Adjuvant durvalumab for esophageal squamous cell carcinoma after neoadjuvant chemoradiotherapy: a placebo-controlled, randomized, double-blind, phase II study.

BACKGROUND: We evaluated the efficacy of adjuvant durvalumab after neoadjuvant concurrent chemoradiotherapy (CCRT) in patients with esophageal squamous cell carcinoma (ESCC). PATIENTS AND METHODS: This randomized, double-blind, phase II study included patients with ESCC who underwent curative surgery after neoadjuvant CCRT. Patients were randomized to receive either durvalumab (20 mg/kg/i.v. every 4 weeks for 12 months) or placebo in a 1:1 ratio and were stratified by age and pathologic tumor stage. The primary endpoint was disease-free survival (DFS). RESULTS: Between March 2016 and June 2018, 86 patients were randomized to the durvalumab (n = 45) or placebo (n = 41) arm. The median follow-up duration was 38.7 months. There was no difference in DFS [hazard ratio (HR) 1.18, 95% confidence interval (CI) 0.62-2.27, P = 0.61] or overall survival (HR 1.08, 95% CI 0.52-2.24, P = 0.85) between the two arms. Subgroup analysis was performed for patients for whom the post-CCRT programmed death-ligand 1 (PD-L1) expression profile could be assessed (n = 54). In the PD-L1-positive group, based on tumor proportion score ≥1%, durvalumab was associated with longer overall survival compared with the placebo (36-month survival rate: 94% versus 64%; HR 0.42, 95% CI 0.10-1.76), while in the PD-L1-negative group, it was associated with shorter overall survival (42% versus 55%; HR 1.53, 95% CI 0.48-4.83), showing the tendency of interaction between post-CCRT PD-L1 status and adjuvant durvalumab therapy for overall survival (interaction P = 0.18). CONCLUSIONS: We failed to demonstrate that adjuvant durvalumab improved survival after neoadjuvant CCRT in patients with ESCC. However, post-CCRT PD-L1 expression could predict the survival of patients who receive adjuvant durvalumab after neoadjuvant CCRT, which needs to be validated.

Prognostic significance of volume-based 18F-FDG PET/CT parameter in patients with surgically resected non-small cell lung cancer. Comparison with immunohistochemical biomarkers.

AIM: We investigated the prognostic value of volume-based 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) parameters compared with other factors including several immunohistochemical biomarkers in patients with surgically resected non-small cell lung cancer (NSCLC). STUDY PARTICIPANTS: 290 patients with surgically resected and histopathologically confirmed NSCLC. The maxmum standardized uptake value (SUVmax) and metabolic tumour volume (MTV) of the primary tumour were obtained on 18F-FDG PET/ computed tomography (CT) for initial staging and Ki-67 labeling index (LI), p16, CD31 and cyclin E were evaluated in the primary tumours by immunohistochemical staining. Survival analyses for variables including PET parameters, immunohistochemical biomarker and other clinical factors were performed using the Kaplan-Meier method and Cox proportional hazards regression analysis. RESULTS: In univariate analyses, tumour stage, tumour size, and MTV were significant prognostic factors for decreased overall survival (OS) and disease-free survival (DFS). Multivariate analyses showed MTV and tumour stage were significant predictors of poor OS (MTV, hazard ratio (HR) = 1.135, p = 0.015; stage, HR = 0.644, p = 0.025) and DFS (MTV, HR = 1.128, p = 0.043; stage, HR = 0.541, p = 0.009). CONCLUSION: The MTV of primary tumours is a significant prognostic factor for survival along with tumour stage in patients with surgically resected NSCLC. The MTV can predict OS and DFS better than immunohistochemical biomarkers.

Changes in tumour expression of programmed death-ligand 1 after neoadjuvant concurrent chemoradiotherapy in patients with squamous oesophageal cancer.

