Proposal of New ypStage Grouping System for Esophageal Squamous Cell Carcinoma Patients who Underwent Neoadjuvant Chemoradiotherapy followed by Surgery.

OBJECTIVE: To propose a new ypTNM grouping system to address these limitations and improve prognostic relevance. SUMMARY BACKGROUND DATA: The current 8th edition of the American Joint Committee on Cancer (AJCC) ypStage system shows unsatisfactory prognostic relevance in patients with esophageal squamous cell carcinoma (ESCC) treated with neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy. METHODS: The study cohort included 501 ESCC patients who received nCRT followed by esophagectomy at the Samsung Medical Center in Korea between 1994 and 2018 (development cohort) and 422 patients treated at Asan Medical Center (validation cohort). Recursive partitioning with a tree-structured regression model was used to develop and validate a new ypStage grouping system. RESULTS: In the new ypStage grouping system, ypStage I includes ypT0N0 only; ypStage II includes ypTis-T2N0 or ypT0-T2N1; ypStage III includes ypT3N0-N1; and ypStage IV includes ypT4N0-N1 or ypTanyN2-3. This system adequately addressed the limitations of the existing AJCC classification system, including overlapping and reversal of survival rates. Moreover, the discrimination ability of the new system was higher than that of the existing system [concordance-index (C-index): 61.9%] in the development (C-index: 66.6%) and validation (C-index: 66.0%) cohorts. NRIe was 0.17 [95% confidence interval (CI): 0.09-0.26, P-<0.001) and 0.18 (95% CI: 0.10-0.27, P-<0.001)] in the development and validation cohorts, respectively. CONCLUSIONS: The current study proposes a clear revised version of the 8th edition of the AJCC ypStage grouping system that exhibits superior prognostic stratification in patients with ESCC treated with nCRT followed by esophagectomy.

Clinical and Pathologic Supraclavicular Lymph Node Metastases in Esophageal Squamous Cell Carcinoma Treated by Esophagectomy with Three-Field Lymph Node Dissection.

BACKGROUND: This study investigated the survival outcomes for surgically treated esophageal squamous cell carcinoma (ESCC) patients based on clinically suspicious supraclavicular lymph node (SCN) metastasis (cSCN+) and pathologically confirmed SCN metastasis (pSCN+). METHODS: Using an institutional registry between 1994 and 2018, this study retrospectively analyzed 611 patients who received curative-intent esophagectomy with 3-field lymph node dissection for ESCC. The study used computed tomography and positron emission tomography to define cSCN+. RESULTS: Among 611 patients, 24.4% had cSCN+ and 12.2% had pSCN+. The 5-year overall survival (OS) rates were 68.2% for cN0, 43.5% for cN+ without cSCN+, and 30.3% for cN+ with cSCN+ (p = 0.018). Although the univariable analysis showed that cSCN+ was associated with poorer survival than cN0 or cN+ with cSCN- (hazard ratio [HR], 1.818; p < 0.001), the multivariable analysis did not support this finding (HR, 1.281; p = 0.681). The 5-year OS rates were 64.2% for pN0, 41.5% for pN+ without pSCN+, and 25.6% for pN+ with pSCN+ (p = 0.054). Univariable analysis showed an association of pSCN+ with poor OS (HR, 1.830; p < 0.001), but the difference in the multivariable analysis was not significant (HR, 0.912; p = 0.587). CONCLUSIONS: The presence of SCN metastasis did not have a significant impact on the OS of ESCC patients with 3-field lymph node dissection regardless of clinical suspicion or pathologic confirmation.

Comparison of the Oncologic Outcomes for Patients with Middle to Lower Esophageal Squamous Cell Carcinoma Undergoing Surgical Treatment Using the Ivor-Lewis or McKeown Operation.

