Mapping of lymph node metastasis from esophageal squamous cell carcinoma after neoadjuvant treatment: a prospective analysis from a high-volume institution in China.

The study aimed to describe the prevalence of lymph node metastases per lymph node station for esophageal squamous cell carcinoma (ESCC) after neoadjuvant treatment. Clinicopathological variables of ESCC patients were retrieved from the prospective database of the Surgical Esophageal Cancer Patient Registry in West China Hospital, Sichuan University. A two-field lymphadenectomy was routinely performed, and an extensive three-field lymphadenectomy was performed if cervical lymph node metastasis was suspected. According to AJCC/UICC 8, lymph node stations were investigated separately. The number of patients with metastatic lymph nodes divided by those who underwent lymph node dissection at that station was used to define the percentage of patients with lymph node metastases. Data are also separately analyzed according to the pathological response of the primary tumor, neoadjuvant treatment regimens, pretreatment tumor length, and tumor location. Between January 2019 and March 2023, 623 patients who underwent neoadjuvant therapy followed by transthoracic esophagectomy were enrolled. Lymph node metastases were found in 212 patients (34.0%) and most frequently seen in lymph nodes along the right recurrent nerve (10.1%, 58/575), paracardial station (11.4%, 67/587), and lymph nodes along the left gastric artery (10.9%, 65/597). For patients with pretreatment tumor length of >4 cm and non-pathological complete response of the primary tumor, the metastatic rate of the right lower cervical paratracheal lymph nodes is 10.9% (10/92) and 10.6% (11/104), respectively. For patients with an upper thoracic tumor, metastatic lymph nodes were most frequently seen along the right recurrent nerve (14.2%, 8/56). For patients with a middle thoracic tumor, metastatic lymph nodes were most commonly seen in the right lower cervical paratracheal lymph nodes (10.3%, 8/78), paracardial lymph nodes (10.2%, 29/285), and lymph nodes along the left gastric artery (10.4%, 30/289). For patients with a lower thoracic tumor, metastatic lymph nodes were most frequently seen in the paracardial station (14.2%, 35/247) and lymph nodes along the left gastric artery (13.1%, 33/252). The study precisely determined the distribution of lymph node metastases in ESCC after neoadjuvant treatment, which may help to optimize the extent of lymphadenectomy in the surgical management of ESCC patients after neoadjuvant therapy.

Increased resected lymph node stations improved survival of esophageal squamous cell carcinoma.

BACKGROUND: Neoadjuvant chemoradiotherapy (nCRT) and surgery have been recommended as the standard treatments for locally advanced esophageal squamous cell carcinoma (ESCC). In addition, nodal metastases decreased in frequency and changed in distribution after neoadjuvant therapy. This study aimed to examine the optimal strategy for lymph node dissection (LND) in patients with ESCC who underwent nCRT. METHODS: The hazard ratios (HRs) for overall survival (OS) and disease-free survival (DFS) were calculated using the Cox proportional hazard model. To determine the minimal number of LNDs (n-LNS) or least station of LNDs (e-LNS), the Chow test was used. RESULTS: In total, 333 patients were included. The estimated cut-off values for e-LNS and n-LNS were 9 and 15, respectively. A higher number of e-LNS was significantly associated with improved OS (HR: 0.90; 95% CI 0.84-0.97, P = 0.0075) and DFS (HR: 0.012; 95% CI: 0.84-0.98, P = 0.0074). The e-LNS was a significant prognostic factor in multivariate analyses. The local recurrence rate of 23.1% in high e-LNS is much lower than the results of low e-LNS (13.3%). Comparable morbidity was found in both the e-LNS and n-LND subgroups. CONCLUSION: This cohort study revealed an association between the extent of LND and overall survival, suggesting the therapeutic value of extended lymphadenectomy during esophagectomy. Therefore, more lymph node stations being sampled leads to higher survival rates among patients who receive nCRT, and standard lymphadenectomy of at least 9 stations is strongly recommended.

Impact of deep muscle invasion on nodal status and survival in patients with pT2 esophageal squamous cancer.

