A Single-Arm Confirmatory Study of Definitive Chemoradiotherapy Including Salvage Treatment for Clinical Stage II/III Esophageal Squamous Cell Carcinoma (JCOG0909 Study)

PURPOSE

Definitive chemoradiotherapy (CRT) is the standard treatment for patients with locally advanced esophageal cancer (EC) who refuse surgery as the initial therapy. However, poor survival, a high incidence of late toxicities, and severe complications after salvage surgery remain issues to be resolved. This single- arm multicenter trial (Trial name XXXX) aimed to confirm the efficacy of CRT modifications, including salvage treatment, for reducing CRT-related toxicities and facilitating salvage treatment for improved survival.

METHODS AND MATERIALS

Patients with clinical stage II/III EC (UICC 6th, non-T4) were eligible. Chemotherapy comprised cisplatin (75 mg/m2 on days 1and 29) and 5- fluorouracil (1,000 mg/m2/d on days 1-4 and 29-32). Radiotherapy was administered at a total dose of 50.4 Gy. Good responders received 1-2 additional cycles of chemotherapy. For residual or recurrent disease, salvage endoscopic resection (ER) or salvage surgery was performed based on specific criteria. The primary endpoint was the 3-year overall survival (OS). The calculated sample size was 95 patients, with a one-sided alpha of 5% and a power of 80%. The expected and threshold 3-year OS were 55% and 42%, respectively.

RESULTS

Overall, 96 patients were enrolled, and 94 were included in the efficacy analysis. A complete response was achieved in 55 patients (59%). Salvage ER and salvage surgery were performed in 5 (5%) and 25 patients (27%), respectively. R0 resection by salvage surgery was achieved in 19 patients (76%). Five patients (20%) showed grade 3 or 4 early operative complications, and 9 patients (9.6%) showed grade 3 late toxicities during the long-term follow-up. The 3-year OS was 74.2% (90% CI, 65.9%-80.8%).

CONCLUSION

The combination of definitive CRT and salvage treatment has lower CRT- related toxicities and yields good OS, thus making it a promising novel treatment option for patients with locally advanced EC.

Long-term survival of patients with T1bN0M0 esophageal cancer after thoracoscopic esophagectomy using data from JCOG0502: a prospective multicenter trial

BACKGROUND

Thoracoscopic esophagectomy (TE) is considered the standard surgery for esophageal cancer because of its superiority over open esophagectomy (OE) in terms of short-term outcomes. However, few prospective multicenter studies have evaluated its long-term survival after TE. This study aimed to investigate whether the prognosis for patients with T1bN0M0 esophageal cancer after TE is not inferior to OE using data from the Japan Clinical Oncology Group Study (JCOG0502), a prospective multicenter trial comparing esophagectomy with chemoradiotherapy.

METHODS

Data of patients in JCOG0502 after esophagectomy were used to compare the overall survival (OS) and relapse-free survival (RFS) after OE versus TE. OE or TE was selected at the surgeon's discretion. A hazard ratio and 95% confidence interval (CI) were calculated via Cox proportional-hazards model.

RESULTS

Of the 210 patients who underwent esophagectomy, 109 underwent OE, whereas 101 underwent TE. The 5-year OS was 88.9% after OE and 85.0% after TE. The hazard ratio of TE for OS was 1.53 (95% CI, 0.84-2.78; p = 0.16) and 1.10 (95% CI, 0.52-2.35; p = 0.80) in the univariable and multivariable analyses, respectively. The 5-year RFS was 85.3% after OE and 79.1% after TE. The hazard ratio of TE for RFS was 1.39 (95% CI, 0.81-2.38; p = 0.23) and 0.88 (95% CI, 0.44-1.74; p = 0.70) in the univariable and multivariable analyses, respectively.

CONCLUSION

The prognosis for patients with T1bN0M0 esophageal cancer after TE was not inferior to OE.

Second primary malignancies in patients with clinical T1bN0 esophageal squamous cell carcinoma after definitive therapies: supplementary analysis of the JCOG trial: JCOG0502

BACKGROUND

Previous studies have suggested that patients with esophageal squamous cell carcinoma (ESCC) are still at a high risk of developing second primary malignancies (SPMs) after definitive therapies. We evaluated the development of SPMs and explored its risk factors in patients with clinical T1bN0 ESCC.

METHODS

JCOG0502 prospectively compared esophagectomy with definitive chemo-radiotherapy for clinical T1bN0 ESCC. Here, we reviewed all JCOG0502 patients' data for SPMs and investigated the risk factors for SPMs using uni-variable and multivariable analyses by Fine and Gray model.

RESULTS

Among 379 enrolled patients, 213 underwent esophagectomy and 166 received chemo-radiotherapy. Patient characteristics were male (85%); median age [63 (range 41-75) years; location of the primary tumor (upper/middle/lower thoracic esophagus, 11%/63%/27%, respectively]; alcohol consumption history (79%); smoking history (66%); prevalence of no/several/many/unknown Lugol-voiding lesions (LVLs) (45%/36%/8%/11%, respectively). In a median follow-up of 7.1 years, 118 SPMs occurred in 99 (26%) patients. Cumulative incidences of SPMs after 3, 5, and 10 years were 9%, 15%, and 36%, respectively. The most common primary tumor sites were the head and neck (35%), stomach (20%) and lungs (14%). In multivariable analyses, compared to no LVLs, several LVLs [hazard ratio (HR) 2.24, 95% confidential interval (CI) 1.32-3.81] and many LVLs (HR 2.88, 95% CI 1.27-6.52) were significantly associated with the development of SPMs. Sixteen patients died due to the SPMs.

CONCLUSION

The incidence of SPMs was high. The presence of LVLs, which was a predictive factor for SPMs, may be useful for surveillance planning.

A prognostic biomarker study in patients with clinical stage I esophageal squamous cell carcinoma: JCOG0502-A1

We conducted genomic analyses of Japanese patients with stage I esophageal squamous cell carcinoma (ESCC) to investigate the frequency of genomic alterations and the association with survival outcomes. Biomarker analysis was conducted for patients with clinical stage T1bN0M0 ESCC enrolled in JCOG0502 (UMIN000000551). Whole-exome sequencing (WES) was performed using DNA extracted from formalin-fixed, paraffin-embedded tissue of ESCC and normal tissue or blood sample. Single nucleotide variants (SNVs), insertions/deletions (indels), and copy number alterations (CNAs) were identified. We then evaluated the associations between each gene alteration with a frequency ≥10% and progression-free survival (PFS) using a Cox regression model. We controlled for family-wise errors at 0.05 using the Bonferroni method. Among the 379 patients who were enrolled in JCOG0502, 127 patients were successfully analyzed using WES. The median patient age was 63 years (IQR, 57-67 years), and 78.0% of the patients ultimately underwent surgery. The 3-year PFS probability was 76.3%. We detected 20 genes with SNVs, indels, or amplifications with a frequency of ≥10%. Genomic alterations in FGF19 showed the strongest association with PFS with a borderline level of statistical significance of p = 0.00252 (Bonferroni-adjusted significance level is 0.0025). Genomic alterations in FGF4, MYEOV, CTTN, and ORAOV1 showed a marginal association with PFS (p < 0.05). These genomic alterations were all CNAs at chromosome 11q13.3. We have identified new genomic alterations associated with the poor efficacy of ESCC (T1bN0M0). These findings open avenues for the development of new potential treatments for patients with ESCC.

Severe reflux esophagitis after total gastrectomy successfully treated by transposition of the jejunojejunal anastomosis: a report of two cases

Background

Reflux esophagitis after total gastrectomy is often difficult to treat. In this report, we describe two cases of reflux esophagitis that were refractory to medical therapy and successfully treated by transposition of the jejunojejunal anastomosis.