BACKGROUND: The upper mediastinum is the most common metastatic site of esophageal squamous cell carcinoma (ESCC), and complete dissection of this region is important for oncologic reasons. This study aimed to compare the oncologic outcomes and completeness of upper mediastinal dissection for ESCC patients undergoing the Ivor-Lewis (IL) or McKeown (MK) operations. METHODS: Between 2013 and 2018, 680 patients (IL, 433; MK, 247) underwent upfront esophagectomy with two-field lymph node (LN) dissection for mid-to-lower ESCCs. Propensity score-matching (1:1 ratio) was performed to minimize the effects of confounding factors. RESULTS: The mean age was 64.5 ± 8.8 years, and 635 (93.4%) of the patients were male. The median follow-up period was 71.66 months (interquartile range [IQR], 59.60-91.04 months). The IL group had a higher mean age, lower body mass index, higher proportion of advanced T and N, and higher adjuvant therapy rates, but these differences were well-balanced after propensity score-matching. The mean number of dissected LNs at the mediastinum and at the right recurrent laryngeal nerve (RLN) were similar between the two groups after matching, whereas the IL group exhibited a slightly greater number of dissected LNs at the left RLN. Among the matched patients, the IL and MK groups exhibited similar 5-year overall survival (OS: 75.1% vs 78.0%; p = 0.368). The multivariate model showed no differences in OS, disease-free survival, or recurrence-free survival for locoregional, upper mediastinum, or neck between the two groups. CONCLUSIONS: This study suggests that both the IL and MK operations are oncologically feasible for patients with mid-to-lower ESCC.

PD-L1 expression in resected lung adenocarcinoma: prevalence and prognostic significance in relation to the IASLC grading system.

AIMS: Programmed death-ligand 1 (PD-L1) expression is a predictive biomarker for adjuvant immunotherapy and has been linked to poor differentiation in lung adenocarcinoma. However, its prevalence and prognostic role in the context of the novel histologic grade has not been evaluated. METHODS: We analysed a cohort of 1233 patients with resected lung adenocarcinoma where PD-L1 immunohistochemistry (22C3 assay) was reflexively tested. Tumour PD-L1 expression was correlated with the new standardized International Association for the Study of Lung Cancer (IASLC) histologic grading system (G1, G2, and G3). Clinicopathologic features including patient outcome were analysed. RESULTS: PD-L1 was positive (≥1%) in 7.0%, 23.5%, and 63.0% of G1, G2, and G3 tumours, respectively. PD-L1 positivity was significantly associated with male sex, smoking, and less sublobar resection among patients with G2 tumours, but this association was less pronounced in those with G3 tumours. PD-L1 was an independent risk factor for recurrence (adjusted hazard ratio [HR] = 3.25, 95% confidence intervals [CI] = 1.93-5.48, P < 0.001) and death (adjusted HR = 2.69, 95% CI = 1.13-6.40, P = 0.026) in the G2 group, but not in the G3 group (adjusted HR for recurrence = 0.94, 95% CI = 0.64-1.40, P = 0.778). CONCLUSION: PD-L1 expression differs substantially across IASLC grades and identifies aggressive tumours within the G2 subgroup. This knowledge may be used for both prognostication and designing future studies on adjuvant immunotherapy.

Prognostic role of pathologic status other than complete response after neoadjuvant therapy followed by surgery in esophageal squamous cell carcinoma.

