Systemic inflammation score as a predictor of death within one year after esophagectomy.

BACKGROUND: After radical resection for esophageal cancer, death within 1 year of surgery can occur due both to recurrence and to other diseases, even after postoperative complications have been overcome. This study identified risk factors for early death within 1 year of esophagectomy for reasons other than death in hospital in patients undergoing esophagectomy for esophageal cancer or esophagogastric junction cancer. METHODS: We reviewed 366 patients who underwent esophagectomy without adjuvant treatment between January 2009 and July 2022 for thoracic esophageal cancer or esophagogastric junction cancer. Patients who died within 1 year excluding in-hospital death were compared with those who did not. Multivariable logistic regression analysis was used to identify predictors of death within 1 year after surgery. RESULTS: Death within 1 year occurred in 32 of 366 patients, 24 from primary disease and 8 from other diseases. Deaths within 1 year were significantly older than the other cases, had significantly lower % vital capacity (%VC), and occurred significantly more often in cases in advanced stages of disease. In a multivariable analysis, a systemic inflammation score (SIS) based on serum albumin level and lymphocyte-to-monocyte ratio was identified as an independent predictor of death within 1 year. As SIS increased, %VC decreased significantly, and CRP level and neutrophil-lymphocyte ratio increased significantly. There was no relationship between SIS and pN. Death within 1 year increased as SIS increased (p = 0.001 for trend). CONCLUSION: SIS assessment undertaken before beginning esophageal cancer treatment is a useful predictor of death within 1 year of surgery.

Skeletal Muscle Loss During Neoadjuvant Chemotherapy Predicts the Incidence of Postoperative Infectious Complications in Esophageal Cancer Patients Undergoing Esophagectomy.

BACKGROUND/AIM: Malnutrition, immune deficiency, and skeletal muscle loss are associated with a risk of postoperative complications in patients with various types of cancer. This study evaluated whether malnutrition, immunological deficiencies, and skeletal muscle loss during neoadjuvant chemotherapy (NAC) predict postoperative complications in patients with esophageal cancer. PATIENTS AND METHODS: We retrospectively reviewed 123 patients with esophageal squamous cell carcinoma treated with NAC and esophagectomy at our hospital between 2014 and 2019. Patients were divided into two groups based on the presence or absence of postoperative infectious complications, such as pneumonia, anastomotic leakage, surgical site infections, pyothorax, acalculous cholecystitis, and peripheral phlebitis. Neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and Onodera prognostic nutritional index were used as indicators of systemic inflammation and nutritional status. Skeletal muscle mass was evaluated using the skeletal muscle index (SMI), calculated by evaluating the total cross-sectional area of muscle tissue at the third lumbar level in computed tomography imaging. Univariable and multivariable logistic regression analyses were used to identify predictors of postoperative infectious complications. RESULTS: Postoperative infectious complications occurred in 41 patients (33.3%). A reduction in SMI was observed in 105 patients (87.8%) during NAC. Univariable and multivariable analyses indicated that the reduction in SMI during NAC was an independent predictor of postoperative complications (odds ratio=0.89; 95% confidence interval=0.79-0.99; p=0.048). CONCLUSION: Skeletal muscle loss during NAC is a useful predictor of postoperative complications in patients with esophageal cancer undergoing esophagectomy.

Esophageal cancer presenting with brain abscess.

A 76-year-old man experienced fatigue and progressive dysphagia. He underwent endoscopy at another hospital and was diagnosed with thoracic esophageal cancer. Three days after the endoscopy, the patient was rushed to our hospital with sudden seizures of the right upper and lower extremities. Contrast-enhanced computed tomography scan revealed a ring-shaped contrast-enhanced mass formation in the left parietal lobe with edema in the surrounding brain parenchyma. Contrast-enhanced magnetic resonance imaging showed a ring-shaped lesion with a high intensity on diffusion-weighted images. He was diagnosed with a brain abscess in the left parietal lobe. For abscess drainage, a quasi-emergent small craniotomy was performed. Culture of the drainage fluid revealed Streptococcus species and Haemophilus parainfluenzae. After 6 weeks of antibiotic therapy, the patient underwent a thoracoscopic esophagectomy. After the esophagectomy, there was no recurrence of the brain abscess for more than 2 years and only symptomatic epilepsy remained. Conclusively, although brain abscesses caused by esophageal cancer are rare, the possibility of brain abscess and metastasis should be considered when patients present with convulsions or higher brain disorders.