Case presentation

Case 1: A 66-year-old man underwent total gastrectomy and cholecystectomy for gastric cancer, and Roux-en-Y (RY) reconstruction was performed. The pathological diagnosis was T4aN3aM0 stage IIIC. Five months later, esophagogastroduodenoscopy identified reflux esophagitis. Although he was treated with various oral medications and was hospitalized six times, he lost 19 kg of weight. Finally, the patient was reoperated 3 years postoperatively. Intraoperative findings showed that there was no evidence of recurrence or severe adhesions that could have caused obstruction, and the anastomotic distance between the esophagojejunostomy and the jejunojejunostomy was approximately 40 cm. The jejunojejunostomy was re-anastomosed to increase the distance to 100 cm. Two years and 6 months after the reoperation, there was no recurrence of reflux esophagitis, and the patient’s weight increased by 14 kg.

Case 2: A 68-year-old woman underwent total gastrectomy and cholecystectomy for gastric cancer, and RY reconstruction was performed. The pathological diagnosis was T4aN0M0 stage IIB. Similar to Case 1, the patient was diagnosed with reflux esophagitis 5 months later. She lost 23 kg of weight and was reoperated at 6 months postoperatively. Intraoperative findings showed that there was no evidence of recurrence or severe adhesions, and transposition of the jejunojejunostomy was performed to increase the distance between anastomoses from 40 to 100 cm. Two years and 8 months after the reoperation, there was no recurrence of reflux esophagitis, and her weight increased by 15 kg.

Conclusions

Transposition of the jejunojejunostomy was an effective treatment for medication-resistant severe reflux esophagitis after total gastrectomy.

Parallel-Group Controlled Trial of Surgery Versus Chemoradiotherapy in Patients With Stage I Esophageal Squamous Cell Carcinoma

BACKGROUND & AIMS

Surgery is the standard of care for T1bN0M0 esophageal squamous cell carcinoma (ESCC), whereas chemoradiotherapy (CRT) is a treatment option. This trial aimed to investigate the noninferiority of CRT relative to surgery for T1bN0M0 ESCC.

METHODS

Clinical T1bN0M0 ESCC patients were eligible for enrollment in this prospective nonrandomized controlled study of surgery versus CRT. The primary endpoint was overall survival, which was determined using inverse probability weighting with propensity scoring. Surgery consisted of an esophagectomy with 2- or 3-field lymph node dissection. CRT consisted of 2 courses of 5-fluorouracil (700 mg/m²) on days 1-4 and cisplatin (70 mg/m²) on day 1 every 4 weeks with concurrent radiation (60 Gy).

RESULTS

From December 20, 2006 to February 5, 2013, a total of 368 patients were enrolled in the nonrandomized portion of the study. The patient characteristics in surgery arm and CRT arm, respectively, were as follows: median age, 62 and 65 years; proportion of males, 82.8% and 88.1%; and proportion of performance status 0, 99.5% and 98.1%. Comparisons were made using the nonrandomized groups. The 5-year overall survival rate was 86.5% in the surgery arm and 85.5% in the CRT arm (adjusted hazard ratio, 1.05; 95% confidence interval, 0.67-1.64 [<1.78]). The complete response rate in the CRT arm was 87.3% (95% confidence interval, 81.1-92.1). The 5-year progression-free survival rate was 81.7% in the surgery arm and 71.6% in the CRT arm. Treatment-related deaths occurred in 2 patients in the surgery arm and none in the CRT arm.

CONCLUSIONS

CRT is noninferior to surgery and should be considered for the treatment of T1bN0M0 ESCC.

Impact of preoperative therapy for locally advanced thoracic esophageal cancer on the risk of perioperative complications: Results from multicenter phase III trial JCOG 1109

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Background: We have conducted randomized three-arm phase III trial comparing cisplatin plus 5-FU (CF) versus docetaxel plus CF (DCF) versus radiation with CF (CF-RT) as preoperative therapy for locally advanced esophageal cancer, which is on-follow-up for primary analysis planned in 2023 (JCOG 1109). This study aimed to evaluate the influence of preoperative therapies on perioperative complications and risk factors for perioperative complications after three-arm preoperative therapies. Methods: Patients with potentially resectable advanced thoracic esophageal cancer were randomly assigned to three preoperative therapies and followed by open or thoracoscopic esophagectomy with regional lymphadenectomy. Clinical data, surgical results, and perioperative complications in the patients received DCF and CF-RT were compared with those in the patients received CF. Univariate and multivariate analyses were performed to explore the risk factors of perioperative complications. Results: Between December 2012 and July 2018, 601 patients were randomized (CF/DCF/CF-RT; 199/202/200). Of 589 eligible patients, 546 patients underwent surgery (185/183/178). Patients` characteristics were not different between arms. Median number of harvested lymph node in patients received CF-RT was significantly lower than that in patients received CF (49 vs. 58; P < 0.0001). Incidence of ≥ Grade 2 perioperative complications in patients received DCF was lower than that in patients received CF (44.8% vs. 56.2%; P = 0.036). Incidence of ≥ Grade 2 chylothorax in patients received CF-RT was higher than that in patients received CF (5.1% vs. 1.1%; P = 0.032). Incidence of reoperation and intra-hospital death in patients received DCF and CF-RT did not differ from that in patients received CF. Multivariate analysis showed that operation time (≥ median) and open esophagectomy were independently associated with an increase in ≥ Grade 2 perioperative complications. CF-RT was associated with an increase in occurrence of ≥ Grade 2 chylothorax (Relative Risk 4.84; P = 0.043). Conclusions: Preoperative DCF and CF-RT does not increase the risk of perioperative complications and mortality when compared with standard preoperative CF therapy, but CF-RT increases the risk of chylothorax after esophagectomy for advanced thoracic esophageal cancer.

Second primary malignancies in patients with clinical T1bN0 esophageal squamous cell carcinoma after definitive therapies: Supplementary analysis of the JCOG trial, JCOG0502

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Background: Esophageal squamous cell carcinoma (ESCC) is associated with synchronous or metachronous cancer at other primary sites. Previous studies have suggested that patients (pts) with ESCC are still at a high risk of second primary malignancies after definitive therapies. In particular, early-stage ESCCs result in good prognosis, which is associated with a higher risk of second primary malignancies. Methods: The JCOG0502 was a phase III trial, which included a randomized and a non-randomized part and compared esophagectomy with definitive chemoradiotherapy in clinical T1bN0 ESCC. We additionally reviewed data of all pts enrolled in the JCOG0502 for second primary malignancies. Lugol-voiding lesions (LVLs) were assessed in the noncancerous esophageal mucosa before the treatments. Results: Among 379 enrolled pts, 213 pts received esophagectomy and the remaining received chemoradiotherapy. Patient characteristics of overall cohort were as follows: male, 85%; median age, 63 (range, 41–75) years; upper- /middle- /lower thoracic esophagus, 11/63/27%; alcohol consumption history, 79%; smoking history, 66%; prevalence of no LVLs/several LVLs/many LVLs/unknown, 45/36/8/11%. With a median follow-up of 7.1 years, a total of 118 second malignancies were observed in 99 pts (26%). Cumulative incidences of second malignancies after 3, 5, 10 years were 9, 15, 36%, respectively. Most common primary tumor sites were head and neck (35%), followed by stomach (20%) and lung (14%). In multivariable analyses, several LVLs [hazard ratio (HR): 2.24, 95% confidential interval (CI): 1.32–3.81, vs. no LVLs] and many LVLs (HR: 2.88, 95% CI: 1.27–6.52, vs. no LVLs) were significantly associated with the development of second malignancies. Regarding the three most common types of cancers, 62 out of the 77 cancers (81%) were diagnosed in clinical stage 0–I. Seventeen pts died due to second primary malignancies. There were 4 and 3 deaths from head and neck and lung cancer, respectively. Whereas, mortality caused by stomach cancer was not observed. Conclusions: In the JCOG0502, the incidence of second malignancies was high, indicating that careful follow-up is required for ESCC pts even after treatment completion. The presence of LVLs in esophagus was identified as an independent predictive factor for second primary malignancies, which may be useful for surveillance strategies. Clinical trial information: UMIN000000551 .