BACKGROUND: Programmed death-ligand 1 (PD-L1) expression has been suggested as a potential predictive biomarker of response to anti-PD-1/PD-L1 therapy. In this study, we investigated whether the expression of PD-L1 in tumour cells is affected by neoadjuvant concurrent chemoradiotherapy (CCRT) or chemotherapy in oesophageal squamous cell carcinoma. PATIENTS AND METHODS: Between 2004 and 2014, we collected the medical records of locally advanced oesophageal cancer patients consecutively diagnosed and treated with neoadjuvant CCRT or chemotherapy, followed by curative resection. PD-L1 expression in acquired tissue specimens was evaluated by immunohistochemistry using the H-score. The changes in PD-L1 expression between paired samples were evaluated and we also analysed PD-L1 expression in surgical tumour specimens to evaluate its prognostic role. RESULTS: Twenty-eight paired tumour tissues that were acquired before and after neoadjuvant therapy were available: 19 patients with CCRT and 9 with chemotherapy before complete oesophagectomy. The PD-L1 H-score increased significantly from baseline tumour tissues to surgical tumour tissues after neoadjuvant CCRT (P = 0.007, median H-score from 28 to 52), whereas it decreased significantly after neoadjuvant chemotherapy (P = 0.048, median H-score from 53 to 22). In a total of 73 patients, including 45 additional cases for the prognosis analysis, patients with higher PD-L1 H-scores (≥ 20) had poorer overall survival (median 16.7 versus 32.9 months, P = 0.02) than those with lower H-scores (<20). CONCLUSIONS: PD-L1 expression in tumour cells increased in oesophageal cancer patients who received neoadjuvant CCRT. Further studies with more cases are necessary to validate these findings.

Needs regarding care and factors associated with unmet needs in disease-free survivors of surgically treated lung cancer.

BACKGROUND: To evaluate the long-term needs of lung cancer survivors and to explore factors associated with unmet need. PATIENTS AND METHODS: We recruited lung patients treated with curative surgery from 2001 through 2006 at two centers in Korea. Needs in the domains of information, supportive care, education and counseling, and socioeconomic support were measured. We selected the four most frequently reported items of unmet need among 19 items in four domains. RESULTS: The most frequently reported unmet needs were Complementary and alternative medicine (CAM) and folk remedies (59.8%) in the Information domain, Counseling and treatment of depression and anxiety (63.5%) in the Supportive care domain, diet, exercise and weight control (55.1%) in the Education and counseling domain and Financial support (90.4%) in the socioeconomic support domain. Unmet needs for psychological treatment was significantly greater in participants who were employed (adjusted odds ratio [aOR], 2.25; 95% confidential interval [CI], 1.12 to 4.53). Unmet needs for diet, exercise and weight control were significantly greater in participants who had not received chemotherapy (aOR, 1.76; 95% CI, 1.09 to 2.85). Unmet need for financial support was greater in participants who were married (aOR, 4.14, 95%CI, 1.12 to 15.22) and those who had not received chemotherapy (aOR, 5.91, 95%CI, 1.91 to 18.31). CONCLUSION: There were substantial unmet needs for information regarding psychological support, education for diet and exercise, and financial support among lung cancer survivors.

Can common hepatic artery lymph node dissection be safely omitted in surgery for clinical T1N0 thoracic esophageal squamous cell carcinoma?

Common hepatic artery lymph node dissection is regarded as a standard procedure in esophageal cancer surgery because of aggressive lymphatic dissemination of esophageal cancer. However, lymph node dissection can prolong operation time and may be associated with complications such as chylous ascites. Here, we aimed to evaluate the effectiveness of common hepatic artery lymph node dissection in clinical T1N0 thoracic esophageal squamous cell carcinoma. Between 1996 and 2009, 1390 patients underwent surgery for esophageal cancer in our institution, and 209 were found to have clinical T1N0 disease. Exclusion criteria were nonsquamous carcinoma, double primary cancer, definite distant metastasis, administration of neoadjuvant treatment, and incomplete abdominal lymph node dissection. We retrospectively analyzed medical records, operative and pathologic data, and follow-up information. Forty-two patients were excluded from the study. Among the 167 enrolled patients, preoperative endoscopic ultrasound evaluation was performed in 160 patients. Fifty-two patients had distal esophageal or esophagogastric junction tumor. Surgery included 2 cases of tri-incisional esophagectomy, 17 cases of transhiatal esophagectomy, and 148 cases of two-field esophagectomy (Ivor Lewis operation). Common hepatic artery lymph node dissection was performed in all cases, and none of the patients had metastasis. Mean follow-up period was 35.4 ± 28.7 months. In-hospital mortality was one, and 5-year survival rate was 80.6%. Among the 15 patients with recurrence, there were two distant metastases and five distant and local recurrences but no intra-abdominal recurrence with common hepatic artery lymph node. Common hepatic artery lymph node dissection may be safely omitted in surgery for clinical T1N0 esophageal squamous cell carcinoma when preoperative evaluations including chest computed tomography, positron emission tomography and computed tomography, and esophagogastroduodenoscopy or endoscopic ultrasound are performed.