Duodenal Heterotopic Pancreas with a Large Retention Cyst: A Case Report and Literature Review.

A 75-year-old man was referred to our hospital with a suspected pancreatic cyst. Imaging tests revealed a 3-cm cystic lesion located ventrally in the duodenal bulbus, which was suspected to be a duplication cyst with its muscularis propria contiguous to that of the duodenum. One year later, the cyst grew to 6 cm due to intracystic hemorrhaging; therefore, surgery was performed. Histopathology revealed a heterotopic pancreas (HP) in the duodenal wall. The diagnosis was a large, non-malignant retention cyst. Inflammation due to impaired outflow of pancreatic juice from the HP was identified as the cause of cyst enlargement.

The impact of the American Society of Anesthesiology-Physical Status classification system on the treatment and prognosis of patients with esophageal cancer undergoing esophagectomy.

BACKGROUND: The American Society of Anesthesiologists-Physical Status (ASA-PS) classification system has been shown to predict morbidity and mortality after surgery. However, the impact of the ASA-PS on esophageal cancer treatment remains unclear. This study examined both the impact of the ASA-PS on treatment, including surgery and perioperative chemotherapy, and the prognostic effects of ASA-PS class in patients who had undergone esophagectomy for thoracic esophageal cancer or esophagogastric junction cancer. METHODS: ASA-PS status was collected for 301 patients who had undergone esophagectomy between January 2007 and June 2016 for thoracic esophageal cancer or esophagogastric junction cancer at a single institution. As the ASA-PS was updated in 2014, the previous classifications of all patients were reevaluated using the updated standard by a surgeon with the previous classifications masked. The dose intensity of preoperative chemotherapy was also compared across classes. Multivariate Cox regression analysis was used to analyze the association between ASA-PS class and overall survival. RESULTS: Patients whose reevaluations had placed them in a more severe ASA-PS class showed significantly poorer overall and cancer-specific survival rates. The dose intensities of cisplatin and 5-fluorouracil for preoperative chemotherapy were significantly lower in patients in the more severe ASA-PS classes. Multivariate analysis showed that ASA-PS class was an independent prognostic factor for overall survival. CONCLUSION: Preoperative ASA-PS classification may influence the intensity of perioperative treatment and may be a valuable long-term prognostic factor for patients with esophageal cancer undergoing esophagectomy.

Relationship between the serum cancer antigen 125 level and the weight of surgically enucleated adenomyosis.

Elevated serum levels of cancer antigen 125 (CA125) are known to occur in adenomyosis. However, the relationship between the severity of adenomyosis and serum CA125 levels has not yet been elucidated. The present study aimed to examine the correlation between the weight of adenomyosis and the serum CA125 level. This retrospective study, after applying exclusion criteria, investigated 308 patients who underwent conservative surgery for adenomyosis. Serum CA125 levels were measured before surgery and weights of surgically enucleated adenomyosis were measured in the operating room. Both serum CA125 and surgically enucleated adenomyosis weight showed log-normal distributions. Pearson's product-moment correlation coefficient for the logarithmically converted values was 0.617 (95% confidence interval, 0.54-0.68).The serum CA125 level correlated positively with the weight of adenomyosis. Although the qualitative characteristics and clinical significance of adenomyosis lesions remain unclear, it seems that the investigation of the relative relationship between the serum CA125 level and the size of the affected lesion is useful to observe one of the qualitative features of adenomyosis. Furthermore, the present study supports the use of postoperative serum CA125 levels as an important indicator for determining the therapeutic effects of conservative surgical treatment for adenomyosis and detecting early signs of recurrence. Impact StatementWhat is already known on this subject? Elevated serum cancer antigen 125 (CA125) levels are known to occur in adenomyosis and are widely recognised as helpful in the diagnosis of adenomyosis.What do the results of this study add? There is a positive correlation between the serum CA125 level and the weight of adenomyosis.What are the implications of these findings for clinical practice and/or further research? The postoperative serum CA125 level is an important indicator for evaluating the extent of the affected lesion remaining after conservative surgical treatment for adenomyosis and also helpful for detecting early signs of recurrence. Further study is required to examine whether it is possible to clarify the qualitative characteristics of adenomyosis in each different case based on the CA125-producing ability of the lesion.