Final analysis of single-arm confirmatory study of definitive chemoradiotherapy including salvage treatment in patients with clinical stage II/III esophageal carcinoma: JCOG0909

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Background: Definitive chemoradiotherapy (dCRT) consisting of 5-fluorouracil (5-FU) and cisplatin (CDDP) with 60 Gy radiotherapy (RT) for clinical (c) Stage II/III esophageal carcinoma (EC) is a standard treatment for patients (pts) refusing surgery (S) in Japan based on the previous trial (JCOG9906). However, poor survival, high incidence of late toxicities, and severe complications of salvage S are problems. We conducted a single-arm confirmatory study of CRT modifications including salvage treatment (ST) to reduce CRT toxicities and facilitate ST to improve survival. We reported the 3-year survival at 2018 ASCO Annual Meeting. We report the final data after 5-year follow-up. Methods: EC pts with cStage II/III (UICC 6th, non-T4), PS 0-1, and age 20-75 years were eligible. Chemotherapy (CT) was CDDP (75 mg/m2 on days 1, 29) and 5-FU (1000 mg/m2/d on days 1-4, 29-32). RT was administered to a total dose of 50.4 Gy with elective nodal irradiation of 41.4 Gy. Good responders after dCRT received additional 1-2 cycles of CT. For residual or recurrent disease, salvage endoscopic resection (ER) or S was performed based on the prespecified criteria. Planned sample size was 95, with one-sided alpha of 5% and power of 80%, expected and threshold 3-year overall survival (OS) as 55% and 42%. Key secondary endpoint was ST related toxicity. Final analysis was planned after 5-year follow-up for all pts. Results: From 4/2010 to 8/2014, 96 pts were enrolled, two were ineligible and 94 were included in efficacy analysis (cStage IIA/IIB/III, 22/38/34). Complete response was achieved in 55 pts (59%). Salvage ER and S were performed in 5 (5%) and 27 pts (29%). R0 resection of salvage S was achieved in 23 (85%). With a median follow-up of 5.95 years, 3- and 5-year OS was 74.2% (90% CI 65.9-80.8%) and 64.5% (95% CI 53.9-73.3%). 5-year progression-free survival and esophagectomy-free survival were 48.3% (95% CI 37.9-58.0%) and 54.9% (95% CI 44.3-64.4%). 5-year OS after salvage S was 31.0% and hazard ratio of R1-2 to R0 was 5.635 (95% CI: 1.818-17.467). No complications occurred after salvage ER. Five pts (19%) showed ≥ grade 3 operative complications and 1 treatment related death due to bronchus-pulmonary artery fistula occurred after salvage S. Only 9 pts (9.6%) showed grade 3 late toxicities. And no late operative complications more than grade 3 were observed. Conclusions: This combined modality treatment of dCRT with ST showed acceptable toxicities, favorable 5-year survival, and promising esophageal preservation. Clinical trial information: jRCTs031180110 .

Rare squamous cell carcinoma arising from a presacral epidermoid cyst: A case report

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Presacral epidermoid cysts are extremely rare and require further study.

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Thorough preoperative imaging evaluation is important for complete resection.

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Multidisciplinary treatments may be effective.

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Presacral epidermoid cysts may be malignant.

Introduction

Presacral epidermoid cysts are uncommon, usually benign cysts caused by developmental abnormalities in the fetal period. We present a rare case of squamous cell carcinoma arising from a presacral epidermoid cyst.

Presentation of case

A 59-year-old woman complained of tenesmus and discomfort in the buttocks. Computed tomography revealed a 50-mm well-defined cystic mass in the presacrum and a 70-mm solid mass extending from the cyst into the rectum, vagina, and left sciatic spine. On T1-weighted magnetic resonance images, the cyst was unilocular and the mass was marginated with low intensity. On T2-weighted images, the mass had high intensity. A malignant presacral developmental cyst was diagnosed, without obvious metastasis. Using abdominal and parasacral approaches, Hartmann’s operation was performed with multiorgan resection, including the sacrum, coccyx, left sciatic spine, internal obturator muscle, rectum, and uterine appendage. Histopathology of the excised specimen revealed a squamous cell carcinoma originating from the presacral epidermoid cyst.

Discussion

Reports of malignant transformation of epidermoid cysts in the presacral space, as in the present case, are extremely rare. Because of their unusual location and slow growth, epidermoid cysts tend to remain asymptomatic. Because the patient had a malignant tumor with suspected invasion of adjacent organs, combination surgery was selected.

Conclusion

Although further research is required, presacral epidermoid cysts are extremely rare and may be malignant. Thorough preoperative image evaluation is crucial for complete resection.

Influence of radiation field on safety and efficacy for stage II/III esophageal cancer treated with definitive chemoradiotherapy: An exploratory analysis of JCOG0909

104

Background: JCOG0909, a single-arm confirmatory trial of definitive chemoradiotherapy (dCRT) including salvage treatment, demonstrated promising efficacy and safety for cStage II/III (UICC-TNM 6th) esophageal cancer (EC) (Ito Y, ASCO 2018). Radiation (RT) fields included the elective regional lymph node during initial 41.4 Gy, such as bilateral supraclavicular fossae and superior mediastinal lymph nodes for upper thoracic (Ut), and mediastinal and perigastric lymph nodes for middle thoracic (Mt)/lower thoracic (Lt) EC. It is unclear whether the safety and efficacy are associated with the tumor location in patients with cStage II/III EC treated with dCRT. Methods: Patients who were enrolled in JCOG0909 and underwent dCRT were analyzed. Patients were categorized into three groups according to primary tumor location (Ut/Mt/Lt). We compared adverse events during dCRT, complete response (CR) rate, progression-free survival (PFS) and overall survival (OS) among groups. Results: Ninety-four patients (Ut/Mt/Lt: 16/59/19) were analyzed. The proportions of cStage IIA/IIB/III were 31%/44%/25% in Ut group, 20%/42%/37% in Mt group, and 21%/32%/47% in Lt group, respectively. The summary of safety and efficacy was listed in Table 1. Grade 3-4 leukopenia, neutropenia and thrombocytopenia were more frequently observed in Mt and Lt groups than in Ut group. CR rate was 63% in Ut, 63% in Mt, and 42% in Lt, respectively. 3-year PFS in Ut/Mt/Lt was 60%/59%/47% and 3-year OS was 73%/78%/58%, respectively. Conclusions: The RT field by the tumor location might be associated with efficacy and safety of dCRT for cStage II/III esophageal cancer. [Table: see text]

Parallel-group controlled trial of esophagectomy versus chemoradiotherapy in patients with clinical stage I esophageal carcinoma (JCOG0502)

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Background: Esophagectomy (E) is the standard of care for stage I esophageal squamous cell carcinoma (ESCC), while chemoradiotherapy (CRT) is a treatment option. A parallel-group controlled trial including randomized arms to confirm the non-inferiority of CRT to E for stage IA ESCC was conducted. Methods: Patients (pts) with thoracic ESCC, adenosquamous cell, or basaloid cell carcinoma with stage IA (T1bN0M0), age 20 to 75, performance status 0 to 1, and adequate organ function were eligible. If pts accepted randomization, they were randomly allocated to E with 2-3 field lymph node dissection (arm A) or CRT (arm B). However, if pts had a preference and refused randomization, they were allocated to pts preference arm, E (arm C) or CRT (arm D). CRT consisted of cisplatin and 5-FU, with radiation at the dose of 60 Gy concurrently. The primary endpoint was overall survival (OS) of arm A and B, secondary endpoint included OS of arm C and D using inverse probability weighting with propensity score. The planned sample size in arm A and B was 114 pts in total with one-sided alpha of 10%, power of 75% and non-inferiority margin of HR as 1.78. The sample size in arm C and D was at least 156 pts in each arm with one-sided alpha of 2.5%, power of 85% and non-inferiority margin of HR as 1.78. Results: Between December 2006 and February 2013, 379 (Arm A: 4, B: 7, C: 209 C, D: 159) pts were enrolled. Primary endpoint was not calculated due to small number of randomized arms. Patients characteristics of arm C and D were as follows; median age: 62 and 65, male (%): 82.8 and 88.1, PS 0 (%): 99.5 and D 98.1. All histologic type was SCC except one basaloid cell carcinoma in arm C. The 3- and 5-year OS were 94.7% and 86.5% in arm C, and 93.1% and 85.5% in arm D (adjusted HR 1.05; 95% CI 0.67-1.64 [< 1.78]).Treatment related death were observed in two pts in arm C and none in arm D. Conclusions: Though the accrual of randomized arms was shortened, CRT showed trend toward non-inferiority compared to E in pts preference arms. CRT is considered as a treatment option for stage IA ESCC with organ preservation. Clinical trial information: UMIN000000551.

