Efficacy and safety of esophagectomy via left thoracic approach versus via right thoracic approach for middle and lower thoracic esophageal cancer: a multicenter randomized clinical trial (NST1501).

Background: Left thoracic approach (LTA) has been a favorable selection in surgical treatment for esophageal cancer (EC) patients in China before minimally invasive esophagectomy (MIE) is popular. This study aimed to demonstrate whether right thoracic approach (RTA) is superior to LTA in the surgical treatment of middle and lower thoracic esophageal squamous cell carcinoma (TESCC). Methods: Superiority clinical trial design was used for this multicenter randomized controlled two-parallel group study. Between April 2015 and December 2018, cT1b-3N0-1M0 TESCC patients from 14 centers were recruited and randomized by a central stratified block randomization program into LTA or RTA groups. All enrolled patients were followed up every three months after surgery. The software SPSS 20.0 and R 3.6.2. were used for statistical analysis. Efficacy and safety outcomes, 3-year overall survival (OS) and disease-free survival (DFS) were calculated and compared using the Kaplan-Meier method and the log-rank test. Results: A total of 861 patients without suspected upper mediastinal lymph nodes (umLN) were finally enrolled in the study after 95 ineligible patients were excluded. 833 cases (98.7%) were successfully followed up until June 1, 2020. Esophagectomies were performed via LTA in 453 cases, and via RTA in 408 cases. Compared with the LTA group, the RTA group required longer operating time (274.48±78.92 vs. 205.34±51.47 min, P<0.001); had more complications (33.8% vs. 26.3% P=0.016); harvested more lymph nodes (LNs) (23.61±10.09 vs. 21.92±10.26, P=0.015); achieved a significantly improved OS in stage IIIa patients (67.8% vs. 51.8%, P=0.022). The 3-year OS and DFS were 68.7% and 64.3% in LTA arm versus 71.3% and 63.7% in RTA arm (P=0.20; P=0.96). Conclusions: Esophagectomies via both LTA and RTA can achieve similar outcomes in middle or lower TESCC patients without suspected umLN. RTA is superior to LTA and recommended for the surgical treatment of more advanced stage TESCC due to more complete lymphadenectomy. Trial Registration: ClinicalTrials.gov NCT02448979.

Nomogram for predicting the overall survival of the patients with oesophageal signet ring cell carcinoma.

BACKGROUND: The purpose of this study was to explore the prognostic factors of oesophageal signet ring cell (SRC) carcinoma and to construct a nomogram for predicting the outcome of SRC carcinoma of oesophagus. METHODS: A total of 968 cases of oesophageal SRC carcinoma were extracted from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2016. Cases were divided into training cohort and validation cohort. Univariate and multivariable Cox analyses was performed to select the predictors of overall survival (OS for the nomogram. The performance of nomogram was validated with Harrell's concordance index (C-index), calibration curves and decision curve analysis (DCA). RESULTS: The 1- and 5-year OS in the training cohort were 0.446 and 0.146, respectively, and the 1- and 5-year OS in the validation cohort were 0.459 and 0.138. The independent prognostic factors for establishing the nomogram were marital status, invasion of the surrounding tissue, lymph node metastasis, distant metastasis, surgery and chemotherapy. The Harrell's c-index value of the training cohort and validation cohort were 0.723 and 0.708. In the calibration curves, the predicted survival probability and the actual survival probability have a considerable consistency. DCA indicated the favourable potential clinical utility of the nomogram. CONCLUSIONS: A nomogram to predict the OS of patients with oesophageal SRC carcinoma was established. The validation of the nomogram fully demonstrates its great performance.

Clinical recommendations for perioperative immunotherapy-induced adverse events in patients with non-small cell lung cancer.

Perioperative adjuvant treatment has become an increasingly important aspect of the management of patients with non-small cell lung cancer (NSCLC). In particular, the success of immune checkpoint inhibitors, such as antibodies against PD-1 and PD-L1, in patients with lung cancer has increased our expectations for the success of these therapeutics as neoadjuvant immunotherapy. Neoadjuvant therapy is widely used in patients with resectable stage IIIA NSCLC and can reduce primary tumor and lymph node stage, improve the complete resection rate, and eliminate microsatellite foci; however, complete pathological response is rare. Moreover, because the clinical benefit of neoadjuvant therapy is not obvious and may complicate surgery, it has not yet entered the mainstream of clinical treatment. Small-scale clinical studies performed in recent years have shown improvements in the major pathological remission rate after neoadjuvant therapy, suggesting that it will soon become an important part of NSCLC treatment. Nevertheless, neoadjuvant immunotherapy may be accompanied by serious adverse reactions that lead to delay or cancellation of surgery, additional illness, and even death, and have therefore attracted much attention. In this article, we draw on several sources of information, including (i) guidelines on adverse reactions related to immune checkpoint inhibitors, (ii) published data from large-scale clinical studies in thoracic surgery, and (iii) practical experience and published cases, to provide clinical recommendations on adverse events in NSCLC patients induced by perioperative immunotherapy.

Log odds of positive lymph nodes is a better prognostic factor for oesophageal signet ring cell carcinoma than N stage.