BACKGROUND: Whether T2 esophageal squamous cell carcinoma should be subclassified remains controversial. We aimed to investigate the impact of the depth of muscularis propria invasion on nodal status and survival outcomes. METHODS: We identified patients with pT2 esophageal squamous cell carcinoma who underwent primary surgery from January 2009 to June 2017. Clinical data were extracted from prospectively maintained databases. Tumor muscularis propria invasion was stratified into superficial or deep. Binary logistic regression was used to determine risk factors for lymph node metastases. The impact of the depth of muscularis propria invasion on survival was investigated using Kaplan‒Meier analysis and a Cox proportional hazard regression model. RESULTS: A total of 750 patients from three institutes were investigated. The depth of muscularis propria invasion (odds ratio [OR]: 3.95, 95% confidence interval [CI]: 2.46-6.35; p < 0.001) was correlated with lymph node metastases using logistic regression. T substage (hazard ratio [HR]: 1.37, 95% CI: 1.05-1.79; p < 0.001) and N status (HR: 1.51, 95% CI: 1.05-2.17; p < 0.001) were independent risk factors in multivariate Cox regression analysis. The deep muscle invasion was associated with worse overall survival (HR: 1.52, 95% CI: 1.19-1.94; p = 0.001) than superficial, specifically in T2N0 patients (HR: 1.38, 95% CI: 1.08-1.94; p = 0.035). CONCLUSIONS: We found that deep muscle invasion was associated with significantly worse outcomes and recommended the substaging of pT2 esophageal squamous cell carcinoma in routine pathological examination.

Vitamin D receptor induces oxidative stress to promote esophageal squamous cell carcinoma proliferation via the p53 signaling pathway.

Background: Esophageal squamous cell carcinoma (ESCC) is a common pathological esophageal cancer with poor prognosis. Vitamin D deficiency reportedly occurs in ESCC patients, and this is related to single nucleotide polymorphism of vitamin D receptor (VDR). Objective: We investigated the effect of VDR on ESCC proliferation, invasion, and metastasis and its potential mechanism. Methods: ESCC and normal tissues were collected from 20 ESCC patients. The ESCC tissue microarray contained 116 pairs of ESCC and normal tissues and 73 single ESCC tissues. VDR expression and its clinicopathological role were determined by real-time quantitative polymerase chain reaction, Western blot, and immunohistochemistry staining. sh-VDR and VDR overexpression were used to validate the effect of VDR on ESCC cell phenotype, and tandem mass tag-based quantitative proteomics and bioinformatics methods identified differential VDR-related proteins. The downstream pathway and regulatory effect were analyzed using ingenuity pathway analysis (IPA). Differentially expressed proteins were verified through parallel reaction monitoring and Western blot. In vivo imaging visualized subcutaneous tumor growth following tail vein injection of VDR-deficient ESCC cells. Results: High VDR expression was observed in ESCC tissues and cells. Gender, T stage, and TNM stage were related to VDR expression, which was the independent prognostic factor related to ESCC. VDR downregulation repressed ESCC cell proliferation, invasion, and migration in vitro and subcutaneous tumor growth and lung metastases in vivo. The cell phenotype changes were reversed upon VDR upregulation, and differential proteins were mainly enriched in the p53 signaling pathway. TP53 cooperated with ABCG2, APOE, FTH1, GCLM, GPX1, HMOX1, JUN, PRDX5, and SOD2 and may activate apoptosis and inhibit oxidative stress, cell metastasis, and proliferation. TP53 was upregulated after VDR knockdown, and TP53 downregulation reversed VDR knockdown-induced cell phenotype changes. Conclusions: VDR may inhibit p53 signaling pathway activation and induce ESCC proliferation, invasion, and metastasis by activating oxidative stress.

The prognostic impact of preoperative body mass index changes for patients with esophageal squamous cell carcinoma who underwent esophagectomy: A large-scale long-term follow-up cohort study.