A Resected Case of Primary Malignant Melanoma of the Esophagus—Early Detection of Recurrence by FDG-PET/CT

Primary malignant melanoma of the esophagus (PMME) is a rare, aggressive, therapy-resistant malignant tumor arising from esophageal mucosal melanocytes. It has been reported that fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) has a clinical impact on PMME diagnosis; however, it remains unclear whether postoperative surveillance using FDG-PET/CT is useful for PMME patients. In this case study, FDG-PET/CT detected the recurrent tumors in their early stage after a curative resection of PMME. We report on a case of a 67-year-old Japanese male admitted to our hospital for the evaluation of polypoid tumors of the esophagogastric junction, which were diagnosed as PMME. He was treated with a curative resection by esophagectomy and 6 cycles of adjuvant chemotherapy of DAV (dacarbazine, nimustine, and vincristine). However, the PMME recurred 26 months after the surgery when surveillance FDG-PET/CT detected the recurrent tumors in their early stage. FDG-PET/CT may be useful to detect recurrence in the postoperative surveillance phase for PMME patients.

A prospective multicenter trial of S-1 with lafutidine vs S-1 as adjuvant chemotherapy for gastric cancer in Japan: AEOLUS

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Background: From the result of ACTS-GC study, adjuvant chemotherapy with S-1 for one year is standard therapy of gastric cancer in Japan. In this study, completion rate of pre-planned S-1 treatment was 65.8% and there is still room for improvement on this rate. Lafutidine is a H2 blocker and enhances submucosal blood flow via capsaicin-sensitive afferent neurons. Alleviating effect of lafutidine on toxicity of 5FU leading to discontinuation of adjuvant treatment could be expected. Methods: Patients with histologically confirmed stage II (excluding T1 cases), IIIA, or IIIB (Japanese Classification of Gastric Carcinoma 13th) who underwent gastrectomy with D2 lymphadenectomy were randomly assigned to receive S-1 with lafutidine(L) or S-1 (S). All patients were given S-1 (40mg/m2) for 4 weeks with 2 weeks rest, repeated for 1 year after surgery. Patients of L group received lafutidine (20mg/day) every day for 1 year with S-1. The primary end point was treatment completion rate (TCR) of S-1. Definition of treatment completion was S-1 continuation for 1 year with over 70% planned dose. The secondary end points were toxicity (CTCAE v3.0) and relative total administration dose (RD) of S-1. Results: We randomly assigned 101 patients to the L group and 101 patients to the S group between February 2010 and December 2012 from 17 centers in Japan. After randomization, two patients were found to be ineligible in L group (the absence of cytologic examination of the peritoneal fluid, stageIB) and 1 in S group (allocation violation). TCR was 68.3% in the L group and 60.4% in the S group (p = 0.072, Cochran-Mantel-Haenzel test at a pre-specified one-sided significance level of 0.1). Adverse events of grade 3/4 excluding ineligible example was 30.0% in the L group, and 36.0% in the S group. Patients who require a dose reduction and/or delay of S-1 was 41.6% in the L group, and 51.5% in the S group. RD was 83.9% (range: 1.6-103.7) in the L group, and 84.0% (range: 1.7-103.8) in the S group. No any toxicity of lafutidine was observed. Conclusions: Lafutidine may increase a completion rate of adjuvant chemotherapy using S-1 within a 30% dose reduction for gastric cancer. This result need to be confirmed in double-blind placebo control study. Clinical trial information: UMIN000002703.

Impact of laparoscopy on the prevention of pulmonary complications after thoracoscopic esophagectomy using data from JCOG0502: a prospective multicenter study

BACKGROUND

Postoperative pulmonary complications (PPCs) are the most common causes of serious morbidity after esophagectomy, which involves both thoracic and abdominal incisions. Although the thoracoscopic approach decreases PPC frequency after esophagectomy, it remains unclear whether the frequency is further decreased by combining it with laparoscopic gastric mobilization. This study aimed to determine the impact of laparoscopy on the prevention of PPCs after thoracoscopic esophagectomy using data from the Japan Clinical Oncology Group Study 0502 (JCOG0502).

METHODS

JCOG0502 is a four-arm prospective study comparing esophagectomy with definitive chemo-radiotherapy. The use of thoracoscopy and/or laparoscopy was decided at the surgeon's discretion. PPCs were defined as one or more of the following postoperative morbidities grade ≥2 (as per Common Terminology Criteria for Adverse Events v3.0): pneumonia, atelectasis, and acute respiratory distress syndrome.

RESULTS

A total of 379 patients were enrolled in JCOG0502. Of these, 210 patients underwent esophagectomy via thoracotomy with laparotomy (n = 102), thoracotomy with laparoscopy (n = 7), thoracoscopy with laparotomy (n = 43), and thoracoscopy with laparoscopy (n = 58). PPC frequency was reduced to a greater extent by thoracoscopy than by thoracotomy (thoracoscopy 15.8%, thoracotomy 30.3%; p = 0.015). However, following thoracoscopic esophagectomy, laparoscopy failed to further decrease the PPC frequency compared with laparotomy (laparoscopy 15.5%, laparotomy 16.3%; p = 1.00). Univariable analysis showed that thoracoscopy (shown above) and less blood loss (<350 mL 16.3%, ≥350 mL 30.2%; p = 0.022) were associated with PPC prevention, whereas laparoscopy showed a borderline significant association (laparoscopy 15.4%, laparotomy 26.9%; p = 0.079). Multivariable analysis also showed that thoracoscopy and less blood loss were associated with PPC prevention.

CONCLUSION

Thoracoscopic approach to esophagectomy significantly reduced PPC frequency with minimal additional effect from laparoscopic gastric mobilization.

Evaluation of preventive factors for postoperative pulmonary complications following esophagectomy for T1bN0M0 cancer using data from JCOG0502

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Background: Postoperative pulmonary complications (PPCs) are the most common cause of serious morbidity following esophageal cancer resection and are associated with a poorer prognosis in esophagectomized patients (pts). We have recently reported that thoracoscopic esophagectomy (TSE) decreases PPC frequency. However, it remains unclear whether the frequency is further decreased by the combination with laparoscopic esophagectomy (LSE). This study aimed to clarify the combined effect of TSE with LSE on the prevention of PPCs and to determine the preventive factors for PPCs following esophagectomy using data from JCOG0502. Methods: JCOG0502 is a four-arm prospective study comparing esophagectomy with definitive chemoradiotherapy for T1bN0M0 cancer, with randomized and patient preference arms. The primary endpoint is overall survival, which will be analyzed in 2018. PPCs were defined as one or more of the following ≥ grade 2 postoperative morbidities per CTCAE v3.0: pneumonia, atelectasis, and acute respiratory distress syndrome. The use of TSE and/or LSE was decided at the surgeon’s discretion. Results: Totally, 379 pts (11 in the randomized and 368 in the patient preference arm) were enrolled between 2006 and 2013 from 37 institutions. Of the 210 pts who underwent esophagectomy, TSE was performed in 101 pts (TSE with laparotomy in 43 pts and TSE with LSE in 58 pts), while esophagectomy via thoracotomy was performed in 109 pts. PPCs occurred less often in pts who underwent TSE than esophagectomy via thoracotomy (15.8% vs 30.3%, p = 0.01); however, there was no difference in the frequency of PPCs between those who underwent TSE with laparotomy and TSE with LSE (16.3% vs 15.5%). In univariate analysis, both TSE (shown above) and less blood loss ( < 350 mL) were associated with the prevention of PPCs (16.3% vs 30.2%, p = 0.02). Multivariate analysis showed that TSE was associated with the prevention of PPCs [Odds ratio, 0.33; 95% confidence interval (0.12-0.88); p = 0.03]. Conclusions: This study indicated that TSE was the only independent preventive factor for PPCs following esophagectomy, and LSE had limited effectiveness in the prevention of PPCs when it is combined with TSE. Clinical trial information: UMIN000000551.

