Impact of minimally invasive surgery in the treatment of esophageal cancer

Impact of Different Histopathological Factors on Recurrence and Survival in Operated Carcinoma Esophagus

Background Even with radical surgery, a significant percentage of patients of esophageal cancer experience recurrent disease.

Aims The aim of the current study is to define the impact of different histopathological factors on the recurrence and survival in carcinoma esophagus following surgery.

Materials and Methods A retrospective review of 182 patients of esophageal carcinoma, operated between January 2011 and December 2016, was done. In our study, 92 patients underwent upfront surgery and 90 took neo-adjuvant/perioperative treatment before planned surgery. To compare the proportion between two groups, chi-square test was used and to compare the median between the two groups, Mann—Whitney U test was used. Factors affecting the survival were analyzed using the Kaplan–Meier survival curve to compare the median survival time across groups log rank (Mantel–Cox) test was used.

Results Out of 182 patients, 55 patients developed recurrences, in which 19 were loco-regional and 36 were systemic. Patients with lymph node-positive disease on final histopathology had more recurrence than lymph node-negative (39.74%, 31/78) versus (23%, 24/104), p = 0.01 (significant). Patients with features such as PNI-positive, poor differentiation, lymph node-positive, ENE, and higher stage disease had statistically significant, lower DFS and OS with p-value < 0.05. Patients with adenocarcinoma histology had more systemic recurrences and statistically significant lower DFS than SCC with p-value < 0.05.

Conclusions Systemic recurrences are more common. PNI, ENE, grade, lymph node-positive disease, and higher pathologic stage had statistically significant negative impact on both DFS and OS. On multivariate analysis, whereas ENE had an impact on DFS alone.

LYMPHOPARIETAL INDEX IN ESOPHAGEAL CANCER IS STRONGER THAN TNM STAGING IN LONG-TERM SURVIVAL PROGNOSIS IN A LATIN-AMERICAN COUNTRY

BACKGROUND

The identification of prognostic factors of esophageal cancer has allowed to predict the evolution of patients.

AIM

Assess different prognostic factors of long-term survival of esophageal cancer and evaluate a new prognostic factor of long-term survival called lymphoparietal index (N+/T).

METHOD

Prospective study of the Universidad de Chile Clinical Hospital, between January 2004 and December 2013. Included all esophageal cancer surgeries with curative intent and cervical anastomosis. Exclusion criteria included: stage 4 cancers, R1 resections, palliative procedures and emergency surgeries.

RESULTS

Fifty-eight patients were included, 62.1% were men, the average age was 63.3 years. A total of 48.3% were squamous, 88% were advanced cancers, the average lymph node harvest was 17.1. Post-operative surgical morbidity was 75%, with a 17.2% of reoperations and 3.4% of mortality. The average overall survival was 41.3 months, the 3-year survival was 31%. Multivariate analysis of the prognostic factors showed that significant variables were anterior mediastinal ascent (p=0.01, OR: 6.7 [1.43-31.6]), anastomotic fistula (p=0.03, OR: 0.21 [0.05-0.87]), N classification (p=0.02, OR: 3.8 [1.16-12.73]), TNM stage (p=0.04, OR: 2.8 [1.01-9.26]), and lymphoparietal index (p=0.04, RR: 3.9 [1.01-15.17]. The ROC curves of lymphoparietal index, N classification and TNM stage have areas under the curve of 0.71, 0.63 and 0.64 respectively, with significant statistical difference (p=0.01).

CONCLUSION

The independent prognostic factors of long-term survival in esophageal cancer are anterior mediastinal ascent, anastomotic fistula, N classification, TNM stage and lymphoparietal index. In esophageal cancer the new lymphoparietal index is stronger than TNM stage in long-term survival prognosis.

