Comparison of Outcomes Between Additional Esophagectomy After Noncurative Endoscopic Resection and Upfront Esophagectomy for T1N0 Esophageal Squamous Cell Carcinoma

Effects of pre-operative enteral immunonutrition for esophageal cancer patients treated with neoadjuvant chemoradiotherapy: protocol for a multicenter randomized controlled trial (point trial, pre-operative immunonutrition therapy)

BACKGROUND

Neoadjuvant chemoradiation followed by esophagectomy has been established as the first-line treatment for locally advanced esophageal cancer. Postoperative enteral nutrition has been widely used to improve perioperative outcomes. However, whether to implement preoperative nutritional intervention during neoadjuvant therapy is yet to be verified by prospective studies.

METHODS

POINT trial is a multicenter, open-labeled, randomized controlled trial. A total of 244 patients with surgically resectable esophageal cancer are randomly assigned to nutritional therapy group (arm A) or control group (arm B) with a 2:1 ratio. Both groups receive neoadjuvant chemotherapy with concurrent radiotherapy based on the CROSS regimen followed by minimally invasive esophagectomy. The primary endpoint is the rate of nutrition and immune-related complications after surgery. Secondary endpoints include completion rate of neoadjuvant chemoradiation and related adverse events, rate of pathological complete response, perioperative outcomes, nutritional status, overall survival, progression-free survival and quality of life.

DISCUSSION

This trial aims to verify whether immunonutrition during neoadjuvant chemoradiation can reduce the rate of complications and improve perioperative outcomes. Frequent communication and monitoring are essential for a multicenter investigator-initiated trial.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04513418. The trial was prospectively registered on 14 August 2020, https://www.

CLINICALTRIALS

gov/ct2/show/NCT04513418 .

Additional Esophagectomy Following Noncurative Endoscopic Resection for Early Esophageal Squamous Cell Carcinoma: A Multicenter Retrospective Study

BACKGROUND

Esophagectomy is recommended after endoscopic resection (ER) for early esophageal squamous cell carcinoma (ESCC) when histopathological factors indicate a risk of nodal metastasis and incomplete resection. We aimed to analyze the outcomes of surgery management in this clinical setting and evaluate risk factors for residual disease after ER.

PATIENTS AND METHODS

We conducted a retrospective review of cT1N0M0 ESCC patients with noncurative ER and additional esophagectomy (2009-2019, eight centers). Noncurative ER was defined as positive resected margins on pathology, lymphovascular invasion (LVI), poor differentiation, or submucosal invasion. The pathology after ER and esophagectomy was analyzed to identify predictors of nodal metastasis and residual tumor.

RESULTS

The study enrolled 128 patients. Primary residual tumor and nodal metastasis were confirmed in 25 (19.5%) and 15 (11.7%) patients, respectively. On multivariate analysis, nodal metastasis was independently associated with submucosal invasion [odds ratio (OR), 9.9; 95% CI, 1.1-96.1], LVI (OR, 20.9; 95% CI, 2.9-150.5), and tumor size ≥ 2 cm (OR, 8.1; 95% CI, 1.4-48.2) (all P < 0.05), but not with poor differentiation (P = 0.613). Regarding residual primary tumor, only positive vertical margin was significant factor (OR, 147; 95% CI, 18 to > 999; P < 0.001).

CONCLUSIONS

Additional esophagectomy after noncurative ER allowed the resection of residual tumor and nodal metastasis, with favorable outcomes. Close follow-up may be feasible for a positive horizontal margin alone or poor differentiation alone, whereas intensive treatment should be considered for patients with submucosal invasion, LVI, and a positive vertical margin, especially when combined with tumor size ≥ 2 cm. Prospective research is needed to confirm the optimal management after ER.

Risk of metastatic recurrence after endoscopic resection for esophageal squamous cell carcinoma invading into the muscularis mucosa or submucosa: a multicenter retrospective study

BACKGROUND

We aimed to elucidate the risk of metastatic recurrence after endoscopic resection (ER) without additional treatment for esophageal squamous cell carcinomas (ESCCs) with tumor invasion into the muscularis mucosa (pT1a-MM) or submucosa (T1b-SM).

METHODS

We retrospectively enrolled patients with pT1a-MM/pT1b-SM ESCC after ER at 21 institutions in Japan between 2006 and 2017. We compared metastatic recurrence between patients with and without additional treatment, stratified into category A (pT1a-MM with negative lymphovascular invasion [LVI] and vertical margin [VM]), B (tumor invasion into the submucosa ≤ 200 µm [pT1b-SM1] with negative LVI and VM), and C (others). Subsequently, using multivariate Cox analysis, we evaluated risk factors for metastatic recurrence after ER without additional treatment.

RESULTS

We enrolled 593 patients, and metastatic recurrence occurred in 38 patients. Metastatic recurrence after additional treatment was significantly lower than that after no additional treatment in category C (9.1% vs. 23.6% in 5 years, p = 0.001), whereas no significant difference was noted in categories A (0.0% vs. 2.6%) and B (0.0% vs. 4.3%). In patients without additional treatment after ER, risk factors for metastatic recurrence were lymphatic invasion (hazard ratio [HR], 5.61), positive VM (HR, 4.55), and tumor invasion into the submucosa > 200 μm (HR, 3.25), and, but near half of the patients with metastatic recurrence had no further recurrence after salvage treatment, resulting in excellent 5-year disease-specific survival in categories A (99.6%) and B (100.0%).

CONCLUSIONS

Closed follow-up with no additional treatment may be an acceptable option after ER in pT1a-MM/pT1b-SM1 ESCC with negative LVI and VM.

Additional Treatment Following Noncurative Endoscopic Resection for Esophageal Squamous Cell Carcinoma: A Comparison of Outcomes between Esophagectomy and Chemoradiotherapy

BACKGROUND

Endoscopic resection (ER) has been widely implemented for cT1N0 esophageal squamous cell carcinoma (ESCC). Additional therapy, including esophagectomy and chemoradiotherapy (CRT), is sometimes required after noncurative ER.

METHODS

We retrospectively reviewed 108 patients who received any additional treatment following noncurative ER (positive vertical margins, lymphovascular invasion, or invasion depth of submucosa or more), and compared the short- and long-term outcomes between the two treatment modalities.

RESULTS

Of 108 patients, 56 underwent esophagectomy (E group), and 52 received CRT (CRT group). A positive vertical margin was observed in 17 (14.8%) patients and high risks of occult lymph node metastasis were observed in 91 (85.2%) patients, as well as lymphovascular invasion in 35 (32.4%) patients, invasion depth of the submucosa or more in 27 (25.0%) patients, and both in 29 (26.9%) patients. The E group patients were significantly younger (p = 0.046) and tended to present with larger tumors than those in the CRT group (p = 0.057). Lymphatic invasion was more frequent in the E group (p = 0.019), and, furthermore, one treatment-related death was observed in the E group. There were no significant differences between the groups in overall and disease-specific survival (p = 0.406 and 0.151, respectively), however, recurrence was only observed in the CRT group.

CONCLUSION

Both esophagectomy and CRT are safe and effective as additional treatments after noncurative ER in patients with ESCC. Esophagectomy is oncologically safe, whereas a risk of postoperative morbidity and mortality remains. Although the adverse events are acceptable, CRT has a certain degree of risk of disease recurrence.