BACKGROUND: Signet ring cell carcinoma is a rare type of oesophageal cancer, and we hypothesized that log odds of positive lymph nodes (LODDS) is a better prognostic factor for oesophageal signet ring cell carcinoma. AIM: To explore a novel prognostic factor for oesophageal signet ring cell carcinoma by comparing two lymph node-related prognostic factors, log odds of positive LODDS and N stage. METHODS: A total of 259 cases of oesophageal signet ring cell carcinoma after oesopha-gectomy were obtained from the Surveillance, Epidemiology, and End Results database between 2006 and 2016. The prognostic value of LODDS and N stage for oesophageal signet ring cell carcinoma was evaluated by univariate and multivariate analyses. The Akaike information criterion and Harrell's C-index were used to assess the value of two prediction models based on lymph nodes. External validation was performed to further confirm the conclusion. RESULTS: The 5-year cancer-specific survival (CSS) and 5-year overall survival (OS) rates of all the cases were 41.3% and 27.0%, respectively. The Kaplan-Meier method showed that LODDS had a higher score of log rank chi-squared (OS: 46.162, CSS: 41.178) than N stage (OS: 36.215, CSS: 31.583). Univariate analyses showed that insurance, race, T stage, M stage, TNM stage, radiation therapy, N stage, and LODDS were potential prognostic factors for OS (P < 0.1). The multivariate Cox regression model showed that LODDS was an significant independent prognostic factor for oesophageal signet ring carcinoma patients after surgical resection (P < 0.05), while N stage was not considered to be a significant prognostic factor (P = 0.122). Model 2 (LODDS) had a higher degree of discrimination and fit than Model 1 (N stage) (LODDS vs N stage, Harell's C-index 0.673 vs 0.656, P < 0.001; Akaike information criterion 1688.824 vs 1697.519, P < 0.001). The results of external validation were consistent with those in the study cohort. CONCLUSION: LODDS is a superior prognostic factor to N stage for patients with oesophageal signet ring cell carcinoma after oesophagectomy.

Clinical characteristics and medical service utilization of lung cancer in China, 2005-2014: Overall design and results from a multicenter retrospective epidemiologic survey.

OBJECTIVES: This study aimed to explore the clinical profile and its trajectory of lung cancer on clinicopathological characteristics and medical service utilization in China. METHODS: Patients diagnosed with primary lung cancer in tertiary hospitals during 2005-14 were selected from seven geographic regions of China. Data on clinical characteristics and medical service utilization was extracted from medical record, and the ten-year trends were explored. RESULTS: A total of 7184 patients were included, the mean age was 58.3 years and the male-to-female-ratio was 2.7. From 2005 to 2014, the proportion of ≥60 year-old patients increased from 41.2% to 56.2% (p < 0.001). The smoking rate decreased from 62.9% to 51.1% (p < 0.001) and the proportion of females increased from 23.5% to 31.9% (p < 0.001). The proportion of advanced stage increased from 41.9% to 47.4% (p < 0.001). Adenocarcinoma's proportion increased from 36.4% to 53.5% (p < 0.001) while that of squamous carcinoma decreased from 45.4% to 34.4% (p < 0.001). The application of chest X-ray dropped from 50.2% to 31.0% (p < 0.001) but that of chest CT increased from 65.8% to 81.4% (p < 0.001). As two main treatment options, chemotherapy (p = 0.290) and surgery (p = 0.497) remained stable. The medical expenditure per patient increased from 40,508 to 66,020 Chinese Yuan (p < 0.001). CONCLUSIONS: The sustaining high smoking exposure, increasing proportion of female patients, advancing clinical stage, shifting of predominant pathology and increasing medical expenditure demonstrate potential challenges and directions on lung cancer prevention and control in China. Despite substantial changes of clinical characteristics, main treatment options remained unchanged, which needs further investigation.

Clinicopathological parameters predicting recurrence of pT1N0 esophageal squamous cell carcinoma.

AIM: To identify the clinicopathological characteristics of pT1N0 esophageal squamous cell carcinoma (ESCC) that are associated with tumor recurrence. METHODS: We reviewed 216 pT1N0 thoracic ESCC cases who underwent esophagectomy and thoracoabdominal two-field lymphadenectomy without preoperative chemoradiotherapy. After excluding those cases with clinical follow-up recorded fewer than 3 mo and those who died within 3 mo of surgery, we included 199 cases in the current analysis. Overall survival and recurrence-free survival were assessed by the Kaplan-Meier method, and clinicopathological characteristics associated with any recurrence or distant recurrence were evaluated using univariate and multivariate Cox proportional hazards models. Early recurrence (≤ 24 mo) and correlated parameters were assessed using univariate and multivariate logistic regression models. RESULTS: Forty-seven (24%) patients had a recurrence at 3 to 178 (median, 33) mo. The 5-year recurrence-free survival rate was 80.7%. None of 13 asymptomatic cases had a recurrence. Preoperative clinical symptoms, upper thoracic location, ulcerative or intraluminal mass macroscopic tumor type, tumor invasion depth level, basaloid histology, angiolymphatic invasion, tumor thickness, submucosal invasion thickness, diameter of the largest single tongue of invasion, and complete negative aberrant p53 expression were significantly related to tumor recurrence and/or recurrence-free survival. Upper thoracic tumor location, angiolymphatic invasion, and submucosal invasion thickness were independent predictors of tumor recurrence (Hazard ratios = 3.26, 3.42, and 2.06, P < 0.001, P < 0.001, and P = 0.002, respectively), and a nomogram for predicting recurrence-free survival with these three predictors was constructed. Upper thoracic tumor location and angiolymphatic invasion were independent predictors of distant recurrence. Upper thoracic tumor location, angiolymphatic invasion, submucosal invasion thickness, and diameter of the largest single tongue of invasion were independent predictors of early recurrence. CONCLUSION: These results should be useful for designing optimal individual follow-up and therapy for patients with T1N0 ESCC.