A Hopeful Natural Product, Pristimerin, Induces Apoptosis, Cell Cycle Arrest, and Autophagy in Esophageal Cancer Cells

Esophageal cancer is one of the most common malignant digestive diseases worldwide. Although many approaches have been established for the treatment of esophageal cancer, the survival outcome has not improved. Pristimerin is a quinone methide triterpenoid with anticancer, antiangiogenic, anti-inflammatory, and antiprotozoal activities. However, the role of pristimerin in cancers such as esophageal cancer is unclear. In this study, we investigated the role and mechanisms of action of pristimerin in esophageal cancer. First, we found that pristimerin can induce apoptosis in esophageal cancer in vivo and in vitro. CCK-8 and clonogenic assays showed that pristimerin decreased the growth of Eca109 cells. In addition, we found that pristimerin decreased the protein expression of CDK2, CDK4, cyclin E, and BCL-2 and increased the expression of CDKN1B. Meanwhile, pristimerin elevated the ratio of LC3-II/LC3-I. Otherwise, downregulation of CDKN1B can reduce the esophageal cancer tumor growth induced by pristimerin. In conclusion, our findings revealed an important role of pristimerin in esophageal cancer and suggest that pristimerin might be a potential therapeutic agent for this cancer.

PROGNOSTIC FACTORS AND SURVIVAL ANALYSIS IN ESOPHAGEAL CARCINOMA

Background:

Despite recent advances in diagnosis and treatment, esophageal cancer still has high mortality. Prognostic factors associated with patient and with disease itself are multiple and poorly explored.

Aim:

Assess prognostic variables in esophageal cancer patients.

Methods:

Retrospective review of all patients with esophageal cancer in an oncology referral center. They were divided according to histological diagnosis (444 squamous cell carcinoma patients and 105 adenocarcinoma), and their demographic, pathological and clinical characteristics were analyzed and compared to clinical stage and overall survival.

Results:

No difference was noted between squamous cell carcinoma and esophageal adenocarcinoma overall survival curves. Squamous cell carcinoma presented 22.8% survival after five years against 20.2% for adenocarcinoma. When considering only patients treated with curative intent resection, after five years squamous cell carcinoma survival rate was 56.6 and adenocarcinoma, 58%. In patients with squamous cell carcinoma, poor differentiation histology and tumor size were associated with worse oncology stage, but this was not evidenced in adenocarcinoma.

Conclusion:

Weight loss (kg), BMI variation (kg/m²) and percentage of weight loss are factors that predict worse stage at diagnosis in the squamous cell carcinoma. In adenocarcinoma, these findings were not statistically significant.

Prognostic Significance of Sarcopenia in Patients with Esophagogastric Junction Cancer or Upper Gastric Cancer

BACKGROUND

The association between sarcopenia and postoperative outcomes for patients with gastrointestinal malignancies remains controversial. This study aimed to assess the impact of sarcopenia on short- and long-term outcomes after surgery for esophagogastric junction cancer (EGJC) or upper gastric cancer (UGC).

METHODS

The study reviewed 148 patients with EGJC or UGC who underwent surgical resection. The patients were categorized into the sarcopenia group or the non-sarcopenia group according to their skeletal muscle index calculated using abdominal computed tomography images. The study compared clinicopathologic factors, postoperative complications, and prognosis between the two groups.

RESULTS

Sarcopenia was present in 19 patients (32.2%) with EGJC and 23 patients (25.8%) with UGC. The 5-year overall survival (OS) and recurrence-free survival (RFS) rates were significantly poorer in the sarcopenia group than in the non-sarcopenia group (OS 85.5 vs 54.8%, P = 0.0010; RFS 78.7 vs 51.7%, P = 0.0054). The development of postoperative complications did not differ significantly between the two groups. Both the uni- and multivariate analyses showed that N stage (P < 0.0001) and sarcopenia (P = 0.0024 and 0.0293, respectively) were independent poor prognostic factors for OS.

CONCLUSIONS

Sarcopenia was strongly associated with a poor long-term prognosis for patients with EGJC or UGC who underwent surgery. The results suggest that special attention might be needed during the development of treatment strategies for patients with sarcopenia who intend to undergo operations for EGJC and UGC.