Risk Factors for Candidiasis as an Intra-Abdominal Infection after Gastrectomy in Patients with Gastric Cancer.

Intra-abdominal infections (IAIs) develop in 2.4%-26.6% of patients who underwent gastrectomy for gastric cancer and are occasionally serious. However, there are few reports on the causative organisms of IAI following upper gastrointestinal tract surgery and subsequent risk factors for Candida infections. This study aimed to identify the microorganisms that cause IAIs after gastrectomy and risk factors for Candida-related IAI. The records of patients who underwent gastrectomy for gastric cancer between January 2009 and December 2019 at Shizuoka General Hospital were retrospectively collected. Patients with IAIs of grade II or higher, as measured by the Clavien-Dindo classification, were included in the analysis. The selected patients were divided into the Candida and non-Candida groups according to the presence or absence of Candida as the causative organism. Of 1,379 patients, 56 (4.1%) were diagnosed with IAIs after gastrectomy. Fifty-two patients were included in the study based on culture analyses. A total of 111 strains and 28 bacterial species were isolated during the initial culture test. Candida constituted 7.2% of all identified pathogens. Regarding the risk factors for Candida-related IAI, a history of antimicrobial use and ≥ 4 postoperative days of IAI development were independent risk factors for Candida-related IAI.

Comparison of short-term outcomes between transthoracic and robot-assisted transmediastinal radical surgery for esophageal cancer: a prospective study.

BACKGROUND: The present study aimed to assess the lower invasiveness of robot-assisted transmediastinal radical esophagectomy by prospectively comparing this procedure with transthoracic esophagectomy in terms of perioperative outcomes, serum cytokine levels, and respiratory function after surgery for esophageal cancer. METHODS: Patients who underwent a robot-assisted transmediastinal esophagectomy or transthoracic esophagectomy between April 2015 and March 2017 were included. The perioperative outcomes, preoperative and postoperative serum IL-6, IL-8, and IL-10 levels, and respiratory function measured preoperatively and at 6 months postoperatively were compared in patients with a robot-assisted transmediastinal esophagectomy and those with a transthoracic esophagectomy. RESULTS: Sixty patients with esophageal cancer were enrolled. The transmediastinal esophagectomy group had a significantly lower incidence of postoperative pneumonia (p = 0.002) and a significantly shorter postoperative hospital stay (p < 0.0002). The serum IL-6 levels on postoperative days 1, 3, 5, and 7 were significantly lower in the transmediastinal esophagectomy group (p = 0.005, 0.0007, 0.022, 0.020, respectively). In the latter group, the serum IL-8 level was significantly lower immediately after surgery and on postoperative day 1 (p = 0.003, 0.001, respectively) while the serum IL-10 level was significantly lower immediately after surgery (p = 0.041). The reduction in vital capacity, percent vital capacity, forced vital capacity, and forced expiratory volume at 1.0 s 6 months after surgery was significantly greater in the transthoracic esophagectomy group (p < 0.0001 for all four measurements). CONCLUSIONS: Although further, large-scale studies are needed to confirm our findings, robot-assisted transmediastinal esophagectomy may confer short-term benefits in radical surgery for esophageal cancer. TRIAL REGISTRATION: This trial was registered in the UMIN Clinical Trial Registry ( UMIN000017565 14/05/2015).

Esophageal inflammatory pseudotumor with low-dose corticosteroid therapy after surgery.