Background: This study aims to investigate the relationship between preoperative body mass index changes (ΔBMI) and prognosis in patients with esophageal squamous cell carcinoma who underwent esophagectomy. Methods: We identified 1,883 patients with esophageal squamous cell carcinoma who underwent curative resection in our department between January 2005 and December 2013. Patients were grouped into a stable body mass index (ΔBMI = 0) group and a decreased body mass index (ΔBMI < 0) group. Risk factors for ΔBMI were assessed using logistic regression analysis. The impact of ΔBMI on survival was investigated using Kaplan-Meier curves and Cox regression. A nomogram for survival prediction was constructed and validated. Results: The results showed that T stage (OR: 1.30, 95% CI: 1.16-1.45, P < 0.001) and N stage (OR: 1.24, 95% CI: 1.11-1.38, P < 0.001) were independent risk factors for ΔBMI. The ΔBMI < 0 group had worse overall survival than the stable body mass index group (HR: 1.25, 95% CI: 1.08-1.44, P = 0.002). When stratified by stage, ΔBMI had the greatest prognostic impact in stage I tumors (HR: 1.82, 95%: 1.05-3.15, P = 0.033). In addition, multiple comparisons showed that decreasing ΔBMI correlated with worse prognosis. The ΔBMI-based nomogram presented good predictive ability with a C-index of 0.705. Conclusion: This study demonstrates that ΔBMI < 0 had an adverse impact on the long-term survival of patients with esophageal squamous cell carcinoma undergoing esophagectomy. These results may support further investigation of preoperative nutrition support.

Is Tumor Regression Grade Sufficient to Predict Survival in Esophageal Cancer with Trimodal Therapy?

BACKGROUND: This study aimed to assess the predictive value of tumor regression grade (TRG) and nodal status on survival in esophageal carcinoma with neoadjuvant chemoradiotherapy (nCRT). METHODS: Tumor pathologic regression and nodal status were assessed. Differences in survival stratified by TRG or nodal status were analyzed using the Kaplan-Meier method and log-rank test. The prognostic value of TRG and nodal status were analyzed using univariate and multivariate Cox proportional hazards methods. RESULTS: From July 2016 to June 2019, 253 patients with esophageal cancer underwent nCRT followed by surgery. Significant differences were presented in survival according to nodal status but not TRG. Multivariate analysis showed that nodal status and not TRG was the only independent predicter for overall survival (HR: 3.550, 95% CI: 2.264-5.566, P < 0.001) and disease-free survival (HR: 2.801, 95% CI: 1.874-4.187, P < 0.001). The modified TRG system combining tumor regression with nodal status stratified patients survival with good discrimination. CONCLUSIONS: Lymph node status impacts more importantly than TRG on survival for patients with esophageal cancer undergoing nCRT plus esophagectomy. The modified TRG system may facilitate postoperative treatment decisions and survival surveillance.

Effect of circumferential resection margin status on survival and recurrence in esophageal squamous cell carcinoma with neoadjuvant chemoradiotherapy.

Background: The aim of this study was to investigate whether circumferential resection margin (CRM) status has an impact on survival and recurrence in esophageal squamous cell carcinoma after neoadjuvant chemoradiotherapy. Methods: We screened patients with esophageal squamous cell carcinoma who underwent esophagectomy from January 2017 to December 2019. The CRM was reassessed. Patients were grouped into a CRM of 1 mm or less (0 < CRM ≤ 1 mm) and a CRM greater than 1 mm (CRM>1 mm). The impact of CRM on survival was investigated using Kaplan-Meier analysis and Cox regression modeling. The optimal CRM cut point was evaluated using restricted cubic spline curve. Results: A total of 89 patients were enrolled in this study. The CRM status was an independent risk factor for the prognosis (HR: 0.35, 95% CI: 0.16-0.73). Compared with a CRM of 1 mm or less, a CRM greater than 1 mm had better overall survival (HR: 0.35, 95% CI: 0.16-0.73, log-rank P = 0.011), longer disease-free survival (HR: 0.51, 95% CI: 0.27-0.95, log-rank P = 0.040), and less recurrence (HR: 0.44, 95% CI: 0.23-0.85, log-rank P = 0.015). We visualized the association between CRM and the hazard ratio of survival and identified the optimal cut point at 1 mm. Conclusions: A CRM greater than 1 mm had better survival and less recurrence compared to a CRM of 1 mm or less. A more radical resection with adequate CRM could benefit survival in patients with esophageal squamous cell carcinoma after neoadjuvant therapy.