Evaluation of safety profile of thoracoscopic esophagectomy for T1bN0M0 cancer using data from JCOG0502: a prospective multicenter study

BACKGROUND

Thoracoscopic esophagectomy is rapidly and increasingly being used worldwide because it is a less invasive alternative to open esophagectomy. However, few prospective multicenter studies have evaluated its safety profile. This study aimed to evaluate the safety profile of thoracoscopic esophagectomy using perioperative data from the Japan Clinical Oncology Group Study (JCOG0502).

METHODS

JCOG0502 is a four-arm prospective study comparing esophagectomy with chemoradiotherapy for esophageal cancer, with randomized and patient preference arms. Patients with clinical stage T1bN0M0 esophageal cancer were enrolled until patient accrual was completed. Open or thoracoscopic esophagectomy was selected at the surgeon's discretion. Perioperative complications were defined as adverse events of ≥grade 2 as per Common Terminology Criteria for Adverse Events ver. 3.0.

RESULTS

A total of 379 patients were enrolled between December 2006 and February 2013. Of the 210 patients who underwent surgery, 109 patients underwent open esophagectomy, and 101 patients underwent thoracoscopic esophagectomy. Although thoracoscopic esophagectomy decreased the incidence of postoperative atelectasis (open: 22.0%, thoracoscopy: 10.9%; P = 0.041), reoperation was more frequent in the thoracoscopy group (open: 1.8%, thoracoscopy: 9.9%; P = 0.016). The incidence of overall complications did not differ between the two groups (open: 44.0%, thoracoscopy: 44.6%; P = 1.00). There was one in-hospital death in each group (open: 0.9%, thoracoscopy: 1.0 %; P = 1.00).

CONCLUSIONS

Thoracoscopic esophagectomy is a safe procedure with morbidity and mortality comparable with those of open esophagectomy. However, it is associated with a higher frequency of reoperation.

The prevalence of lymph node metastases in clinical T1N0 thoracic esophageal cancer from the results of JCOG0502

10

Background: Recently, a limited operation to avoid needless lymph node (LN) dissection in clinical T1bN0 esophageal cancer (EC) is considered. However, how LN dissection or radiation field should be decided for such cases has not yet been clarified. The information about prevalence of LN metastases (LNMs) would be valuable when the radiation field and extent of LN dissection are considered in the treatment of T1bN0 EC. Methods: JCOG0502 is a randomized controlled trial including a patient preference arm comparing surgery alone to definitive chemoradiotherapy in clinical T1bN0 EC. By using baseline clinical and pathological data of JCOG0502, diagnosis accuracy of LNM was evaluated by comparing clinical and pathologic findings. Then, the sites of pathologic LNMs were determined and the initial sites and the prevalence of LNM were estimated. Results: Between Dec 2006 and Feb 2013, 213 patients (pts) enrolled to the surgery arm in JCOG0502. Pts with multiple lesions or without esophagectomy were excluded and remaining 186 pts were analyzed. Of the 186 pts of clinical T1bN0, 137 pts were diagnosed as LNM negative (73.7%: accuracy of diagnosis), however, 49 pts (26.3%) had pathologic LNMs. Pathologic LNMs were seen at 106recR, 106recL (all in mediastinal region) in upper thoracic (Ut) EC, 101R, 101L, 104R, 104L (in the neck region), 106recR, 106recL, 106tbL, 105, 107, 108, 109L, 110 (in the mediastinal region), 1,2,3,7, 11 (in the abdominal region) in middle thoracic (Mt) EC, and 105, 106recL, 110 (in the mediastinal region), 1, 2, 3, 7 (in the abdominal region) in lower thoracic (Lt) EC, respectively. Of the 49 pts who had pathologic LNMs, 32 pts (65%) were of pathologically N2 or more. Furthermore, 18 pts (37%) had skip LNM (LNM of N2, N3 or N4 without N1). The solitary pathologic LNM was observed in 25 pts: N1 (106recR, 106recL) in Ut, N1 (106recR, 106recL, 108), N2 (101R, 105, 110, 1, 3, 7), in Mt, N1(110, 1), N2 (106recL, 3, 7) in Lt, respectively. Conclusions: In the current status of clinical diagnosis, limited LN dissection or limited field of radiation are not recommended. In surgery, D2 LN dissection is necessary and three-field LN dissection is recommended especially in middle thoracic EC even for clinical T1bN0. Clinical trial information: UMIN000000551.

Prognostic impact of postoperative morbidity after esophagectomy for esophageal cancer: Supplementary exploratory analysis of JCOG9907

155

Background: Although the impact of postoperative complications, especially infectious complications (IC), on long-term survival after transthoracic esophagectomy remains controversial to date, we hypothesized that postoperative IC may affect tumor recurrence and survival of the patients (pts) undergoing transthoracic esophagectomy. Methods: The data from JCOG9907 (Ando N; Ann Surg Oncol 2012) was used to estimate the influence of IC on the outcome of current standard preoperative chemotherapy followed by surgery for clinical stage II/III squamous cell carcinoma of the thoracic esophagus. IC were classified into three: pneumonia, anastomotic leakage, and the others. OS and PFS were estimated by landmark method at 6 months from randomization. Univariate and multivariate analyses using Cox proportional hazard model were performed to assess the impact of postoperative complications on the survival after right-transthoracic esophagectomy with extended lymphadenectomy. Results: Among the 152 analyzed pts, the incidence of overall IC was 36%, among which pneumonia and anastomotic leakage were observed both in 14%. OS of pts with any IC (n=54) was shorter than that of pts without IC (HR 1.66, 95%CI [1.02-2.71]) and PFS also tended to be shorter in pts with any IC (HR 1.44, [0.92-2.23]). OS of pts with pneumonia (n=22) was shorter than that of pts without pneumonia (HR 1.82, [1.01-3.29]), and PFS also tended to be shorter in pts with pneumonia (HR 1.50, [0.85-2.62]). OS of pts with anastomotic leakage (n=21) were nearly identical to that for pts without leakage (HR 1.06, [0.52-2.13]) and PFS was slightly shorter in pts with leakage (HR 1.28, [0.71-2.32]). Multivariate analysis revealed that pneumonia tended to compromise OS and PFS (HR 1.66, [0.87-3.17] and HR 1.37, [0.75-2.51]). Conclusions: This study reveals that postoperative morbidity, especially pneumonia may deteriorate the survival of pts undergoing esophagectomy after preoperative chemotherapy. Achieving esophagectomy without postoperative complications might prolong OS and PFS. Clinical trial information: NCT00190554.

Determination factors of patients' decision between surgery and chemoradiotherapy for stage I esophageal carcinoma: From the results of JCOG0502—A comparative study of the two modalities

114

Background: Surgery is the standard of care for stage I esophageal squamous cell carcinoma. However, definitive chemoradiothearpy (CRT) is optional treatment which can preserve organ function with cure. The aim of this study was to investigate what factors have influence patients(pts)’ decision on the treatment, surgery or CRT. Methods: JCOG0502 is a randomized controlled trial comparing surgery to CRT. Sufficient information about both treatments was provided for pts before enrollment. Pts who declined to participate in randomized part can choose a preferred treatment and join a non-randomized part of JCOG0502. Between Dec 2006 and Feb 2013, 379 pts were enrolled to JCOG0502 from 37 institutions of Japan Clinical Oncology Group. Among those, 368 pts who enrolled to non-randomized part were analyzed. Clinical baseline data, social data and doctor’s preference which was not mandatory informed to patients were collected on the case report forms and compared between surgery arm and CRT arm. Preference of doctors for each pt was divided into three categories, A: “surgery is preferred”, B: “either is adequate” and C: “CRT is preferred”. This trial was registered as UMIN000000551. Logistic regression were performed to evaluate the influence of each factors. Results: Of the 368 pts, 209 pts chose surgery with their own intention, while 159 pts chose CRT. There were no differences on baseline clinical characteristics between two groups except median age (Surgery: CRT = 62:65 years). Multivariate logistic regression analyses showed that >=65 years (vs<65) (OR 2.04, p=0.006), male (vs female) (OR 2.10, p=0.043), multi-focal primary (vs single) (OR 2.76, p=0.013), status of patient’s children (vs presence of children) (absence of children: OR 2.27, p=0.034) (unknown: OR 4.422, p=0.13), and B or C category of preference of the doctor (vs A) (B:OR 11.67, p<0.001)(C:HR 29.64, p<0.001) were associated with selection of CRT. Conclusions: Older age, male, multifocal primary, absence of children and doctor’s preference are independent factor to choose CRT. Doctor’s preference to each pt was the strongest factor on decision making of patients.