Inflammatory pseudotumors of the esophagus are extremely rare, and the treatment has been controversial. Herein, we report a case of esophageal inflammatory pseudotumor with low-dose corticosteroid treatment following surgery. A 50-year-old woman with a 3-month history of progressive dysphagia and weight loss, was admitted to our hospital for examination and treatment. Esophagography and endoscopic examination revealed a mass present from the cervical esophagus to the upper thoracic esophagus with severe esophageal stricture. Ultrasound-guided fine needle aspiration cytology, boring biopsy, and mucosal incision-assisted biopsy reveal chronic inflammation, but histological diagnosis was not proven. Surgery was performed to confirm diagnosis and to relieve esophageal stricture. However, because of dense adhesions around the tumor, complete tumor resection was not achieved. Histopathological examination showed an inflammatory infiltrate with plasma cells, eosinophils, neutrophils, and lymphocytes, suggesting an inflammatory pseudotumor. After surgical resection, the esophageal stricture remained, possibly due to the residual tumor. We used a postoperative low-dose steroid treatment that resulted in complete resolution. There has not been any evident sign of recurrence for more than 2 years.

Preoperative skeletal muscle index and visceral-to-subcutaneous fat area ratio are associated with long-term outcomes of elderly gastric cancer patients after gastrectomy.

PURPOSE: Sarcopenia is a risk factor of severe surgical complications, short-term outcomes, and long-term outcomes for patients with gastric cancer. Several computed tomography (CT) measurements have been performed to diagnose sarcopenia. However, the optimal CT measurements for determining long-term outcomes have not been revealed. METHODS: A retrospective review of gastric cancer patients with clinical stage I, II, or III who underwent gastrectomy at age 75 years or more at Shizuoka General Hospital from 2007 to 2015 was performed. Using preoperative CT, skeletal muscle index (SMI), total psoas area, intramuscular adipose tissue content in multifidus muscle, morphologic change of psoas muscle, and visceral-to-subcutaneous adipose tissue area ratio (VSR) were measured in the third lumbar section. A Cox regression analysis was used to explore prognostic factors for overall survival. RESULTS: A total of 257 patients were reviewed. There were 171, 53, and 33 patients with clinical stages I, II, and III, respectively. A multivariate analysis indicated that, in addition to age, performance status, clinical stage, and types of resection, which are known prognostic factors, SMI and VSR are prognostic factors (p = 0.016, 0.046, respectively). The prognostic score, which was the frequency of positive SMI and VSR values within the cutoff, also indicates overall survival. The five-year OS rates of patients with prognostic scores of 0, 1, and 2 were 90.9%, 62.3%, and 52%, respectively (p < 0.001). CONCLUSION: Preoperative SMI and VSR were prognostic factors for the overall survival of elderly patients with gastric cancer after gastrectomy.

Hand-assisted robotic surgery in the abdominal phase of robot-assisted oesophagectomy.

Robot-assisted minimally invasive oesophagectomy (RAMIE) has been developed to overcome the technical limitations of conventional thoracoscopic oesophagectomy. Hand-assisted laparoscopic surgery (HALS) is used as a practical and useful technique during the abdominal phase of thoracoscopic oesophagectomy. During RAMIE, a robotic vessel sealer cannot be used with HALS; another vessel sealer or ultrasonic coagulating device for laparoscopic surgery is required. We report an initial experiment using hand-assisted robotic surgery (HARS) for abdominal manipulation during RAMIE as a novel method. Under the pneumoperitoneum induced by insufflating the abdomen to 10 mmHg with carbon dioxide, the assistant surgeon lifted the stomach and greater omentum using the left hand through a 7 cm upper abdominal midline incision at approximately 2 cm below the xiphoid. Subsequently, gastric mobilisation was performed by robot-assisted surgery. Between January 2019 and February 2020, eight patients with thoracic oesophageal cancer underwent RAMIE with HARS at our hospital. The median operative time for extracorporeal manipulation and preparation for the roll-in of the robot was 39.5 min. The median console time was 47.5 min. There were no intraoperative or postoperative complications related to the use of the robot and no in-hospital mortality. In conclusion, HARS seems to be feasible and safe for abdominal manipulation during oesophageal cancer surgery.

Duplicate left gastric artery identified during laparoscopic distal gastrectomy.