AKR1B10 is associated with smoking and smoking-related non-small-cell lung cancer.

This prospective study explored the relationship between expression of AKR1B10 mRNA and various clinical parameters in non-small-cell lung cancer (NSCLC) in terms of its validation as a marker for NSCLC. Tumour tissue samples were collected from 229 patients with NSCLC. Tissue samples from adjacent non-malignant lung tissue (> 5 cm from the tumour) of 89 of these patients and samples from 20 patients with benign lung disease were used as controls. Quantitative reverse transcription- polymerase chain reaction showed significantly higher levels of AKR1B10 mRNA expression in NSCLC tumour tissue than in adjacent non-malignant lung tissue and benign lung tissue. Statistically significant factors for AKR1B10 mRNA over-expression were found to be male gender, smoking, squamous cell carcinoma and moderate or poor cell differentiation. It is concluded that AKR1B10 seems to have potential as a prognostic marker for NSCLC and warrants further investigation.

Prediction of acute pulmonary complications after resection of lung cancer in patients with preexisting interstitial lung disease.

INTRODUCTION: Interstitial lung disease (ILD) is associated with a high morbidity from acute pulmonary complications, such as acute lung injury (ALI) or acute respiratory distress syndrome (ARDS), after pulmonary resection. This study attempts to uncover the risk factors for postoperative ALI/ARDS in lung cancer patients with ILD. MATERIALS AND METHODS: We retrospectively reviewed 100 patients with ILD who underwent curative lung resection for lung cancer, from January 2000 to December 2008. RESULTS: Of the 100 patients, 91 were male, and 9 were female. The median age was 66 years. Fifty-eight patients underwent a preoperative carbon monoxide diffusing capacity test (DLCo). Twelve pneumonectomies and 88 lobectomies were performed. Acute pulmonary complications were observed in 28 patients (13 with ALI and 15 with ARDS). Operative mortality was 14%. Cause of death was due to respiratory failure from ALI/ARDS in all patients, except in one patient who died due to complications of acute renal failure. For all 100 patients, univariate analysis revealed that preexisting comorbidities, such as ischemic heart disease, renal failure, COPD, and neoadjuvant treatment for lung cancer, were risk factors for the development of postoperative ALI/ARDS. For the 58 patients who underwent preoperative DLCo testing, significant univariate risk factors included preexisting comorbidities and decreased DLCo. Multivariate analysis did not show any significant risk factors for ALI/ARDS. CONCLUSIONS: Preexisting comorbidities and decreased preoperative DLCo were the most significant risk factors for the development of acute pulmonary complications after pulmonary resection in patients with lung cancer and ILD.

Thymidine synthase, thymidine phosphorylase, and excision repair cross-complementation group 1 expression as predictive markers of capecitabine plus cisplatin chemotherapy as first-line treatment for patients with advanced oesophageal squamous cell carcinoma.