BACKGROUND: This retrospective study was performed to investigate the survival differences according to the pathologic status after neoadjuvant chemotherapy followed by surgery in esophageal squamous cell carcinoma (ESCC), and to investigate whether current AJCC 8th ypStage can predict survival accurately. METHODS: Data of 563 patients who received neoadjuvant therapy and esophagectomy for ESCC between 1994 and 2018 were retrospectively reviewed. RESULTS: The mean age was 62.00 ± 8.01 years, of which 524 (93.1%) were males. The median follow-up period was 29.12 months. A total of 153 (27.1%) patients showed pathologic complete response (pCR) and 92 (16.3%) patients showed pCR of the primary lesion with residual metastatic lymph nodes (ypT0N +). A total of 196 (35%) and 122 (21.6%) patients showed ypT + N + and ypT + N, respectively. The 5-year overall survival (OS) of each group was 75.1% (CR), 42.4% (ypT + N0), 54.9% (ypT0N +), and 26.1% (ypT + N +); CR patients showed better survival than the other groups, and no survival differences were found in the 5-year OS between ypT + N0 and ypT0N + patients (p = 0.811). In ypStage I, there were survival differences between ypT0N0 and ypTis-2N0 patients, and ypT1N0 (ypStage I) and ypT0N1 (ypStageIIIA) showed similar OS (5-year OS in 49.3% vs. 67.1%, p = 0.623). CONCLUSIONS: pCR offers long-term survival in patients; however, survival significantly declines with the presence of residual primary lesion and nodal metastases.

Efficacy of health coaching and a web-based program on physical activity, weight, and distress management among cancer survivors: A multi-centered randomised controlled trial.

OBJECTIVES: To investigate the efficacy of health coaching and a web-based program on survivor physical activity (PA), weight, and distress management among stomach, colon, lung and breast cancer patients. METHODS: This randomised, controlled, 1-year trial conducted in five hospitals recruited cancer survivors within 2 months of completing primary cancer treatment who had not met ≥1 of these behavioural goals: (i) conducting moderate PA for at least 150 minutes/week or strenuous exercise for over 75 minutes per week or, in the case of lung cancer patients, low or moderate intensity exercise for over 12.5 MET per week, (ii) maintaining normal weight, and (iii) attaining a score >72 in the Post Traumatic Growth Inventory (PTGI). Participants were randomly assigned to one of three groups: the control group, a web-only group, or a health coaching + web group. The primary endpoint was based on a composite of PA, weight, and PTGI score at 12 months. RESULTS: Patients in the health coaching + web group (difference = 6.6%, P = .010) and the web-only group (difference = 5.9%, P = .031) had greater overall improvements across the three-outcome composite than the control group. The health coaching + web group had greater overall improvement in PTGI (difference = 12.6%; P < .001) than the control group, but not in PA and weight. CONCLUSION: The web-based program, with or without health coaching, may improve health behaviours including PA, weight, and distress management among cancer survivors within 2 months of completing primary cancer treatment. The web-based program with health coaching was mainly effective for reducing psychological distress.

Diagnostic value of surveillance 18F-fluorodeoxyglucose PET/CT for detecting recurrent esophageal carcinoma after curative treatment.

PURPOSE: Esophageal carcinoma recurs within two years in approximately half of patients who receive curative treatment and is associated with poor survival. While 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is a reliable method of detecting recurrent esophageal carcinoma, in most previous studies FDG PET/CT scans were performed when recurrence was suspected. The aim of this study was to evaluate FDG PET/CT as a surveillance modality to detect recurrence of esophageal carcinoma after curative treatment where clinical indications of recurrent disease are absent. METHODS: A total of 782 consecutive FDG PET/CT studies from 375 patients with esophageal carcinoma after definitive treatment were reviewed. Abnormal lesions suggestive of recurrence on PET/CT scans were then evaluated. Recurrence was determined by pathologic confirmation or other clinical evidence within two months of the scan. If no clinical evidence for recurrence was found at least 6 months after the scan, the case was considered a true negative for recurrence. RESULTS: The diagnostic sensitivity and specificity of PET/CT for detecting recurrent esophageal carcinomas were 100% (64/64) and 94.0% (675/718), respectively. There were no significant differences in the diagnostic performance of PET/CT for detecting recurrence according to initial stage or time between PET/CT and curative treatments. Unexpected second primary cancers were detected by FDG PET/CT in seven patients. CONCLUSIONS: Surveillance FDG PET/CT is a useful imaging tool for detection of early recurrence or clinically unsuspected early second primary cancer in patients with curatively treated esophageal carcinoma but without clinical suspicion of recurrence.