The reported incidence of duplicate left gastric artery is not very low, with a rate of 0.4%. However, there have been no reports of the surgical management of patients with a duplicate left gastric artery. Here, we report a 60-year-old Japanese man diagnosed with clinical T1bN0M0 stage IA gastric cancer. Preoperative 5-mm slice CT showed no anatomical abnormality, and the patient underwent laparoscopic distal gastrectomy. When we dissected the nerve plexus around the left gastric artery with an ultrasonic vessel-sealing device, pulsating bleeding was observed from a small vessel in the nerve plexus. The bleeding was stopped by suture and clipping. A 1.2-mm vessel was identified on 1-mm slice preoperative CT and postoperative CT angiography. The patient was discharged without any complications. To the best of our knowledge, this is the first report of a patient undergoing surgery for a duplicate left gastric artery.

One-by-One Comparison of Lymph Nodes Between 18F-FDG Uptake and Pathological Diagnosis in Esophageal Cancer.

PURPOSE: Esophagectomy with extended lymph node (LN) dissection is a standard treatment for resectable esophageal cancer to prevent recurrence, but severe, potentially life-threatening postoperative complications are still important issues. Accurate diagnosis of LN metastases would enable the decision to dissect or leave the LNs in regions with high risk of complications. Advancements in intraoperative gamma probe and radioactivity detectors have made intraoperative navigation surgery possible using a radiotracer as a marker. F-FDG is one such candidate markers, and the diagnostic power of FDG through counting the radioactivity close to each LN should be elucidated. MATERIALS AND METHODS: In 20 patients, 1073 LNs including 38 metastatic LNs were prospectively investigated. Preoperative FDG PET was performed on the same day before esophagectomy and visually surveyed in each LN station to identify abnormal uptake. The FDG radioactivity of each individual dissected LN was measured by a well-type counter, and the pathological diagnosis was compared with LN radioactivity on a one-by-one basis and with the preoperative FDG PET findings for each LN station. RESULTS: Lymph node station-based analysis showed a sensitivity and specificity of 28.6% and 96.7%, respectively. One-by-one LN-based analysis using a cutoff value obtained from the receiver operating characteristic curve showed a sensitivity and specificity of 94.7% and 78.7%, respectively, demonstrating higher accuracy compared with the use of LN weight or the shortest diameter. CONCLUSIONS: The FDG uptake by each LN is a potentially useful marker for navigation surgery in esophageal cancer and has higher accuracy than LN weight or diameter.

Size of the thoracic inlet predicts cervical anastomotic leak after retrosternal reconstruction after esophagectomy for esophageal cancer.

BACKGROUND: Although an anastomotic leak after esophagectomy is one of the most common postoperative complications, it is not well understood whether specific anatomic factors of the different route of reconstruction can predispose to the development of anastomotic leak after esophagectomy. This study aimed to clarify whether various factors related to the size of the thoracic inlet are independent predictors of anastomotic leak after esophagectomy. METHODS: We reviewed 248 patients who underwent esophagectomy with retrosternal reconstruction of the gastric conduit between January 2013 and March 2019. Various factors related to the size of the thoracic inlet were measured using computed tomography. Multivariate logistic regression was used to analyze the association between various measurements and anastomotic leak. RESULTS: Anastomotic leak occurred in 38 patients (15.3%). On univariate analysis, the thickness of the sternum, the thickness of the clavicle, the sternum-trachea distance, the ratio of the sternum-trachea distance/sternum-vertebral body distance, sex, body mass index, and method of anastomosis were statistically significantly associated with anastomotic leak. On multivariate analysis, the ratio of the sternum-trachea distance/sternum-vertebral body distance and the method of anastomosis were the independent risk factors for anastomotic leak. CONCLUSION: The ratio of the sternum-trachea distance/sternum-vertebral body distance is associated with cervical anastomotic leak after retrosternal gastric conduit reconstruction after esophagectomy. Measurement of the thoracic inlet space may contribute to preoperative planning, such as for the route of the conduit for reconstruction and anastomotic site.

Associations of Systemic Inflammation and Sarcopenia With Survival of Esophageal Carcinoma Patients.