BACKGROUND: Our purpose was to evaluate thymidine synthase (TS), thymidine phosphorylase (TP), and excision repair cross-complementation group 1 (ERCC1) expression as biomarkers for capecitabine and cisplatin (XP) combination chemotherapy in patients with metastatic oesophageal squamous cell cancer. METHOD: A total of 113 patients with metastatic oesophageal squamous cell cancer were treated with XP chemotherapy at the Samsung Medical Center between 2003 and 2007, of whom 72 had available clinical data and paraffin blocks for immunohistochemistry of TS, TP, and ERCC1. RESULTS: The median age of the 72 patients was 62 years. The overall response rate (RR) was 51.4%. The median progression-free survival (PFS) and overall survival (OS) were 4.2 and 12.0 months, respectively. High expression of TS and TP was associated with a higher RR than was low expression of TS and TP (54.1 vs 40.5%, P=0.022). Strong ERCC1 expression and a low TS score were identified as unfavourable independent risk factors for PFS (HR 10.71, 95% confidence interval (CI) 2.1-54.7, P=0.004 for strong ERCC1 expression; and HR 2.9, 95% CI 1.0-7.9, P=0.044 for low TS score). Strong ERCC1 expression was identified as an unfavourable independent risk factor for OS (HR 3.73, 95% CI 1.39-10.0, P=0.009). CONCLUSION: These data indicate that expression of TS, TP, and ERCC1 may be predictive markers for response and survival in patients with metastatic oesophageal squamous cell cancer receiving XP chemotherapy.

Outcomes after repeated resection for recurrent pulmonary metastases from colorectal cancer.

BACKGROUND: It remains controversial whether metastasectomy is still feasible in patients with pulmonary recurrence from colorectal cancer, after initial metastasectomy. The aim of this study was to evaluate outcomes of repeated metastasectomy in these patients. MATERIALS AND METHODS: From 1995 to 2007, 202 patients had received a pulmonary metastasectomy from colorectal cancer at our institution. Over a median follow-up of 28.9 months, 48 patients received second metastasectomy (29 wedge resections, 5 segmentectomies, 13 lobectomies, and 1 completion pneumonectomy). The median disease-free interval was 9.6 months. Among these 48 patients, 28 showed pulmonary recurrence again and of those, 10 patients received third metastasectomy (two wedge resections, two segmentectomies, four lobectomies, and two completion pneumonectomies). RESULTS: There was no postoperative mortality. Of the 48 patients who underwent second metastasectomy, overall and disease-free 5-year survivals were 79% and 49%, respectively, after second operation. Of the 10 patients who received third metastasectomy, overall survival was 78% at 5 years after last operation. CONCLUSIONS: Repeated resection after initial metastasectomy can be carried out safely and provides long-term survival in patients with recurrent pulmonary metastasis from colorectal cancer. Our findings indicate that close follow-up for the early detection of recurrence and parenchyma-saving resection can improve the results after repeated resection.

Risk factors for post-pneumonectomy acute lung injury/acute respiratory distress syndrome in primary lung cancer patients.

Acute lung injury/acute respiratory distress syndrome (ALI / ARDS) is the most serious pulmonary complication after lung resection. This study investigated the incidence and outcome of patients with ALI / ARDS who required mechanical ventilation within one week of undergoing pneumonectomy for primary lung cancer and analysed the risk factors. We retrospectively reviewed the medical records of 146 patients who underwent pneumonectomy for primary lung cancer between May 2001 and April 2006. Preoperative, perioperative and postoperative clinical data were analysed. Post-pneumonectomy ALI / ARDS developed within the first postoperative week in 18 (12%) patients. Patients who developed ALI / ARDS had a longer hospital duration of stay (median [interquartile range], 26 [18 to 75] vs. 8 [7 to 11] days; P < 0.001) and higher in-hospital mortality (12 [67%] vs. 0 [0%]; P < 0.001). In an univariate analysis, post-pneumonectomy ALI / ARDS was associated with larger tidal volume (V(T)) and higher airway pressure (P(aw)) during one-lung ventilation (V(T) 8.2 [7.5 to 9.0] vs. 7.7 [6.9 to 8.2] ml/kg predicted body weight, P = 0.016; P(aw), 28.9 [27.6 to 30.0] vs. 27.2 [25.6 to 28.5] cmH2O, P = 0.001). V(T) during two-lung ventilation was also greater in patients who developed ALI / ARDS (P = 0.014) than in those who did not, but P(aw) during two-lung ventilation did not differ (P = 0.950). In a multiple logistic regression analysis, post-pneumonectomy ALI / ARDS was independently associated with a larger V(T) (OR 3.37 per 1 ml/kg predicted body weight increase; 95% confidence interval 1.65 to 6.86) and higher P(aw) (OR 2.32 per 1 cmH2O increase; 95% confidence interval 1.46 to 3.67) during the period of one-lung ventilation. In conclusion, a large V(T) and high P(aw) during one-lung ventilation were associated with an increased risk of post-pneumonectomy ALI / ARDS in primary lung cancer patients.