A nomogram for predicting recurrence after complete resection for thymic epithelial tumors based on the TNM classification: A multi-institutional retrospective analysis.

OBJECTIVES: This study aimed to compare the predictive ability between the Masaoka-Koga (M-K) staging system and the 8th TNM staging system for the recurrence of thymic epithelial tumors (TETs). In addition, a nomogram was developed on the basis of the proposed TNM classification to predict individual recurrence rate. METHODS: A retrospective study was performed on 445 patients who underwent complete resection (R0) of TETs between January 2000 and February 2013. Concordance index (C-index) was used as a statistical indicator to quantify the prediction power of the prediction models. RESULTS: In multivariate analysis, tumor stage and WHO classification were independent recurrence factors in a predictive model on the basis of M-K and TNM stage. The TNM model showed higher C-index than the M-K model (0.837 vs 0.817). The nomogram, on the basis of the TNM model, revealed a highly predictive performance, with a bootstrap-corrected C-index of 0.85 (95% CI, 0.76 to 0.93). CONCLUSIONS: A predictive model based on the 8th TNM stage was slightly better than that based on M-K stage with respect to recurrence after R0 of TETs. The proposed nomogram could be applied to estimate the individual recurrence rate and make decisions for proper surveillance.

Simultaneous Resection of Synchronous Esophageal and Gastric Cancers.

Background In patients with synchronous esophageal and gastric cancers, selecting an optimal conduit for esophageal reconstruction is a critical decision. The aim of this study was to evaluate the surgical outcomes after simultaneous resection of esophageal and gastric cancers according to the type of esophageal conduit used. Materials and Methods Clinicopathologic features and surgical outcomes were analyzed in 66 patients who underwent esophageal reconstruction with colon (n = 41, group C), jejunum (n = 11, group J), and stomach (n = 14, group S). Results Gastric cancer was adenocarcinoma and esophageal cancer was squamous cell carcinoma in every case. Inhospital mortality rate was 4.6% (n = 3). The complication rates were 6.1% for graft failure and 9.1% for anastomotic leakage. During the follow-up period (mean, 44.0 ± 49.6 months), 5-year overall and disease-free survivals were 50.6 and 48.1%, respectively. Especially, patient with stage I cancer for both esophageal and gastric lesion showed excellent survival outcome with 5-year overall survival rate of 82.0%. There were no significant differences in early mortality, incidence of graft complications or overall survival between the groups. The independent predictors of overall survival were the highest tumor stage (p = 0.008) and age (p = 0.009). Conclusion Simultaneous resection of gastric and esophageal cancers can be performed with reasonable early and late outcomes. The type of esophageal conduit used was not a determinant factor for early and late outcomes.

A retrospective comparative analysis of elderly and younger patients undergoing pulmonary resection for stage I non-small cell lung cancer.

BACKGROUND: Age has been a critical predictor for immediate postoperative and long-term results after the pulmonary resection for lung cancer. In this study, we evaluated and compared surgical outcome of stage I non-small cell lung cancer and associated predictive factors between elderly and younger groups. METHODS: Short- and long-term outcomes of elderly group (≥70 years) who were surgically treated and pathologically diagnosed as stage I non-small cell lung cancer from 2004 to 2010 were compared to the results of younger group (<70 years). RESULTS: Total of 1340 patients were included in this study, and the patients were divided into the elderly group (n=285) and the younger group (n=1055). The proportions of squamous cell carcinoma (36.8 vs. 20.0%, p<0.001) and stage IB cancer (58.3 vs. 40.6%, p<0.001) were significantly higher in the elderly group than the younger group. The 30-day and 90-day mortalities were significantly higher in the elderly group (1.8 vs. 0%; p=0.014, 3.9 vs. 0.5%; p<0.001, respectively). The elderly patients also had significantly worse long-term outcomes than the younger group (5-year overall survival rate, 69.0 vs. 91.1%; p<0.001, 5-year disease-free survival rate, 53.3 vs. 80.2%; p<0.001). Decreased diffusion capacity less than 70% was an important predictive factor for short- and long-term outcomes in both the younger and the elderly group. CONCLUSIONS: Elderly patients with low diffusion capacity are at risk for significantly worse outcome, indicating that patient selection should include assessment of pulmonary function, including diffusion capacity.