Minimally invasive oesophagectomy: the Ivor Lewis approach

Oesophagectomy is a challenging operation involving multiple body cavities. The traditional open approach has several described techniques. The Ivor Lewis approach is one of the most commonly utilized approaches and includes a laparotomy and a thoracotomy. Traditionally, this has resulted in some morbidity. This article describes a stepwise approach to a minimally invasive Ivor Lewis oesophagectomy including laparoscopic mobilization of the stomach, formation of the gastric conduit, placement of a feeding jejunostomy tube, thoracoscopic oesophageal mobilization and resection and a stapled oesophago-gastric anastomosis. Common pitfalls and technical insights will be presented.

Oncological and surgical outcomes of minimally invasive versus open esophagectomy for esophageal squamous cell carcinoma: a matched-pair comparative study

Only a few series have demonstrated the safety and efficacy of minimally invasive esophagectomy (MIE) for esophageal squamous cell carcinoma and the benefits of this approach. This report describes the results of a pair-matched comparative study between minimally invasive and open esophagectomy (OE) for esophageal squamous cell carcinoma. Patients were retrospectively matched in pairs for the following criteria: age, sex, American Society of Anesthesiology (ASA) score, clinical TNM stage, tumor location, and type of resection. A total of 97 patients undergoing MIE were compared with patients undergoing OE during the same period. Operative, postoperative, and oncologic outcomes were compared. Significantly less bleeding was observed in the MIE group (P = 0.001). Transfusion was required for three patients in the MIE group and ten patients in the OE group (P = 0.044). Overall morbidity was similar in the two groups. The hospital stay was significantly shorter for the patients undergoing MIE (P = 0.027). The surgical margin and tumor stage were not affected by MIE. The overall survival rates in the MIE group were 54% at 5 years and 46% in the OE group (P = 0.631). The disease-free survival rates in the MIE group were 45% at 5 years, 41% in the OE group (P = 0.704). In summary, MIE for esophageal squamous cell carcinoma for selected patients gave a better postoperative outcome without oncologic consequences.

Case-matched analysis of combined thoracoscopic-laparoscopic versus open esophagectomy for esophageal squamous cell carcinoma

The aim of this study is to evaluate surgical results and long-term survival of combined thoracoscopic-laparoscopic esophagectomy (TLE) performed for esophageal squamous cell carcinoma. Data of 59 patients with esophageal squamous cell carcinoma, undergoing TLE from January 2007 to January 2015, were compared to a control group of 59 patients who underwent open esophagectomy (OE) during the same period. The two groups were matched in terms of age, sex, American Society of Anesthesiology (ASA) score and clinical TNM stage. Laparoscopic approach resulted in longer operating time (P=0.003) and lower blood loss (P=0.000). There was no difference in perioperative morbidity and mortality rate; TLE approach was associated with a shorter hospital stay (P=0.000). After a mean follow up of 38 months, 5-year disease free survival and 5-year overall survival were 38% and 50% for TLE group, and 36% and 45% for OE group (P>0.05). TLE for esophageal squamous cell carcinoma is feasible and safe in selected patients and can result in good surgical results, with similar outcomes in terms of long-term outcomes.

Understanding Complete Pathologic Response in Oesophageal Cancer: Implications for Management and Survival

Despite significant improvement over recent decades, oesophageal cancer survival rates remain poor. Neoadjuvant chemoradiotherapy followed by oesophageal resection is mainstay of therapy for resectable oesophageal tumours. Operative morbidity and mortality associated with oesophagectomy remain high and complications arise in up to 60% of patients. Management strategies have moved towards definitive chemoradiotherapy for a number of tumour sites (head and neck, cervical, and rectal) particularly for squamous pathology. We undertook to perform a review of the current status of morbidity and mortality associated with oesophagectomy, grading systems determining pathologic response, and data from clinical trials managing patients with definitive chemoradiotherapy to inform a discussion on the topic.