A single institutional experience of thymic epithelial tumours over 11 years: clinical features and outcome and implications for future management.

Thymic epithelial tumours (TETs), the most common tumour of the anterior mediastinum, are epithelial neoplasms of the thymus with a wide spectrum of morphologic features. We retrospectively analysed clinical features of TET and the correlation of World Health Organisation (WHO) histologic classification and Masaoka staging system with different treatment modalities in 195 patients, from 1995 to 2005. According to the Masaoka's staging system, there were 78 (40.0 %) patients with stage I, 38 (19.5%) with stage II, 41 (21.0%) with stage III, 38 (19.5%) with stage IV. All patients were reclassified according to the WHO criteria as follows: Type A (n=9, 4.6%), AB (n=37, 18.9%), B1 (n=29, 14.8%), B2 (n=48, 24.6%), B3 (n=40, 20.5%), C (n=32, 16.4%). There was a fairly good correlation between Masaoka staging and WHO histotype (P<0.05). However, in multivariate analysis, the tumour stage and WHO histotype were two independent factors separately for predicting overall survival (P<0.001, P<0.001, respectively). Thus, both Masaoka stage and WHO histotype should be considered in risk stratification of therapy for TET patients. Patients with completely resected types B2, B3 and C and adjuvant radiotherapy (n=57) had more favourable disease-free and overall survival as compared with those without adjuvant treatment (n=20) (P=0.015, 0.015, respectively). Given that the predominant sites of recurrence after surgery was pleura/pericardium and lung, and the fact that complete resection was a significant influential factor for survival at log-rank test, an active investigation of newer treatment strategies such as neoadjuvant treatment to improve the resectability and development of optimal adjuvant treatment modality is a high priority especially for those with high-risk for recurrence or in patients with advanced stage disease.

Giant fibrovascular polyp of the esophagus: CT findings.

Giant fibrovascular polyp of the esophagus is a rare intraluminal benign tumor that is covered with normal esophageal mucosa, which consists of fibrous tissue, adipose tissue, and vascular structures. We report a case of a giant fibrovascular polyp of the esophagus in which feeding vessels were well visualized within the stalk of the mass at contrast-enhanced helical computed tomography.

Recurrence of squamous cell carcinoma of the oesophagus after curative surgery: rates and patterns on imaging studies correlated with tumour location and pathological stage.

Many factors have been related to recurrence after resection of squamous cell carcinoma of the oesophagus. These include age, gender, location and local stage of tumours, cell differentiation, lymph node metastasis and vascular involvement. The recurrence rates of squamous cell carcinoma after curative surgery are high (34-79%). Tumour recurrence is categorized as locoregional or distant. Lymph node recurrence and haematogenous metastasis to solid organs (commonly to the lung) are the usual patterns of recurrence. Awareness of recurrence patterns, particularly on imaging studies, is essential for the diagnosis of recurrent tumours on follow-up examinations.

Esophageal leiomyoma: radiologic findings in 12 patients.