Surgical outcomes and survival following esophagectomy for squamous cell carcinoma with or without liver cirrhosis: retrospective cohort study.

BACKGROUND AND AIMS: Esophageal squamous cell carcinoma (ESCC) shares common risk factors with liver cirrhosis (LC). The influence of LC in patients with ESCC has not been fully investigated. This study aimed to investigate the postoperative and long-term survival outcomes of esophagectomy for ESCC according to LC presence. METHODS: Among patients who underwent curative-intent surgery for ESCC between 1994 and 2018, 121 patients with Child-Pugh class A LC and 2810 patients without LC were compared. RESULTS: Among the LC patients, 73 (60.3%) were diagnosed with LC before surgery and 48 (39.7%) were diagnosed intraoperatively. There were no significant differences in baseline characteristics between patients with LC and those without LC. However, intraoperative blood loss was higher, and operation time, hospital stay, and ICU stay were longer in patients with LC than in those without LC. Moreover, the reoperation, 30-day morbidity (60.6 vs. 73.6%, P =0.006) and 90-day mortality (2.2 vs. 4.9%, P =0.049) were significantly higher in patients with LC. The 5-year overall survival (OS) rate was significantly higher in patients without LC than in those with LC. After adjusting the confounding variables, LC was an adverse risk factor of OS (hazard ratio 1.402, P =0.004). Among patients with LC, the Model of End-Stage Liver Disease score was related to the development of complications of grade more than III (odds ratio 1.459, P =0.013). CONCLUSION: ESCC patients with Child-Pugh class A LC have high incidences of postoperative morbidity and mortality, and poor OS. Thus, careful patient selection, meticulous operation, and careful postoperative care are needed.

The Role of Adjuvant Chemotherapy after Neoadjuvant Chemoradiotherapy Followed by Surgery in Patients with Esophageal Squamous Cell Carcinoma.

PURPOSE: This study aimed to investigate the efficacy of adjuvant chemotherapy after neoadjuvant chemoradiotherapy (CCRTx) followed by surgery in patients with esophageal squamous cell carcinoma (ESCC). MATERIALS AND METHODS: We retrospectively analyzed the data from 382 patients who received neoadjuvant CCRTx and esophagectomy for ESCC between 2003 and 2018. RESULTS: This study included 357 (93.4%) men, and the years median patient age was 63 (range, 40 to 84 years). Overall, 69 patients (18.1%) received adjuvant chemotherapy, whereas 313 patients (81.9%) did not. The median follow-up period was 28.07 months (interquartile range, 15.50 to 62.59). The 5-year overall survival (OS) and disease-free survival were 47.1% and 42.6%, respectively. Adjuvant chemotherapy did not improve OS in all patients, but subgroup analysis revealed that adjuvant chemotherapy improved the 5-year OS in patients with ypT+N+ (24.8% vs. 29.9%, p=0.048), whereas the survival benefit of adjuvant chemotherapy was not observed in patients with ypT0N0, ypT+N0, or ypT0N+. Multivariable analysis revealed that ypStage and adjuvant chemotherapy (hazard ratio, 0.601; p=0.046) were associated with OS in patients with ypT+N+. Freedom from distant metastasis was marginally different according to the adjuvant chemotherapy (48.3% vs. 41.3%, p=0.141). CONCLUSION: Adjuvant chemotherapy after neoadjuvant therapy followed by surgery reduces the distant metastasis in ypT+N+ ESCC patients, thereby improving the OS. The consideration could be given to administration of adjuvant chemotherapy to ypT+N+ ESCC patients with tolerable conditions.