Limited-stage small cell carcinoma of the esophagus treated with curative esophagectomy: A multicenter retrospective cohort study.

BACKGROUND: This study aimed to investigate the efficacy of surgery in the treatment of small cell carcinoma of the esophagus (SCCE) and explore potential prognostic factors. METHODS: We screened patients with SCCE who underwent esophagectomy from 2010 to 2018 at three institutes. Differences in survival were analyzed using the Kaplan-Meier method and log-rank test. The prognostic factors were identified using univariate and multivariate analyses. RESULTS: A total of 69 patients were included. Multivariate analysis showed that TNM stage (hazard ratio [HR]: 4.10, 95% confidence interval [CI]: 1.57-10.75, p = 0.004) and adjuvant therapy (HR: 0.28, 95% CI: 0.16-0.51, p < 0.001) were independent prognostic factors. Stage I, stage IIA, and stage IIB disease were merged into the surgery response disease (SRD), whereas stage III disease into the surgery nonresponse disease (SNRD). The SRD group had significantly improved survival compared to the SNRD group (HR: 0.33, 95% CI: 0.19-0.58, p < 0.001). In addition, adjuvant therapy increased survival benefit in the SNRD group (p < 0.001) but not in the SRD group (p = 0.061). CONCLUSIONS: Surgery alone appears to be adequate for disease control in the SRD group, whereas multimodality therapy was associated with improved survival in the SNRD group.

The minimum number of examined lymph nodes for accurate nodal staging and optimal survival of stage T1-2 esophageal squamous cell carcinoma: A retrospective multicenter cohort with SEER database validation.

BACKGROUND: The extent of lymphadenectomy during esophagectomy remains controversial for patients with T1-2 ESCC. The aim of this study was to identify the minimum number of examined lymph node (ELN) for accurate nodal staging and overall survival (OS) of patients with T1-2 esophageal squamous cell carcinoma (ESCC). MATERIALS AND METHODS: Patients with T1-2 ESCC from three institutes between January 2011 and December 2020 were retrospectively reviewed. The associations of ELN count with nodal migration and OS were evaluated using multivariable models, and visualized by using locally weighted scatterplot smoothing (LOWESS). Chow test was used to determine the structural breakpoints of ELN count. External validation in the SEER database was performed. RESULTS: In total, 1537 patients were included. Increased ELNs was associated with an increased likelihood of having positive nodal disease and incremental OS. The minimum numbers of ELNs for accurate nodal staging and optimal survival were 14 and 18 with validation in the SEER database (n = 519), respectively. The prognostic prediction ability of N stage was improved in the group with ≥14 ELNs compared with those with fewer ELNs (iAUC, 0.70 (95%CI 0.66-0.74) versus 0.61(95%CI 0.57-0.65)). The higher prognostic value was found for patients with ≥18 ELNs than those with <18 ELNs (iAUC, 0.78 (95%CI 0.74-0.82) versus 0.73 (95%CI 0.7-0.77)). CONCLUSION: The minimum numbers of ELNs for accurate nodal staging and optimal survival of stage T1-2 ESCC patients were 14 and 18, respectively.

Short- and Long-Term Outcomes of Totally Versus Hybrid Minimally Invasive Ivor Lewis Oesophagectomy for Oesophageal Cancer: A Propensity Score-Matched Analysis.

Background: Few objective studies have compared totally minimally invasive Ivor Lewis oesophagectomy with hybrid procedure. Here we investigated whether the choice between totally and hybrid minimally invasive Ivor Lewis oesophagectomy influenced short-term outcomes and long-term patient survival. Methods: Patients who underwent totally or hybrid minimally invasive Ivor Lewis oesophagectomy between January 2014 and December 2017 were propensity score matched in a 1:1 ratio. The short- and long-term outcomes between the two groups were compared before and after matching. Results: Of 138 totally and 156 hybrid minimally invasive oesophagectomy patients were eligible, 104 patients from each group were propensity score matched. Totally minimally invasive oesophagectomy was associated significantly with less blood loss (median(IQR) 100(60-150) vs 120(120-200) ml respectively; P < 0.001), pneumonia (13.5 vs 25.0%; P = 0.035), pleural effusion (3.8 vs 13.5%; P = 0.014), and chest drainage (7.5(6-9) vs 8(7-9) days; P = 0.009) than hybrid procedure. There was no significant difference in 3-year overall survival rate and 3-year disease-free survival rate between the two group. Conclusions: Totally minimally invasive Ivor Lewis oesophagectomy may improve short-term outcomes and specifically reduce the incidence of pulmonary complications compared with hybrid procedure. The long-term overall survival and disease-free survival rates between the two groups were similar.