BACKGROUND: Although both sarcopenia and systemic inflammation reportedly affect long-term outcomes of esophageal carcinoma (EC) patients, their reciprocal associations with survival outcomes have yet to be investigated. This study aimed to evaluate the survival impact of sarcopenia combined with the neutrophil-to-lymphocyte ratio (NLR) in EC patients undergoing esophagectomy. METHODS: In total, 378 EC patients were retrospectively reviewed. The cutoff value for NLR was set at the NLR median of the cohort. Sarcopenia was determined based on decreased skeletal muscle index calculated from computed tomography obtained before surgery. Univariate and multivariate Cox hazards models were applied to determine independent predictors of poor overall survival and cancer-specific survival. RESULTS: Sarcopenia was more common in the high-NLR group (2.57 or greater) than in the low-NLR group (less than 2.57; P = .01). In the high-NLR group, patients with sarcopenia had significantly poorer overall and cancer-specific survival than those without sarcopenia (P < .001). In contrast, there was no survival impact of sarcopenia in the low-NLR group. Patients with both high NLR and sarcopenia exhibited poor overall and cancer-specific survival (5-year overall survival = 44.4%, 5-year cancer-specific survival = 57.0%). Sarcopenia was independently associated with poor overall survival (hazard ratio = 1.95; P = .007) and poor cancer-specific survival (hazard ratio = 2.66; P = .002) as well as pathological stage III disease and noncurative resection in the high-NLR group. CONCLUSIONS: The survival and oncological impact of sarcopenia was noteworthy only when present with elevated NLR. The combination of 2 factors is rational for identifying EC patients likely to have poor survival outcomes.

Preoperative restrictive pulmonary dysfunction influences the survival after gastrectomy for elderly patients with gastric carcinoma.

PURPOSE: We aimed to evaluate the prognostic impact of pulmonary dysfunctions and their relationships with other possible prognostic factors, especially sarcopenia, in elderly patients with gastric carcinoma (GC). METHODS: In total, 402 elderly GC patients (≥ 75 years) who underwent radical gastrectomy were retrospectively reviewed. Restrictive and obstructive pulmonary dysfunction were defined as %VC < 80% and FEV1.0% < 70%, respectively. RESULTS: Forty-two patients (10.4%) had a low %VC, which was associated with ASA-PS, comorbidity and sarcopenia while correlating with neither the FEV1.0% nor pathological variables. The overall survival in the low %VC group was significantly worse than that in the high %VC group, especially in those with pStage I/II diseases. The survival was not stratified by FEV1.0%. Non-gastric cancer-related deaths were more prevalent in the low %VC group than in the high %VC group. The cancer-specific survival showed no significant differences between the two groups. A multivariate analysis revealed a low %VC to be the most powerful predictor of a poor survival among all independent variables, including sex, age, comorbidity, total gastrectomy, and pStage. Patients with both a low %VC and sarcopenia showed an extremely poor survival. CONCLUSIONS: Preoperative restrictive pulmonary dysfunction was independently associated with poor survival outcomes, especially when present in combination with sarcopenia, due to an increased risk of death from non-cancer-related causes.

Pre- and post-operative low prognostic nutritional index influences survival in older patients with gastric carcinoma.

OBJECTIVES: The survival impact of the preoperative prognostic nutritional index (PNI) has been investigated in older patients with gastric carcinoma (GC), while that of the postoperative PNI has yet to be addressed. We evaluated the significance of PNI before and after surgery in older GC patients (≥75 years). MATERIALS AND METHODS: In total, 309 older GC patients undergoing radical gastrectomy between 2006 and 2016 were retrospectively reviewed. The PNI was evaluated before and at six months after gastrectomy. Patients were divided into low (<45) and high (≥45) PNI groups. The impact of low PNI on overall survival (OS), cancer-specific survival (CSS), and non-GC-related death were investigated. RESULTS: Low PNI was present in 134 patients (43.4%) preoperatively and 121 (39.2%) postoperatively. Low pre-PNI was independently associated with poor overall survival (P < .001). Similarly, OS was significantly stratified by post-PNI (P < .001). The significant survival difference according to post-PNI was present only in pStage I disease (P < .001). Low post-PNI independently increased the risk of non-GC-related death in a multivariable analysis (P = .002). In contrast, CSS was not stratified by post-PNI (P = .45). In the high pre-PNI group, total gastrectomy and super-older age (≥80 years) independently increased the risk of low post-PNI, which was significantly associated with poor survival outcomes. CONCLUSIONS: Pre- and post-operative PNI are useful for predicting long-term outcomes in older patients with GC. Low postoperative PNI is a powerful determinant of mortality due to other diseases. Optimal perioperative management is required for those at high risk of malnutrition postoperatively.