Hand-sewn anastomotic technique after esophageal cancer resection

BACKGROUND/AIMS

Mechanical stapled anastomosis can be performed easily and quickly in esophagogastrostomy after esophageal cancer resection. However, we have performed cervical hand-sewn anastomosis in the esophagogastrostomy. Here we introduce the surgical technique and report the outcomes after the anastomosis.

METHODOLOGY

The gastric tube is pulled up via the posterior mediastinal route. A single layer of Gambee sutures is used to approximate the cervical esophagus and the posterior wall of the gastric tube in end-to-side fashion. After the anastomosis, the redundant part in the gastric tube apex is removed. We analyzed 152 consecutive patients who underwent this anastomosis in our institute from 1999 to 2012.

RESULTS

There was no postoperative mortality. We experienced anastomotic leakage in 7 patients (5%) and anastomotic stenosis in 5 patients (3%).

CONCLUSIONS

The anastomotic complication rates in the hand-sewn anastomosis were comparable to those of the mechanical stapled anastomosis in the previous reports.

Safety profile of thoracoscopic esophagectomy for esophageal cancer compared with traditional thoracotomy from the results of JCOG0502: A randomized trial of esophagectomy versus chemoradiotherapy

82

Background: Esophagectomy for esophageal cancer via the thoracoscopic approach (TA) is expected to reduce the extent of trauma compared with traditional thoracotomy (TT). However, there have been few prospective studies comparing perioperative complications between TA and TT after esophagectomy. Therefore, this study aimed to clarify whether TA is a safe procedure with regard to morbidity and mortality using the data of patients (pts) who underwent esophagectomy in the JCOG0502 trial. Methods: The JCOG0502 trial is a currently on-going randomized trial including a patient preference arm of esophagectomy versus chemoradiotherapy for treatment of clinical stage I esophageal cancer. The primary analysis of overall survival is planned in 2018. In this trial, thoracic squamous cell carcinoma, adenosquamous carcinoma, and basaloid carcinoma of stage T1b/N0/M0 were eligible. When pts were randomized to surgery or selected surgery, esophagectomy with D2–3 lymphadenectomy was performed. TA or TT was selected at the surgeon’s discretion. Perioperative complications were defined as adverse events of grade 2 or greater as per CTCAE v3.0. Results: A total of 379 pts (11 randomized and 368 in the patient preference arm) were enrolled between December 2006 and February 2013 from 37 institutions, and 211 pts underwent surgery. Of these 211 pts, TA was performed in 101 pts while TT was performed in 110 pts. Blood loss was less in the TA group than in the TT group (median, 293 vs. 410 mL, respectively), and the surgical duration was longer in the TA group than in the TT group (median, 510 vs. 398 min). The proportion of intraoperative complications was similarly low in both groups. However, postoperative anastomotic leakage, pneumonia, and atelectasis were less common in the TA group than in the TT group (7%, 8%, and 11% vs. 14%, 17%, and 22%). Moreover, the proportion of recurrent nerve palsy was similar among both groups (15% vs. 16%). Each group had one in-hospital death. Conclusions: This study indicated that TA did not increase morbidity or mortality after esophagectomy and can be safely performed with risks comparable to those with TT. Clinical trial information: UMIN000000551.

Incidence of metachronous gastric cancer in the remnant stomach after synchronous multiple cancer surgery

BACKGROUND

In the preoperative evaluation for gastric cancer, high-resolution endoscopic technologies allow us to detect small accessory lesions. However, it is not known if the gastric remnant after partial gastrectomy for synchronous multiple gastric cancers has a greater risk for metachronous cancer. The purpose of this study was to determine the incidence of metachronous cancer in this patient subset compared with that after solitary cancer surgery.

METHODS

Data on a consecutive series of 1,281 patients gastrectomized for early gastric cancer from 1991 to 2007 were analyzed retrospectively. The 715 gastric remnants after distal gastrectomy were periodically surveyed by endoscopic examination in Shikoku Cancer Center. Among those surveyed cases, 642 patients were pathologically diagnosed with solitary lesion (SO group) and 73 patients with synchronous multiple lesions (MU group) at the time of the initial surgery.

RESULTS

In the follow-up period, 15 patients in the SO group and 3 patients in the MU group were diagnosed as having metachronous cancer in the gastric remnant. The cumulative 4-year incidence rate was 1.9 % in the SO group and 5.5 % in the MU group. The difference did not reach the significant level by the log-rank test.

CONCLUSIONS

The incidence of metachronous cancer is higher after multiple cancer surgery; however, the difference is not statistically significant.

Long-term outcome after proximal gastrectomy with jejunal interposition for gastric cancer compared with total gastrectomy

BACKGROUND

Proximal gastrectomy (PG) has been widely accepted as treatment for early gastric cancer located in the upper third of the stomach. Reconstruction by jejunal interposition has been known to reduce reflux esophagitis for PG patients. The aim of this study was to compare the long-term outcomes of patients who underwent PG with jejunal interposition with those treated by total gastrectomy (TG).

METHODS

Data on 102 cases of PG with jejunal interposition and 49 cases of TG with Roux-Y reconstruction for gastric cancer were analyzed retrospectively in terms of overall survival, weight maintenance, anemia and nutritional status, and endoscopic findings.

RESULTS

Median follow-up time was 59 months in the both groups. There was no significant difference in the overall 5-year survival rate between the PG group (94%) and the TG group (84%). The PG group showed significantly better body weight maintenance at the first year. The laboratory blood tests showed that the PG group had a significantly better red blood cell count and hemoglobin and hematocrit levels at the second and third year. However, postoperative endoscopic surveillance detected reflux esophagitis (3%), peptic ulcer (9%), and metachronous gastric cancer (5%) in the PG group.

CONCLUSIONS

Proximal gastrectomy maintains comparable oncological radicality to TG and is preferred over TG in terms of preventing postoperative anemia. However, periodic endoscopic follow-up is necessary to monitor the upper gastrointestinal tract.