OBJECTIVE: The aim of our study was to describe and compare the radiologic findings of esophageal leiomyomas. MATERIALS AND METHODS: The chest radiographic (n = 12), esophagographic (n = 12), CT (n = 12), and MR (n = 1) findings of surgically proven esophageal leiomyomas in 12 consecutive patients [ten men and two women aged 34 - 47 (mean, 39) years] were retrospectively reviewed. RESULTS: The tumors, surgical specimens of which ranged from 9 to 90 mm in diameter, were located in the upper (n = 1), middle (n = 5), or lower esophagus (n = 6). In ten of the 12 patients, chest radiography revealed the tumors as mediastinal masses. Esophagography showed them as eccentric, smoothly elevated filling defects in 11 patients and a multilobulated encircling filling defect in one. In 11 of the 12 patients, enhanced CT scans revealed a smooth (n = 9) or lobulated (n = 2) tumor margin, and attenuation was homogeneously low (n = 7) or iso (n = 4). In one patient, the tumor signal seen on T2-weighted MR images was slightly high. CONCLUSION: Esophageal leiomyomas, located mainly in the middle or distal esophagus, are consistently shown by esophagography to be mainly eccentrically elevated filling defects and at CT, lesions showing homogeneous low or isoattenuation are demonstrated.

Preoperative concurrent chemoradiotherapy for stage IIIA non-small cell lung cancer.

Thirty-one patients with stage IIIA non-small cell lung cancer (NSCLC) were treated with preoperative concurrent chemoradiotherapy (CCRT) followed by surgery. The treatment protocol could not be completed in eight patients. The acute hematologic toxicities of grade III or IV occurred in 48.4%, (15/31) after the first chemotherapy cycle, and in 39.1% (9/23) after the second cycle. The most common non-hematologic toxicity was radiation esophagitis. Surgery was attempted in 23 patients and successful in 22 patients (resection rate = 71.0%. Pathologic complete response and down-staging were achieved in 13.6% (3/22) and 68.2% (15/22). The median survival period, 2-year overall survival, local control and disease-free survival rates of all 31 patients and of 22 patients who underwent surgery were 19 months, 37.2%, 49.1%, 35.5%, and 19 months, 43.2%, 51.8%, 25.6%, respectively. On the basis of our observations, preoperative CCRT followed by surgery for stage IIIA NSCLC has resulted in outcomes comparable with those in previous reports.

In vitro establishment of cis-diammine-dichloroplatinum(II) resistant lung cancer cell line and modulation of apoptotic gene expression as a mechanism of resistant phenotype.

After exposure of H460 cells to an increasing concentrations of cis-diammine-dichloroplatinum(II) (cisplatin, CDDP) for 6 months, cisplatin resistant cells were isolated (H460/CIS). The biologic behaviors of H460 and H460/CIS cells were tested using animal experiments. Only the resistant cells developed lung metastases despite cisplatin treatment. The characteristics of H460/CIS cells are as follows, MTT analyses revealed that H460/CIS cells were markedly resistant to cisplatin compared with their parental cells. Also, H460/CIS cells exhibited cross-resistance to DNA damaging agents such as doxorubicin (DXR) and etoposide. Cisplatin treatment dramatically increased p53 expression in parental cells but not in H460/CIS cells which expressed basal levels of p53. Without cisplatin treatment, Bcl-2 and Bax were expressed in H460/CIS cells, but not in parental cell. Our data suggested that p53, Bax and Bcl-2 were up-regulated in H460/CIS cells. These changes could explain some of the mechanisms of cisplatin resistance. Thus, H460/CIS could be useful to investigate the mechanisms of drug resistance to cisplatin including apoptotic gene expressions conferring drug resistance, thereby making progress in the treatment of cisplatin-resistant tumor cells.

Esophageal resection: indications, techniques, and radiologic assessment.

Various surgical procedures are performed for benign and malignant esophageal lesions. These procedures include transthoracic esophageal resection through a right or left thoracotomy and transhiatal blunt esophageal resection (esophagectomy) without thoracotomy. The whole stomach, colon, gastric tube, jejunum, and free revascularized grafts may be used as substitutes for the resected esophagus. Bypass procedures including substernal stomach bypass surgery and substernal or subcutaneous colon bypass surgery are performed for tracheoesophageal fistula, previous esophagectomy without reconstruction, or obstruction due to lye ingestion. The mortality rate for esophageal resection depends on the stage of the tumor, the patient's condition, and the surgeon's skill and is quite low when the procedure is performed by a highly skilled surgeon. The most frequent sources of morbidity related to esophageal surgery include pneumothorax, pleural effusion, pneumonia, and respiratory failure. Mediastinitis and sepsis due to disruption at an anastomosis site cause serious postoperative morbidity and mortality; therefore, thoracic anastomotic leaks require aggressive surgical treatment. Familiarity with these surgical options, the resultant anatomic changes associated with each option, and the expected findings at postoperative imaging is essential for evaluating the effectiveness of surgical procedures and for the early detection and management of surgery-related complications.

