Salvage Esophagectomy Definition Influences Comparative Outcomes in Esophageal Squamous Cell Cancers

BACKGROUND

In retrospective studies, the definition of salvage esophagectomy has been inconsistent and is a source of bias. We sought to describe how variability in the definition of salvage affects comparative outcomes of TMT and BMT therapy.

METHODS

Patients with locally advanced esophageal squamous cell carcinoma who completed chemoradiation (CRT) from 2002-2017 were identified. TMT included patients who had a planned esophagectomy after CRT. BMT included patients treated with CRT only, plus salvage esophagectomy, variably defined as an esophagectomy occurring either A) 3 months after CRT; B) 3 months after CRT, excluding delayed recovery; C) 3 months after CRT, excluding delayed work-up; or D) 6 months after CRT. Long-term survival outcomes between the TMT and BMT groups were compared for each definition of salvage esophagectomy. Time to surgery was included a priori in a multivariable model for overall survival.

RESULTS

The study included 143 patients. Ninety (63%) underwent esophagectomy; 53(37%) received CRT only. While the total patients remained the same, the composition of the TMT and BMT groups varied by salvage definitions A-D. Various definitions resulted in different 5-year survival rates for TMT vs. BMT groups. A), 56% vs. 39%; B), 61% vs. 34%; C), 50% vs. 42%; and D), 51% vs. 39%. In a Cox multivariable analysis, age and proximal/middle esophageal tumors were associated with worse post-operative survival, but time to surgery was not.

CONCLUSIONS

Slight variations in the definition of salvage esophagectomy can influence the interpretation of TMT and BMT outcomes. Future studies should consistently define treatment groups.

Conversion between Mini-Mental State Examination and Montreal Cognitive Assessment scores in older adults undergoing selective surgery using Rasch analysis

AIMS

To develop and validate a conversion table between the MMSE and the MoCA using Rasch analysis in older adults undergoing selective surgery and examine its diagnostic accuracy in detecting cognitive impairment.

DESIGN

Cross-sectional study.

METHODS

Older patients [N = 129; age 66.0 (4.6) years, education 7.7 (3.5) years] undergoing elective surgery were recruited from December 2017 to June 2018. All participants completed the MMSE and MoCA and 113 of them completed a battery of neuropsychological tests. Common person linking based on Rasch analysis was performed to develop the conversion table. The conversions were validated by calculating the intraclass correlation coefficient (ICC), score differences between actual and converted scores, and root mean squared error of the difference (RMSE). The diagnostic accuracy of the conversions for detecting cognitive impairment was also tested.

RESULTS

The MoCA [person measure: 1.3 (1.1) logits] was better targeted to the patients than the MMSE [person measure: 3.2 (1.3) logits]. Conversion from MoCA to MMSE scores (ICC 0.84, 95% CI 0.77-0.88; RMSE 1.36) was more precise than conversion from MMSE to MoCA (ICC 0.82, 95% CI 0.75-0.87; RMSE 2.56). Conversion from MoCA to MMSE demonstrated better diagnostic accuracy in detecting cognitive impairment than the actual MMSE, whereas conversion from MMSE to MoCA exhibited the opposite pattern.

CONCLUSION

Conversion from MoCA to MMSE was more precise and had better diagnostic accuracy in detecting pre-operative cognitive impairment in older patients undergoing selective surgery than conversion from MMSE into MoCA.

IMPACT

The finding is useful for interpreting, comparing, and integrating cognitive measurements in surgical settings and clinical research. Statistically sound conversion between MoCA and MMSE based on Rasch analysis is now possible for surgical setting and clinical research.

Compartmental Strabismus

Recent reports confirm innervational compartments of select rectus extraocular muscles as well as the superior oblique.¹ Histopathological and orbital imaging studies demonstrate well defined compartmental innervation of the horizontal rectus muscles with less differentiation in the vertical rectus muscles. Acquired vertical misalignment not associated with cyclovertical muscle dysfunction has been associated with horizontal rectus muscle compartment dysfunction. Pattern and other forms of strabismus have been associated with segmental or compartmental abnormal innervation of the extraocular muscles. Taking advantage of segmental function and innervation, selective weakening and strengthening procedures have been used to treat patients with incomitant near/distance disparities, incomitant vertical and torsional strabismus, and patients with A- and V-pattern strabismus.