Next study (JCOG1109): A three-arm randomized phase III study comparing preoperative CDDP+5-FU(CF) versus docetaxel+CF versus CF-radiation followed by esophagectomy with D2-3 lymphadenectomy for locally advanced esophageal squamous cell cancer

TPS4152

Background: Based on the results of JCOG9907, preoperative cisplatin plus 5- fluorouracil (CF) followed by esophagectomy with D2-3 lymphadenectomy has become standard care for advanced esophageal cancer in Japan, while the standard therapy in Western countries is preoperative chemoradiotherapy. A new clinical question has thus arisen of whether CF plus docetaxel (DCF) or CF plus radiotherapy (CF-RT) shows a survival benefit over preoperative CF even with intensive surgery. Methods: Eligibility criteria include histologically proven thoracic esophageal squamous cell carcinoma with stage IB/II/III (excluding T4) based on the 7th UICC-TNM, age 20 to 75, and performance status 0 to 1. No prior chemotherapy, radiotherapy, or hormonal therapy is allowed. Adequate organ function and written informed consent are required. Patients are randomized into any of the following three arms by a minimization method balancing the arms in terms of institution and tumor depth (T1–2 versus T3). Patients in arm A (CF) receive two courses of cisplatin at 80 mg/m2 on day 1 and fluorouracil at 800 mg/m2 on days 1–5, repeated every three weeks. Patients in arm B (DCF) receive three courses of docetaxel at 70 mg/m2, cisplatin at 70 mg/m2 on day 1, and fluorouracil at 750 mg/m2 on days 1–5, repeated every three weeks. Patients in arm C (CF-RT) receive two courses of cisplatin at 75 mg/m2 on day 1 and fluorouracil at 1000 mg/m2 on days 1–4, repeated every four weeks concurrently with radiotherapy at 41.4Gy/23fr. This trial is designed to demonstrate the superiority of preoperative DCF and/or CF-RT over CF in terms of overall survival. We assumed three-year survival with preoperative CF to be 63% and expected a 10% increase in three-year survival for DCF and CF-RT. The sample size was calculated as a total of 501 patients (167 patients per arm) with a study-wise one-sided alpha level of 5%, power of 70% for each pair comparison, an accrual period of 6.25 years, and a follow-up period of three years. This trial was registered as UMIN000009482 and started in December 2012. Clinical trial information: UMIN000009482.

[A case of reversible encephalopathy syndrome caused by hyponatremia during neoadjuvant 5-FU+CDDP therapy for esophageal cancer]

We present a case of reversible encephalopathy syndrome caused by hyponatremia during neoadjuvant chemotherapy with 5-FU+CDDP for esophageal cancer. A 52-year-old woman visited another hospital with the complaint of discomfort during swallowing. Upper gastrointestinal endoscopy revealed an ulcerated lesion in the lower thoracic esophagus, which was pathologically diagnosed as squamous cell carcinoma. She was admitted to our institution, and the diagnosis of esophageal cancer Mt-Lt, type 2, cT2N1M0, stage II was made. We obtained informed consent for her treatment with both CRT and surgery, and she selected surgery. Therefore, she was administered neoadjuvant chemotherapy with 5-FU+CDDP therapy. On day 4, abnormalities of the central nerve, such as unconsciousness, difficulty in speaking, and muscle cramps were, observed. After the examinations she was diagnosed with encephalopathy. It should be noted that hyponatremia induced by renal sodium wasting syndrome(RSWS)was considerd to be the cause, and we report our case with the literature cited.

Association between tuberculosis treatment outcomes and the mobile antiretroviral therapy programme in Zambia

SETTING

Free antiretroviral therapy (ART) services in Zambia were introduced in hospitals beginning in 2005 and in selected rural health centres (RHCs) beginning in 2007 through the mobile ART programme.

OBJECTIVE

To analyse the impact of scaling up ART services on tuberculosis (TB) treatment outcomes in Mumbwa District, Zambia.

DESIGN

TB patients registered at all RHCs in the district between July 2006 and September 2009 were reviewed. RHCs were divided into two groups: 'ART sites', which provided ART services after 2007, and 'non-ART sites', which did not provide such services even after 2007. A before-after comparison analysis of TB patients was conducted between the groups.

RESULTS

A total of 732 patients were enrolled (median age 34.5 years; female 44.4%). The overall human immunodeficiency virus (HIV) testing rate was 72.3% and 66.7% of these patients were HIV-positive. The TB treatment success rate at the ART sites increased significantly compared to non-ART sites after the mobile ART programme was started (P < 0.01). The HIV testing acceptance rate also increased dramatically at ART sites, which facilitated intensified case finding (P = 0.02).

CONCLUSION

Scaling up ART services in rural health facilities through the mobile ART programme was found to be associated with greatly improved anti-tuberculosis treatment outcomes.

A new technique for resecting gastric remnant cancer after proximal gastrectomy with jejunal interposition

Surgery for gastric remnant cancer after distal gastrectomy is well established; however, little is known about the removal of remnant gastric cancer following proximal gastrectomy with jejunal interposition. We introduce a surgical technique for removing remnant cancer under these circumstances. We used this technique to remove a total gastric remnant with radical lymph node dissection, while preserving the interposed jejunum for easy re-reconstruction by Roux-en-Y anastomosis, in five patients. The median operating time was 199 min and the median blood loss was 330 ml. There were no postoperative deaths or major complications and all five patients were discharged within 14 days after surgery. Our technique for total resection of the gastric remnant after proximal gastrectomy and re-reconstruction with preserved interposed jejunum is easy, safe, and effective.

Risk factors for metachronous gastric cancer in the remnant stomach after early cancer surgery

BACKGROUND

Early gastric cancer patients have a good prognosis after radical resection. However, if the patients have a gastric remnant after the surgery, the risk of metachronous gastric cancer remains. The aim of this study was to clarify the risk factors for metachronous gastric cancer after partial gastrectomy for early gastric cancer.

METHODS

Data on a series of 1281 consecutive gastrectomy patients with pathologically confirmed early gastric cancer from 1991 to 2007 in Shikoku Cancer Center were analyzed retrospectively.

RESULTS

The gastric remnants of 868 patients were periodically surveyed by endoscopic examination. Among those surveyed cases, 26 patients were diagnosed as having metachronous gastric cancer in the gastric remnant. They underwent curative resection by remnant gastrectomy (n = 13 patients) or endoscopic mucosal resection (n = 13 patients). Multivariate analysis showed that male sex, older age, submucosal invasion, and proximal gastrectomy were independent risk factors.

CONCLUSIONS

Our data suggested that more intensive endoscopic follow-up is needed for the remnant stomach in patients with these risk factors to detect metachronous gastric cancer at its early stage.

Abstract 2691: Prognostic significance of heat shock protein 90 expression in patients with advanced gastric cancer

Purpose: Heat shock protein 90 (HSP90) is a chaperone mediating the folding and stabilization of many oncoproteins. Considerable attention has been focused on the role of the HSP90 in the therapeutic strategy of molecular targeting HSP90. Recently it has reported that Trastuzumab, a recombinant monoclonal antibody against HER2, plus chemotherapy improved survival in HER2-positive gastric cancer patients. This study was designed to delineate the clinical implications of Hsp90 and HER2 immunoexpression in advanced gastric cancer.

Material and Methods: The study group comprised 47 patients who underwent gastrectomy at Shikoku Cancer Center Hospital excluding patients with stage I. According to the TNM classification, 18 tumors were identified as being stage II, 25 stage III, 4 stage IV. Using immunohistochemical techniques, we analyzed the expressions of HSP90 and HER2 on formalin-fixed paraffin-embedded specimens of surgically removed primary tumors. Immunostaining was graded as follows: low-HSP90 (defined as weaker staining compared with adjacent normal gastric mucosa), moderate-HSP90 (defined as equal), high-HSP90 (defined as stronger). HER2 expression was graded using a 4-point scale according to the criteria of HER2 membranous staining, which have been widely accepted. Chi-square test, Kaplan-Meier and Cox regression analysis were used for statistical analysis.

Results: Low-HSP90 expression was found in 13 tumors (28%) and HER2 high-expression (moderate to strong membrane staining in &gt; 10% of tumor cells) in 13 tumors (28%). Low-HSP90 was significantly detected in diffuse type (p = 0.0047) and was associated with clinicopathological parameters involved with tumor progression, including the depth of tumor invasion (p = 0.049) and advanced stage tumor (p = 0.029). Of note, High-HSP90 and HER2 overexpression (3+) were mutually exclusive (P=0.031). Kaplan-Meier survival analysis determined that tumors with low-HSP90 expression were statistically associated with worse disease-free survival (p = 0.036), and tended to detect poor postoperative survival (p = 0.084). Multivariate survival analysis showed that HSP90-negative expression [hazard ratio (HR) 3.05, 95% confidence interval (95% CI) 1.02-9.18; p = 0.046] and lymph node metastasis (HR 5.55; 95% CI 1.68-18.2; p = 0.005) were significant predictors of poor postoperative survival.

Conclusions: Our results indicate that low-HSP90 expression correlated with more aggressive disease and poor prognosis, and that HSP90 and HER2 overexpression might separately be molecular targets in gastric cancer.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 2691.