Video-assisted thoracoscopic lobectomy versus open lobectomy in the treatment of large lung cancer: propensity-score matched analysis.

BACKGROUND: There are several concerns on thoracoscopic surgery for large tumors because of the increased risk of tumor cell spillage. This study aimed to compare perioperative outcomes and oncological validity between video-assisted thoracoscopic surgery (VATS) and open lobectomy for non-small cell lung cancer (NSCLC) with tumor size > 5 cm. METHODS: We retrospectively reviewed 355 patients who underwent lobectomy with clinical N0 NSCLC with solid tumor component diameter > 5 cm between January 2009 and December 2016. Patients with tumor invading adjacent structures were excluded. The patients were divided into the VATS group (n = 132) and thoracotomy group (n = 223). Propensity score matching (1:1) was applied. RESULTS: After propensity score matching, 204 patients were matched, and clinical characteristics of the two groups were well balanced. The VATS group was associated with a shorter length of hospital stay (6 days vs. 7 days; P < 0.001) than the thoracotomy group. There were no significant differences in the 5-year overall survival (71.5% in VATS vs. 64.4% in thoracotomy, P = 0.390) and 5-year recurrence-free survival (60.1% in VATS vs. 51.5% in thoracotomy, P = 0.210) between the two groups. The cumulative incidence of ipsilateral pleural recurrence was not significantly different between the two groups (12.0% in VATS vs. 7.9% in thoracotomy; P = 0.582). CONCLUSIONS: In clinical N0 NSCLC larger than 5 cm, VATS lobectomy resulted in shorter hospital stay and similar survival outcome compared to open lobectomy. Based on these results, VATS lobectomy is a valuable option in this subset of patients.

Role of intraoperative feeding jejunostomy in esophageal cancer surgery.

BACKGROUND: Feeding jejunostomy was routinely placed during esophagectomy to ensure postoperative enteral feeding. Improved anastomosis technique and early oral feeding strategy after esophagectomy has led to question the need for the routine placement of feeding jejunostomy. The aim of this study is to evaluate role of feeding jejunostomy during Ivor Lewis operation. METHODS: We retrospectively reviewed 414 patients who underwent the Ivor Lewis operations from January 2015 to December 2018. RESULTS: 61 patients (14.7%) received jejunostomy insertion. The most common indication for jejunostomy was neoadjuvant concurrent chemoradiation therapy (CCRT). 48 patients (79%) had jejunostomy removed within 60 days after the surgery and the longest duration of jejunostomy inserted state was 121 days. About two-third of the patients with jejunostomy had never prescribed with an enteral feeding product. Among 353 patients without intraoperative feeding jejunostomy, 11(3.1%) received delayed jejunostomy insertion. Graft-related problems (6 patients), cancer progression (3 patients), acute lung injury (1 patient), and swallowing difficulty (1 patient) were reasons for delayed feeding jejunostomy insertion. Complication rate was relatively high as 24 patients (33.3%) out of 72 patients with jejunostomy insertion had complications and 7 patients (9.7%) visited ER more than twice with jejunostomy-related complications. CONCLUSION: Only 3.6% patients who underwent the Ivor Lewis operation during 4-year span had anastomosis leakage. Although one-third of the patients with jejunostomy were benefited with alternative method of feeding after discharge, high complication rate regarding jejunostomy should be also considered. We believe feeding jejunostomy should not be applied routinely with prophylactic measures and should be reserved to very carefully selected patients with multiple high-risk factors.

Nononcologic Mortality after Pneumonectomy Compared to Lobectomy.