Long-term health-related quality of life following robot-assisted radical transmediastinal esophagectomy.

BACKGROUND: The good short-term and oncological outcomes of robot-assisted radical esophagectomy have been demonstrated, although its impact on long-term health-related quality of life (HRQoL) remains to be investigated. This study aimed to assess long-term HRQoL in patients after robot-assisted radical transmediastinal esophagectomy (TME), which is characterized as non-transthoracic esophagectomy comprising a robotic transhiatal approach and a video-assisted cervical approach, and transthoracic esophagectomy (TTE). METHODS: The European Organization for Research and Treatment of Cancer generic and disease-specific modules (QLQ-C30 and QLQ-OES18), nutritional status and body composition data were prospectively collected in patients undergoing TME or TTE before and at 3, 6, 12, 18, and 24 months after surgery. The results of long-term (≥ 2 years) survivors without recurrence were compared between the two groups. RESULTS: A total of 37 patients (TME; n = 18, TTE; n = 19) were included for analysis. Longitudinal survey of function scales revealed scores of physical, role, social, and emotional function to be significantly better in the TME group than in the TTE group at many points postoperatively. Markedly, the symptoms of general pain, esophageal pain, and dry mouth greatly worsened after surgery in the TTE group, but did not deteriorate in the TME group. In contrast, symptoms relating to eating difficulties, body composition data, and nutritional status did not differ between the groups over time. At 24 months after surgery, TME provided significantly higher scores of global QOL (P = 0.01) and emotional function (P = 0.01) and also resulted in significantly fewer problems of fatigue (P = 0.04), general pain (P = 0.04), insomnia (P = 0.02), and dry mouth (P = 0.03), as compared to TTE. CONCLUSION: This study indicates that TME can provide better long-term HRQoL outcomes than TTE.

Long-term outcomes of multimodal therapy combining definitive chemoradiotherapy and salvage surgery for T4 esophageal squamous cell carcinoma.

BACKGROUND: Survival outcomes of patients with cT4 esophageal squamous cell carcinoma (ESCC) remain extremely poor. We aimed to investigate long-term outcomes and identify prognostic factors in patients treated by definitive chemoradiotherapy (dCRT) alone or with dCRT plus salvage surgery (SALV) for cT4 ESCC. PATIENTS AND METHODS: In total, 73 patients completing dCRT were analyzed. Patients achieving clinical complete response (CR) received follow-up evaluations thereafter. For patients diagnosed with clinical partial response (PR), potentially curative SALV was generally performed. Possible prognostic factors included demographic data, tumor staging, blood chemistry profiles, and esophageal stenosis. RESULTS: The 1- and 3-year overall survival (OS) rates of the 73 patients were 67.1% and 40.8%, respectively. Twenty-one patients (29%) achieved clinical CR with dCRT alone. Among 35 patients (48%) with clinical PR, 31 underwent SALV and 4 opted for non-surgical treatments. In the dCRT-alone group (n = 42), patients with clinical CR-PR (n = 25) showed significantly better 3-year OS than those who responded poorly to dCRT (stable or progressive) (n = 17) (67.5% vs. 0%, P < 0.001). In the SALV group (n = 31), curative SALV (n = 22, 73%) provided significantly better 3-year OS than non-curative SALV (58.7% vs. 0%, P < 0.001). Multivariable analysis revealed stenosis before dCRT (P = 0.02) and pretreatment elevated CRP (P = 0.02) to be independently associated with poor outcomes. CONCLUSIONS: The multimodal treatment strategy combining dCRT and SALV is rational for treating cT4 ESCC patients. When curative resection is feasible, SALV can provide good long-term survival outcome for patients who responded to dCRT but did not achieve clinical CR with dCRT alone.