Esophagectomy via left thoracotomy for esophageal cancer with situs inversus totalis: report of a case

We report a case of successful esophagectomy via a left thoracotomy for esophageal cancer in a 57-year-old Japanese man with situs inversus totalis. An upper gastrointestinal endoscopy, performed to investigate the cause of dysphagia, revealed a 7-cm irregular shaped mass occupying more than half of the circumference of the middle-third of the esophagus. Computed tomography (CT) showed enlarged mediastinal lymph nodes and situs inversus totalis. Histological examination of a biopsy specimen revealed squamous cell carcinoma of the esophagus. Although esophagectomy is usually performed through a right thoracotomy because of the left position of the aortic arch, we performed successful subtotal esophagectomy with radical lymph node dissection through a left thoracotomy. During surgery, we modifi ed the standard surgical technique in a mirrorimage fashion to complete the esophagectomy safely. The patient had an uneventful postoperative course.

Laparoscopic colectomy for colorectal cancer patients with previous abdominal surgery

BACKGROUND/AIMS

Laparoscopic colectomy has been widely accepted as a standard operation for colorectal cancer. The use of this procedure for patients with previous abdominal surgery is now well established. The aim of this study was to evaluate the peri-operative and long-term outcomes of such patients, and to compare them to patients without previous surgery.

METHODOLOGY

Data on a consecutive 121 cases of laparoscopic colectomy performed for colorectal cancer from 1995-1999 in Shikoku Cancer Center were analyzed retrospectively for peri-operative and long-term outcomes.

RESULTS

Twenty one cases (17%) of laparoscopic colectomy were performed for colorectal cancer patients with previous surgery. Although the operation time for the previous surgery group was significantly longer than that of the control group, there was no significant difference in the peri-operative complications and the overall survival between the 2 groups.

CONCLUSIONS

Although the previous abdominal surgery increases the time it takes to perform the laparoscopic colectomy, the peri-operative and long-term outcomes were comparable to those from patients without previous surgery.

Higher incidence of gastric remnant cancer after proximal than distal gastrectomy

BACKGROUND/AIMS

Proximal gastrectomy has been widely accepted as a standard operation for early stage gastric cancer located in the upper third of the stomach. Therefore, cancer of the distal gastric remnant is now increasing. The aims of this study were to clarify and compare the incidences of gastric remnant cancer after proximal and distal gastrectomy.

METHODOLOGY

Data on a consecutive series of 809 cases of gastrectomy performed for early gastric cancer from 1991 to 2003 in Shikoku Cancer Center were analyzed retrospectively with respect to the incidence of gastric remnant cancer.

RESULTS

We performed distal gastrectomy in 624 patients and proximal gastrectomy in 47 patients during the study period. After those operations, the gastric remnants of 457 cases and 33 cases, respectively, were surveyed periodically by endoscopic examination at our hospital. Among those surveyed cases, 10 patients (2.2%) and 3 patients (9.1%) were diagnosed as having gastric remnant cancer, respectively. The gastric remnant cancer-free survival after proximal gastrectomy was significantly lower than that after distal gastrectomy.

CONCLUSIONS

Because of the higher incidence of gastric remnant cancer after proximal gastrectomy, it is more important to survey the gastric remnant after proximal gastrectomy periodically by postoperative endoscopic examination.

The MM2-cortical form of sporadic Creutzfeldt-Jakob disease presenting with visual disturbance

A subclass of sporadic Creutzfeldt-Jakob disease (sCJD) characterized by onset with visual symptoms (Heidenhain variant) has been reported to belong to the MM1 or MV1 type according to Parchi's classification. The authors report a 65-year-old woman with MM2-cortical sCJD with slowly progressive visual disturbance as the initial symptom. Diffusion-weighted MRIs revealed hyperintensity in both occipital cortices at an early stage.

Biliary wound healing, ductular reactions, and IL-6/gp130 signaling in the development of liver disease

Basic and translational wound healing research in the biliary tree lag significantly behind similar studies on the skin and gastrointestinal tract. This is at least partly attributable to lack of easy access to the biliary tract for study. But clinical relevance, more interest in biliary epithelial cell (BEC) pathophysiology, and widespread availability of BEC cultures are factors reversing this trend. In the extra-hepatic biliary tree, ineffectual wound healing, scarring and stricture development are pressing issues. In the smallest intra-hepatic bile ducts either impaired BEC proliferation or an exuberant response can contribute to liver disease. Chronic inflammation and persistent wound healing reactions in large and small bile ducts often lead to liver cancer. General concepts of wound healing as they apply to the biliary tract, importance of cellular processes dependent on IL-6/gp130/STAT3 signaling pathways, unanswered questions, and future directions are discussed.

Simultaneous bone marrow and intestine transplantation promotes marrow-derived hematopoietic stem cell engraftment and chimerism

Organ allografts have been shown to provide a syngeneic microenvironment for organ-based donor hematopoietic stem cells to maintain long-lasting chimerism after transplantation. We hypothesized that organ allografts would also support engraftment and hematopoiesis of adjunctively infused donor marrow stem cells, syngeneic to organ grafts, in nonmyeloablated recipients. In BN-to-LEW and GFP-to-ACI rat combinations, donor bone marrow (BM) infusion together with small intestine transplantation (SITx) under short-course tacrolimus immunosuppression resulted in persistent macrochimerism (more than 5%) for 150 days. In contrast, after BM infusion or SITx alone, chimerism was temporary and disappeared by day 100. Y-chromosome polymerase chain reaction (PCR) in sex-mismatched male BM plus female intestine or female BM plus male intestine transplantation into female recipients suggested that persistent macrochimerism was derived from infused BM. BM infusion together with lymphoid-depleted intestine grafts also supported macrochimerism development; however, third-party intestine grafts did not. After GFP-positive BM plus wild-type (WT) SITx into ACI, large numbers of GFP-positive leukocytes were found in WT intestine grafts. Isolated cells from WT intestine grafts developed GFP-positive CFU-Cs and propagated multilineage GFP-positive leukocytes when adoptively transferred into lethally irradiated WT recipients. These findings suggest that intestine allograft supports simultaneously infused donor (syngeneic to organ grafts) marrow stem cell engraftment, differentiation, and persistence of chimerism.

An inhibitor of cyclin-dependent kinase, stress-induced p21Waf-1/Cip-1, mediates hepatocyte mito-inhibition during the evolution of cirrhosis

During the evolution of cirrhosis, there is a relative decrease in volume percentage of hepatocytes and a relative increase in biliary epithelial cells and myofibroblasts. This is recognized histopathologically as a ductular reaction and leads to gradual distortion of the normal hepatic architecture. The final or decompensated stage of cirrhosis is characterized by a further decline in hepatocyte proliferation and loss of functional liver mass that manifests clinically as ascites, encephalopathy, and other signs of liver failure. In this report, we tested the hypothesis that p21-mediated hepatocyte mito-inhibition accelerates the evolution of cirrhosis using an established mouse model of decompensated biliary cirrhosis, p21-deficient mice, and liver tissue from humans awaiting liver replacement. Despite the same insult of long-term (12-week) bile duct ligation, mice prone to decompensation showed significantly more oxidative stress and hepatocyte nuclear p21 expression, which resulted in less hepatocyte proliferation, an exaggerated ductular reaction, and more advanced disease compared with compensation-prone controls. Mice deficient in p21 were better able than wild-type controls to compensate for long-term bile duct ligation because of significantly greater hepatocyte proliferation, which led to a larger liver mass and less architectural distortion. Mito-inhibitory hepatocyte nuclear p21 expression in humans awaiting liver replacement directly correlated with pathological disease stage and model of end-stage liver disease scoring. In conclusion, stress-induced upregulation of hepatocyte p21 inhibits hepatocyte proliferation during the evolution of cirrhosis. These findings have implications for understanding the evolution of cirrhosis and associated carcinogenesis. Supplementary material for this article can be found on the HEPATOLOGY website (http://interscience.wiley.com/jpages/0270-9139/suppmat/index.html).