Pneumonectomy is associated with high mortality. Knowledge of the cause and timing of death is critically important to reduce mortality. This study aimed to compare long-term nononcologic mortality between pneumonectomy and lobectomy patients and investigate factors associated with nononcologic mortality. Medical records of 337 patients who underwent pneumonectomy and 7545 patients who underwent lobectomy from 2009 to 2018 were reviewed. Postoperative morbidity, mortality, and cause of death were investigated. Competing risk analysis was performed to compare nononcologic mortality between pneumonectomy and lobectomy patients. Independent prognostic factors of nononcologic death were analyzed. The 90 day, 1 year, and 5 year mortality rates after pneumonectomy were 7.1%, 20.8%, and 49.3%, respectively. The respective nononcologic mortality rates after pneumonectomy were 6.5%, 11.6%, and 14.5%. The most common nononcologic cause of death was pneumonia. The 5 year cumulative incidence of nononcologic mortality was higher after pneumonectomy than after lobectomy (14.5% vs. 2.1%; p < 0.001). Risk of nononcologic death was higher after pneumonectomy (hazard ratio 1.54; p = 0.038). Older age (hazard ratio 1.09; p < 0.001) was an independent prognostic factor associated with nononcologic death after pneumonectomy. Higher predicted postoperative diffusion capacity for carbon monoxide (PPO DLCO) approached significance (hazard ratio 0.97; p = 0.054) as a protective factor. Long-term nononcologic mortality was higher after pneumonectomy than lobectomy and the main cause of nononcologic death was pneumonia. Clinicians should prevent and aggressively treat pneumonia after surgery, particularly in older patients and those with low PPO DLCO.

Second primary pleomorphic carcinoma arising from the pneumonectomy cavity of non-small cell lung cancer: A case report.

Here, we report a thirteen years' survivor of initial primary lung cancer, who successfully diagnosed with second primary lung cancer(SPLC). It was arising from the pneumonectomy cavity of a non-small cell lung cancer(NSCLC). Few cases of SPLC associated with the post-pneumonectomy cavity have been reported in the literature. The histologic results of SPLC was metastatic pleomorphic carcinoma. It is a rare type of lung cancer; which incidence has been reported to range from 0.1% to 0.4% among all lung cancers. Based on regular follow-up with chest computed tomography(CT) and an understanding of post-pneumonectomy changes, the second primary pleomorphic carcinoma was correctly diagnosed and appropriately treated.

Utility of positron emission-computed tomography for predicting pathological response in resectable oesophageal squamous cell carcinoma after neoadjuvant chemoradiation.

OBJECTIVES: For patients with locally advanced oesophageal cancer, improved complete pathological response after neoadjuvant chemoradiation (nCRT) and the detrimental effects on the quality of life related to oesophagectomy have led to the need for a reliable method to select patients who have achieved complete pathological response and do not need surgery. The reliability of 18F-fluorodeoxyglucose positron emission-computed tomography (PET-CT) for predicting the pathological response after nCRT was evaluated. METHODS: Patients with locally advanced oesophageal cancer who were treated with nCRT and oesophagectomy from July 2010 to February 2017 were analysed. On the post-nCRT PET-CT, a complete metabolic response was defined as all tumourous lesions demonstrating maximum standardized uptake value (SUVmax) ≤2.5. To minimize the effect of radiation-induced oesophagitis, complete metabolic response was also defined as no viable lesion distinguishable from the background with diffuse uptake. The sensitivity, specificity, positive predictive value and negative predictive value were analysed for SUVmax, [X]ΔSUVmax and %ΔSUVmax. RESULTS: A total of 158 patients with oesophageal squamous cell carcinoma were analysed. The rate of complete pathological response was 27.8%, and that of complete metabolic response was 7.6%. The sensitivity, specificity, positive predictive value and negative predictive value based on SUVmax ≤2.5 and visual normalization were 95%, 14%, 74% and 50%, respectively. Analysis for [X]ΔSUVmax and %ΔSUVmax using the optimal cut-off values determined by the receiver operating characteristic curves did not show an improved predictive efficacy. CONCLUSIONS: PET-CT is not a reliable tool for predicting pathological response. Patients diagnosed with resectable oesophageal cancer who underwent neoadjuvant therapy should not be exempt from surgery based on PET-CT results.