Safety and Feasibility of Esophagectomy Following Neoadjuvant Immunotherapy Combined with Chemotherapy for Esophageal Squamous Cell Carcinoma.

Background: This study aimed to investigate the safety and feasibility of esophagectomy after neoadjuvant immunotherapy and chemotherapy for esophageal squamous cell carcinoma. Methods: We retrospectively identified patients who received neoadjuvant immunotherapy combined with chemotherapy (n = 38) in our center between 2020 and 2021. The primary end point was the risk of major complications (grade ≥3) according to the Clavien-Dindo classification. Secondary end points were surgical details, 30-day mortality, and 30-day readministration. Results: The most commonly used regimens of immunotherapy were camrelizumab (36.8%), pembrolizumab (31.5%), tislelizumab (15.8%), sintilimab (13.2%), and toripalimab (2.6%). The median interval to surgery was 63 days (range, 40-147). Esophagectomy was performed in 37 of 38 patients who received neoadjuvant immunotherapy and chemotherapy. All procedures were performed minimally invasively, except for 1 patient who was converted to thoracotomy. Of 37 surgical patients, R0 resection was achieved in 36 patients (97.3%). Pathologic complete response was observed in 9 patients (24.3%). Tumor regression grade I was identified in 17 patients (45.9%). Morbidity occurred in 12 of 37 patients (32.4%). The most common complication was pneumonia (16.2%). There were no deaths or readministration within 30 days. Conclusions: Esophagectomy following neoadjuvant immune checkpoint inhibitor plus chemotherapy for patients with resectable esophageal squamous cell carcinoma appears to be safe and feasible, with acceptable complication rates.

Surgical Treatment for Persistent Cervical Anastomotic Fistulas With Sinus Formation.

A refractory cervical anastomotic fistula with sinus formation will seriously impede a patient's return to normal life. It is necessary to find ways to shorten the recovery time for such patients. We used a multilayered, pursestring inverted suture-embedding method for 7 patients, 6 of whom recovered; 1 patient with severe anastomotic stricture and failed. A multilayered, pursestring inverted suture-embedding method can be used to treat persistent neck anastomotic fistula with sinus formation, but it is not suitable for patients who still have a fistula to the mediastinum, thoracic cavity, or severely narrowed anastomoses.

Rare location and drainage pattern of right pulmonary veins and aberrant right upper lobe bronchial branch: A case report.

BACKGROUND: Complex aberration in lung is rare, which may increase risk of vascular injury and cause ligation of wrong pulmonary vein or bronchus by mistake during lung surgery, and result in sever complication like pulmonary congestion or atelectasis. CASE SUMMARY: A 44-year-old female was admitted for a ground glass nodule (24 mm in diameter) in her right upper lobe. Video-assisted thoracoscopic (VATS) right upper lobectomy with lymph nodes dissection was performed. During operation, we simultaneously identified extremely rare aberrations of right preeparterial bronchus, right upper lobe vein behind pulmonary artery and right middle lobe vein drained into left atrium in this patient. The patient was well recovered and discharged at the postoperative-day 4. CONCLUSION: Preoperatively, three-dimensional reconstruction can help to identify inconspicuous variation of pulmonary vessels and bronchus effectively. During lung surgery, if anatomic aberration is suspected, careful dissection of vessels and bronchus will help to confirm whether there is an aberration or not.

Effectiveness of Transthoracic Hybrid Minimally Invasive Esophagectomy: A Meta-Analysis.