Surgery is an essential component of multimodality therapy for patients with locally advanced esophageal adenocarcinoma

BACKGROUND

Experience with neoadjuvant chemoradiation (CXRT) has raised questions regarding the additional benefit of surgery after locally advanced esophageal adenocarcinoma patients achieve a clinical response to CXRT. We sought to quantify the value of surgery by comparing the overall (OS) and disease-free survival (DFS) of trimodality-eligible patients treated with definitive CXRT vs. CXRT followed by esophagectomy.

METHODS

We identified 143 clinical stage III esophageal adenocarcinoma patients that were eligible for trimodality therapy. All patients successfully completed neoadjuvant CXRT and were considered appropriate candidates for resection. Patients that were medically inoperable were excluded. Cox regression models were used to identify significant predictors of survival.

RESULTS

Among the 143 patients eligible for surgery after completing CXRT, 114 underwent resection and 29 did not. Poorly differentiated tumors (HR = 2.041, 95% CI = 1.235-3.373) and surgical resection (HR = 0.504, 95% CI = 0.283-0.899) were the only independent predictors of OS. Patients treated with surgery had a 50 and 54 % risk reduction in overall and cancer-specific mortality, respectively. Median OS (41.2 vs. 20.3 months, p = 0.012) and DFS (21.5 vs. 11.4 months, p = 0.007) were significantly improved with the addition of surgery compared to definitive CXRT.

CONCLUSIONS

Surgery provides a significant survival benefit to trimodality-eligible esophageal adenocarcinoma patients with locally advanced disease.

Utilization of surgery in trimodality-eligible patients with locally advanced esophageal adenocarcinoma in a nonprotocol setting

Trimodality therapy with neoadjuvant chemoradiation followed by surgery significantly improves the survival of locally advanced (clinical stage IIA-III) esophageal cancer patients compared to treatment with surgery alone. This has resulted in an increased use of neoadjuvant therapy in recent years, yet little is known regarding how this increase has impacted the utilization of surgery in the treatment of locally advanced disease. Although previous reports of experimental protocols suggest that 90-95% of patients complete trimodality therapy including a surgical resection, trimodality therapy completion among adenocarcinoma patients eligible for curative resection has not been evaluated in a nonprotocol setting. We sought to (i) assess the completion of trimodality therapy among locally advanced esophageal adenocarcinoma patients; (ii) characterize the reasons for avoiding surgery; and (iii) identify factors associated with failure to complete trimodality therapy. We identified 296 patients with locally advanced esophageal adenocarcinoma eligible for trimodality therapy at our institution. All patients were evaluated in a multidisciplinary setting and considered eligible for curative resection after initial staging and physiologic assessment. Multivariable logistic regression was used to identify factors associated with failure to complete trimodality therapy. Of 296 trimodality-eligible patients, 33% (97/296) did not complete trimodality therapy. Reasons for not undergoing surgery included patient choice (27.8%, 27/97), distant progression of disease during chemoradiation (23.7%, 23/97), and physician preference for surveillance (23.7%, 23/97). In addition, 17.5% (17/97) of patients had physical deterioration in performance status, and treatment-related deaths occurred in 7.2% (7/97) prior to surgery. In the total study population (n = 296), multivariable logistic regression identified older age (≥70 years: odds ratio [OR] = 6.611, 95% confidence interval [CI]: 2.900-15.071), pretreatment standard uptake value (6.8-10.1: OR = 2.393, 95% CI: 1.050-5.455; ≥15.8: OR = 3.623, 95% CI: 1.604-8.186), and a radiation dose of 50.4 Gy (OR = 5.312, 95% CI: 2.365-11.929) as being significantly associated with failure to complete trimodality therapy. Among the subgroup of patients that successfully completed chemoradiation (n = 266), older patients (≥70 years: OR = 9.606, 95% CI: 3.637-25.372), those with a comorbidity score of 2 or higher (OR = 4.059, 95% CI: 1.257-13.103), and those that received a radiation dose of 50.4 Gy (OR = 4.878, 95% CI: 1.974-12.054) were at a significantly higher risk of not completing trimodality therapy. Trimodality therapy completion among patients with locally advanced esophageal adenocarcinoma in a nonprotocol setting is considerably lower than what has previously been reported in clinical trials. Our findings suggest that a selective approach to surgery is commonly utilized in clinical practice. Trimodality-eligible patients that are older and have a higher comorbidity score are at risk for not completing trimodality therapy.