative anastomotic state evaluation play important roles in the effect of surgical treatment. As a new imaging method, near-infrared fluorescence imaging (NIRFI) has its unique advantages in the diagnosis and auxiliary surgical treatment of gastrointestinal tumors due to its high sensitivity and the ability to image deep tissues. In this review, we focus on the latest advances of NIRFI technology applied in early diagnosis of gastrointestinal tumors, identification of tumor margins, identification of lymph nodes, and assessment of anastomotic leakage. In addition, we summarize the advances of NIRFI systems such as macro imaging and micro imaging systems, and also clearly describe the application process of NIRFI from system to clinical application, and look into the prospect of NIRFI applied in the theranostics of gastrointestinal tumors.

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

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.

Clinical impact of remnant lymphatic invasion on the recurrence of esophageal squamous cell carcinoma after esophagectomy with neoadjuvant chemotherapy

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.

Long-term outcomes of endoscopic mucosal resection for early-stage esophageal adenocarcinoma

BACKGROUND

With growing application of endoscopic therapy for early-stage esophageal cancer, we sought to review our experience of endoscopic mucosal resections (EMRs). The aim of our study was to understand the natural course of these patients, especially with positive margins.

METHODS

A prospectively maintained database of all patients undergoing endoscopic therapies at Georgetown University Hospital for esophageal cancer was used for the analysis between 2010 and 2020.

RESULTS

Of 80 patients in the EMR database, 35 were performed as index cases for esophageal adenocarcinoma. Majority (74.3%) had a pre-treatment ultrasound confirming absence of regional adenopathy. There were no post-EMR bleeding or perforation events requiring re-intervention. Complete R0 resection was achieved in 22/35 (62.9%) after initial EMR. Thirteen patients had positive margins. Of these 13 patients, only 7 patients underwent repeat endoscopic resection, 2 underwent subsequent esophagectomy, 2 received definitive radiation given poor surgical candidacy, and 2 were lost to follow-up. Overall and 5-year survival of all patients undergoing EMR was 67.9 months and 85%, respectively. Subset analysis of the 13 patients with R1 resection demonstrated an overall survival of 49.2 months and 60% 5-year survival vs overall survival of 78.9 months and 93% 5-year survival for R0 resection. At a median follow-up of 60.5 months, cancer recurrence occurred in 3 patients. All of them were successfully managed with repeat EMR.

CONCLUSIONS

Endoscopic resections represent a safe and effective treatment for early-stage esophageal cancer. Patients with high-risk features should be counseled to undergo an esophagectomy if they are operable candidates.

Impact of chemotherapy and radiotherapy on the survival of elderly esophageal cancer patients undergoing surgery: a SEER database analysis

BACKGROUND

Esophageal cancer (EC) is a common and lethal carcinoma; however, the effectiveness and feasibility of the chemo- and radio-therapy (CRT) for the elderly patients (≥ 70 years) with surgery have not been fully discussed. The purpose of this study was to investigate the potential effect of CRT on the prognosis.

METHODS

A total of 1085 patients (534 CRT patients vs. 551 non-CRT patients) from 1998 to 2016 were collected from the Surveillance, Epidemiology, and End Results database according to the inclusion and exclusion criteria. Using the competing risk regression and survival analysis, an overall estimation of the effectiveness of CRT was performed on a well-balanced cohort via performing propensity score matching. Then, the specific impact of CRT on high- (n = 557) and low-risk (n = 528) cohorts derived from the nomogram's risk quantification for every patient were further evaluated respectively. Additionally, the advantages of the nomogram model and the conventional tumor, node, metastasis (TNM, 6th revision) staging system were compared.

RESULTS

A better survival outcome was observed among patients receiving both surgery and CRT than those who underwent surgery alone (HR: 0.55, 95% CI 0.45-0.68, P < 0.001), especially for those with tumors characterized by poor differentiation, large tumor size, advanced T staging, lymphatic metastasis, and distant metastasis (HR: 0.48, 95% CI 0.39-0.59, P < 0.001), while no benefit was observed among the low-risk patients. Furthermore, the newly established nomogram model might be better than the TNM (6th revision) staging system but more data needed.

CONCLUSION

Aggressive treatments, such as surgery, chemotherapy, and radiotherapy, were considered effective for selected elderly patients with EC according to the newly established nomogram model.

The "Real R0": A Resection Margin Smaller Than 0.1 cm is Associated with a Poor Prognosis After Oncologic Esophagectomy

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.

Outcomes of robotic esophagectomies for esophageal cancer by hospital volume: an analysis of the national cancer database

BACKGROUND

Robotic minimally invasive esophagectomies (RMIE) have been associated with superior outcomes; however, it is unclear if these are specific to robotic technique or are present only at high-volume institutions. We hypothesize that low-volume RMIE centers would have inferior outcomes.

METHODS

The National Cancer Database (NCDB) identified patients receiving RMIE from 2010 to 2016. Based on the total number of RMIE performed by each hospital system, the lowest quartile performed ≤ 9 RMIE over the study period. Ninety-day mortality, number of lymph nodes evaluated, margins status, unplanned readmissions, length of stay (LOS), and overall survival were compared. Regression models were used to account for confounding.

RESULTS

1565 robotic esophagectomies were performed by 212 institutions. 173 hospitals performed ≤ 9 RMIE (totaling 478 operations over the study period, 30.5% of RMIE) and 39 hospitals performed > 9 RMIE (1087 operations, 69.5%). Hospitals performing > 9 RMIE were more likely to be academic centers (90.4% vs 66.2%, p < 0.001), have patients with advanced tumor stage (65.3% vs 59.8%, p = 0.049), andadministered preoperative radiation (72.8% vs 66.3%, p = 0.010). There were no differences based on demographics, nodal stage, or usage of preoperative chemotherapy. On multivariable regressions, hospitals performing ≤ 9 RMIE were associated with a greater likelihood of experiencing a 90-day mortality, a reduced number of lymph nodes evaluated, and a longer LOS; however, there was no association with rates of positive margins or unplanned readmissions. Median overall survival was decreased at institutions performing ≤ 9 RMIE (37.3 vs 51.5 months, p < 0.001). Multivariable Cox regression demonstrated an association with poor survival comparing hospitals performing ≤ 9 to > 9 RMIE (HR 1.327, p = 0.018).

CONCLUSION

Many robotic esophagectomies occur at institutions which performed relatively few RMIE and were associated with inferior short- and long-term outcomes. These data argue for regionalization of robotic esophagectomies or enhanced training in lower volume hospitals.