BACKGROUND: Transthoracic hybrid minimally invasive esophagectomy (HMIE) is frequently performed in patients with esophageal cancer. However, no conclusive benefit has been defined for HMIE compared with open esophagectomy (OE) or totally MIE (TMIE). The aim of this meta-analysis is to evaluate the effectiveness of HMIE compared with OE and TMIE. METHODS: PubMed, Embase (via OVID) and Cochrane databases were comprehensively searched for relevant studies up to January 2019. Studies comparing the efficacy of transthoracic HMIE with OE or TMIE were included in this meta-analysis. RESULTS: Twenty-nine relevant studies comprising 3994 patients were identified and included in the analysis of HMIE vs OE. HMIE decreased the incidence of postoperative total morbidity (OR = 0.66, 95% CI 0.55 to 0.80, p = 0.00), pneumonia (OR = 0.55, 95% CI 0.45 to 0.66, p = 0.00), in-hospital mortality (OR = 0.54, 95% CI 0.36 to 0.83, p = 0.01), duration of hospitalization (SMD=-1.03, 95% CI -1.73 to -0.33, p = 0.00) and the estimated intraoperative blood loss (SMD=-1.01, 95% CI -1.62 to -0.40, p = 0.00) compared with OE. Twenty-one relevant studies comprising 3007 patients were identified and included in the analysis of HMIE vs TMIE. HMIE increased estimated intraoperative blood loss [standardized mean difference (SMD) = 1.02, 95% CI 0.45 to 1.58, p = 0.00] and the incidence of postoperative pneumonia (OR = 1.69, 95% CI 1.26 to 2.26, p = 0.00) compared with TMIE. No statistical differences were observed for other surgical outcomes. CONCLUSIONS: In our opinion, HMIE is a promising surgical technique. But further RCTs are still needed to confirm the advantages and disadvantages of HMIE mentioned above.

Timing of surgery after neoadjuvant chemoradiotherapy affects oncologic outcomes in patients with esophageal cancer.

BACKGROUND: The optimal time interval between neoadjuvant chemoradiotherapy (nCRT) and esophagectomy in esophageal cancer has not been defined. AIM: To evaluate whether a prolonged time interval between the end of nCRT and surgery has an effect on survival outcome in esophageal cancer patients. METHODS: We searched PubMed, Embase, Web of Science, the Cochrane Library, Wanfang and China National Knowledge Infrastructure databases for relevant articles published before November 16, 2019, to identify potential studies that evaluated the prognostic role of different time intervals between nCRT and surgery in esophageal cancer. The hazard ratios and 95% confidence intervals (95%CI) were merged to estimate the correlation between the time intervals and survival outcomes in esophageal cancer, esophageal squamous cell carcinoma and adenocarcinoma using fixed- and random-effect models. RESULTS: This meta-analysis included 12621 patients from 16 studies. The results demonstrated that esophageal cancer patients with a prolonged time interval between the end of nCRT and surgery had significantly worse overall survival (OS) [hazard ratio (HR): 1.107, 95%CI: 1.014-1.208, P = 0.023] than those with a shorter time interval. Subgroup analysis showed that poor OS with a prolonged interval was observed based on both the sample size and HRs. There was also significant association between a prolonged time interval and decreased OS in Asian, but not Caucasian patients. In addition, a longer wait time indicated worse OS (HR: 1.385, 95%CI: 1.186-1.616, P < 0.001) in patients with adenocarcinoma. CONCLUSION: A prolonged time interval from the completion of nCRT to surgery is associated with a significant decrease in OS. Thus, esophagectomy should be performed within 7-8 wk after nCRT.

Clinical and prognostic effects of adjuvant therapy on less advanced esophageal squamous cell carcinoma patients.