Large cell neuroendocrine carcinoma of the lung: clinical, CT, and pathologic findings in 11 patients.

The purpose of this study was to describe the clinical, computed tomographic (CT), and pathologic findings of large cell neuroendocrine carcinoma (LCNEC) of the lung. CT and pathologic findings as well as clinical features of surgically proven LCNEC of the lung were reviewed retrospectively in 11 consecutive patients (eight men and three women; mean age, 63 years; range, 44-77 years). Chest CT showed peripheral mass or nodule (n = 8) and central mass with distal atelectasis (n = 3). Six tumors were accompanied by mediastinal (n = 3) and hilar (n = 3) lymph node enlargement at CT. On pathologic examination, all resected tumors showed necrosis of variable extent (mean: 38%, range; 10-70%). The areas of intrinsic lipoid pneumonia and tumor emboli in two patients appeared at CT as areas of ground-glass opacity surrounding the tumor. Mediastinal nodal metastases were seen in three (27%) patients. Pathologic staging of 11 patients was IB in six, IIA in one, IIB in one, IIIA in two, and IIIB in one. Follow-up data showed extrathoracic metastases in four patients at mean follow-up period of 15 months. One patient died of distant metastasis 5 months after the surgery. CT findings of LCNEC of the lung are nonspecific and similar to those of other non-small cell lung cancers and extrathoracic metastasis is seen in approximately one third of the patients with follow-up study.

Malignant esophagogastric junction obstruction: palliative treatment with an antireflux valve stent.

The authors assessed the efficacy of an antireflux valve stent in the palliation of malignant esophagogastric junction (EGJ) obstruction after in vitro testing of the stent. Seventeen patients with inoperable malignant EGJ obstruction were treated. Antireflux valves, made of three polyurethane leaflets, were attached to the distal part of the stent to prevent reflux. When the flow rate of normal saline was 100 mL/sec in the forward direction, the valve fully opened at a pressure of 10 mm Hg. When the flow rate of normal saline was 0.35 mL/sec in the backward direction, the valve nearly completely closed at a pressure of 10 mm Hg. Stent placement was successful in all patients without complications. The median dysphagia score decreased significantly, from 3.0 (dysphagia to liquids) to 1.0 (dysphagia to normal solid food) (P < .0005). No patients experienced reflux symptoms. There was one case of stent migration. A valve stent that can prevent major reflux is an effective device for the palliation of malignant EGJ obstruction.

Evaluation of lymph node metastases in squamous cell carcinoma of the esophagus with positron emission tomography.

BACKGROUND: Previous studies suggest positron emission tomography (PET) may improve staging accuracy of esophageal cancer compared with conventional methods, especially in detecting occult distant metastases. We evaluated the accuracy of PET in the detection of lymph node metastasis prospectively with pathologic findings. METHODS: Fifty-three patients with squamous cell carcinoma underwent whole-body PET scan and chest computed tomography (CT). The findings of PET and chest CT of 50 patients who underwent curative esophagectomy with radical lymph node dissection were compared with the pathologic findings. RESULTS: Among 53 primary esophageal tumors, PET detected 51 (96.2%) and CT detected 49 (92.5%) tumors correctly. Nodal metastases were present in 108 of 436 dissected lymph node groups. PET detected 56 metastatic node groups (51.9% sensitivity, 94.2% specificity, 83.7% accuracy), compared with CT, which detected 16 (14.8% sensitivity, 96.7% specificity, 76.6% accuracy; sensitivity: p < 0.005). CONCLUSIONS: PET was more sensitive than CT in the detection of nodal metastases and may improve staging of squamous cell carcinoma of the esophagus.