Clinical outcomes of microscopic residual disease after bronchial sleeve resection for non-small cell lung cancer.

OBJECTIVES: To evaluate the significance of microscopic residual disease (MRD) at the bronchial resection margin after bronchial sleeve resection in non-small cell lung cancer. METHODS: We retrospectively reviewed 536 consecutive patients who underwent bronchial sleeve resection between 1995 and 2015. Clinical outcomes, including recurrence and long-term survival, were analyzed according to the bronchial resection margin status (R0 = complete resection and R1 = microscopic residual tumor). RESULTS: Forty patients (7.5%) were identified to have MRD. During a 52.4-month follow-up (range, 0.1-261.0 months), there was no significant difference in 5-year overall survival (61.8% vs 61.5%; P = .550) and 5-year recurrence-free survival (53.7% vs 59.0%; P = .390) between groups R1 and R0. Multivariable cox regression analysis demonstrated that the margin status (group R1) was not associated with significantly decreased overall survival and recurrence-free survival. In group R1, 3 patients (7.5%) showed locoregional recurrence, including 1 patient (2.5%) with anastomotic recurrence. There were no significant differences between both groups in anastomotic recurrence (2.5% vs 2.6%; P = 1.000), locoregional recurrence (7.5% vs 12.7%; P = .476), and distant recurrence (25.0% vs 23.2%; P = .947) rates. Subgroup analysis of group R1 revealed a significant trend toward an increasing recurrence rate as the pathological extent of MRD advanced toward invasive extramucosal carcinoma (P for trend = .015). CONCLUSIONS: In our experience of bronchial sleeve resection, the oncologic outcome of MRD was not jeopardized. Furthermore, the pathological extent of MRD might be helpful for recurrence prediction and treatment planning.

Long-term outcomes of video-assisted thoracoscopic lobectomy for clinical N1 non-small cell lung cancer: A propensity score-weighted comparison with open thoracotomy.

OBJECTIVES: Although the video-assisted thoracic surgery (VATS) approach has been accepted as a safe and effective alternative to lobectomy, its advantage remains unclear in advanced-stage lung cancer. This study is aimed to evaluate the feasibility and long-term outcomes of VATS in lung cancer with clinical N1 (cN1) disease. MATERIALS AND METHODS: We retrospectively reviewed the records of 1149 consecutive patients who underwent lobectomy for cN1 disease from 2006 to 2016. Perioperative outcomes and long-term survival rates were compared using a propensity score-based inverse probability of treatment weighting (IPTW) technique. RESULTS: We performed VATS and open thoracotomy for 500 and 649 patients, respectively. All preoperative characteristics became similar between the two groups after IPTW adjustment. Compared to thoracotomy, VATS was associated with shorter hospitalization (7.7 days vs. 9.2 days, p < 0.001), earlier adjuvant chemotherapy (41.7 days vs. 46.6 days, p = 0.028), similar complete resection rates (95.2 % vs. 94.0 %, p = 0.583), and equivalent dissected lymph nodes (27.5 vs. 27.8, p = 0.704). On IPTW-adjusted analysis, overall survival (OS) (59.4 % vs. 60.3 %, p = 0.588) and recurrence-free survival (RFS) (59.2 % vs. 56.9 %, p = 0.651) at 5 years were also similar between the two groups. Multivariable Cox analysis revealed that VATS was not a significant prognostic factor for cN1 disease (p = 0.764 for OS and p = 0.879 for RFS). CONCLUSIONS: VATS lobectomy is feasible for patients with cN1 disease, providing comparable perioperative outcomes, oncologic efficacy, and long-term outcomes as open thoracotomy.