BACKGROUND: This study aimed to clarify whether adjuvant therapy is suitable for less advanced esophageal squamous cell carcinoma (ESCC) patients postoperatively. METHODS: Data from 973 patients were collected. The prognosis and clinicopathological traits of these patients were calculated in both the TNM I and IIA stages. Meanwhile, 2 separate nomograms were applied in terms of the variables with a multivariate P value <0.05 in the Cox proportional hazard regression model. RESULTS: There were 471 and 502 patients in the I and IIA stage respectively; among all enrolled patients, 641, 130, 73, and 129 patients were in the no-treatment, chemotherapy, radiotherapy, and chemoradiotherapy groups, respectively. Adjuvant therapy was drawn as the independent prognostic factors for stage I (P=0.026; HR =1.081, 95% CI: 1.093, 1.308) and IIA patients (P<0.001; HR =0.788, 95% CI: 0.693, 0.896). Radiotherapy consistently obtained the best prognosis for patients when compared with the other 3 groups in the I and IIA stage. Patients in I stage had the worst prognosis after receiving chemoradiotherapy, and still, the small survival benefits of chemoradiotherapy were seen in patients of IIA stage. Two separate nomograms for the I and IIA stage were constructed. The C-index was 0.665 (95% CI: 0.569, 0.761) in the I stage and 0.645 (95% CI: 0.567, 0.723) in the IIA stage. Meanwhile, the calibration curves for predicting 3-year and 5-year survival for I and IIA patients agreed well with the actual observations. CONCLUSIONS: Among less advanced ESCC patients, adjuvant therapy was not only found to be an independent factor but also proved to be of importance in patient prognosis, and radiotherapy is recommended.

Prognostic value of preoperative weight loss-adjusted body mass index on survival after esophagectomy for esophageal squamous cell carcinoma.

BACKGROUND: The impact of body mass index (BMI) on survival in patients with esophageal squamous cell carcinoma (ESCC) undergoing surgery remains unclear. Therefore, a definition of clinically significant BMI in patients with ESCC is needed. AIM: To explore the impact of preoperative weight loss (PWL)-adjusted BMI on overall survival (OS) in patients undergoing surgery for ESCC. METHODS: This retrospective study consisted of 1545 patients who underwent curative resection for ESCC at West China Hospital of Sichuan University between August 2005 and December 2011. The relationship between PWL-adjusted BMI and OS was examined, and a multivariate analysis was performed and adjusted for age, sex, TNM stage and adjuvant therapy. RESULTS: Trends of poor survival were observed for patients with increasing PWL and decreasing BMI. Patients with BMI ≥ 20.0 kg/m2 and PWL < 8.8% were classified into Group 1 with the longest median OS (45.3 mo). Patients with BMI < 20.0 kg/m2 and PWL < 8.8% were classified into Group 2 with a median OS of 29.5 mo. Patients with BMI ≥ 20.0 kg/m2 and PWL ≥ 8.8% (HR = 1.9, 95%CI: 1.5-2.5), and patients with BMI < 20.0 kg/m2 and PWL ≥ 8.8% (HR = 2.0, 95%CI: 1.6-2.6), were combined into Group 3 with a median OS of 20.1 mo. Patients in the three groups were associated with significantly different OS (P < 0.05). In multivariate analysis, PWL-adjusted BMI, TNM stage and adjuvant therapy were identified as independent prognostic factors. CONCLUSION: PWL-adjusted BMI has an independent prognostic impact on OS in patients with ESCC undergoing surgery. BMI might be an indicator for patients with PWL < 8.8% rather than ≥ 8.8%.

Massive malignant solitary fibrous tumor of the diaphragm: A case report.

INTRODUCTION: Malignant solitary fibrous tumor (MSFT) of the diaphragm is extremely rare, and to the best of our knowledge, only three cases have been reported in the past two decades. In all these cases, the diaphragms were usually reconstructed with artificial diaphragm patch because of the extensive resection. PATIENT CONCERNS: We reported a male patient with complaints of dyspnea, chest pain and massive pleural effusion in the left chest detected by chest X-ray. A huge mass of 20 × 20 cm was seen in the left lower chest in the computed tomography (CT) scan. DIAGNOSIS: The diagnosis of MSFT originating in the diaphragm was made by post-operative immunohistochemical examination. INTERVENTIONS: After draining 4000 ml of pleural effusion by Pleurx catheter to relieve the pressure symptom, the patient underwent en-block resection by left posterolateral thoracotomy. A pedicle tumor originating in the left diaphragm was found, which was smooth, lobular, did not invade surrounding tissues or organs, and received blood supply from the left phrenic vessels. The diaphragm was successfully sutured without tension and did not require artificial reconstruction as the defect was small. OUTCOMES: After 2 months follow-up, the left lung was restored to normalcy, and no pleural effusion or new occupying neoplasm was found in follow-up CT.