Long-term survival of the middle and lower thoracic esophageal cancer patients after surgical treatment through left or right thoracic approach.

BACKGROUND: Esophageal cancer is one of the most prevalent malignancies with a high incidence and mortality in China, the main treatment for esophageal cancer at present is still surgery-based multimodality treatment, and surgery is still the most effective measure. However, the modes of surgical treatment for esophageal cancer have been diverse. The surgical approaches can be mainly divided into the left thoracic approach and right thoracic approach in China. The long-term survival of the patients treated through right approach was reported better than that through left thoracic approach, but until now no statistically significant difference was found between two approaches, especially, for those with middle and lower thoracic esophageal cancer without suspected upper mediastinal lymph node metastasis in preoperative examinations, no definite conclusion have been made on selection of the approach, therefore, this studies try to compare the long-term survival between two approaches . METHODS: The data of 402 cases with complete resection and two-field lymph node dissection from January, 2011 to December, 2011 in the Cancer Hospital, Chinese Academy of Medical Sciences was retrospectively reviewed and analyzed. Propensity score matching (PSM) analysis and life-table in SPSS 22.0 and Stata 14.0 were used to analyze the survival. RESULTS: Totally, 402 cases were surgically treated either via left or right thoracic approach. The overall 5-year survival rate of this series was 38%, it was 37% in 281 cases surgically treated through left approach, and 39% in 121 cases through right approach (P=0.908). The 5-year survival of 256 patients without suspected lymph node metastasis in the upper mediastinum based on the preoperative examinations surgically treated through left approach was 38% versus 43% of 88 cases through right approach (P=0.404). After PSM, the 5-year survival of 110 cases surgically treated through left approach was 32% versus 40% of another matched 110 cases through right approach (P=0.146). for the patients without suspected lymph node metastasis in the upper mediastinum based on preoperative examinations, the 5-year survival of 88 surgically treated through left approach was 33% versus 44% of another matched 88 cases through right approach (P=0.239). CONCLUSIONS: For the middle and lower thoracic esophageal cancer patients, whether or not who has suspected lymph node metastasis in the upper mediastinum based on preoperative CT and EUS, the surgical treatment through right thoracic approach can achieve better but not significantly better overall survival than that through left thoracic approach. Further prospective randomized clinical trials are still needed to verify this disputed issue on approach selection.

Surgery of primary non-small cell lung cancer with oligometastasis: analysis of 172 cases.

BACKGROUND: Previous studies have demonstrated that survival of patients with non-small cell lung cancer (NSCLC) with oligometastasis may benefit from local treatment. The purpose of this study was to compare the efficacy of local surgical treatment with systematic chemoradiotherapy in NSCLC with oligometastasis. METHODS: Data from a total of 172 patients with NSCLC with oligometastasis were collected at our Cancer Hospital from January 2006 to December 2016. The patients were divided into two groups: group A (82 cases) underwent primary surgical treatment and adjuvant chemotherapy was performed after operation, while group B (90 cases) received systematic chemotherapy and local radiotherapy. The median survival time (MST) and the 5-year survival rate of the two groups were compared and analyzed. The effects of various pathological types, surgical methods of the primary tumors and the site of oligometastasis were also analyzed. RESULTS: The MSTs in groups A and group B were 48 months and 18 months, respectively, and the 5-year survival rates were 21.1% and 7.6%, respectively (P<0.05). In group A, the survival rates were higher in patients with adrenal metastasis than patients with metastasis in the brain, bone, the liver or in other oligometastatic patients (P<0.05). There was no significant difference in the survival rate among the various pathological types or surgical methods of primary tumors (P>0.05). CONCLUSIONS: Local surgical treatment of primary lesions in NSCLC significantly prolonged overall survival and 5-year survival rates of patients with NSCLC with oligometastasis.

Long-term outcomes of 307 patients after complete thymoma resection.

BACKGROUND: Thymoma is an uncommon tumor without a widely accepted standard care to date. We aimed to investigate the clinicopathologic variables of patients with thymoma and identify possible predictors of survival and recurrence after initial resection. METHODS: We retrospectively selected 307 patients with thymoma who underwent complete resection at the Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (Beijing, China) between January 2003 and December 2014. The associations of patients' clinical characteristics with prognosis were estimated using Cox regression and Kaplan-Meier survival analyses. RESULTS: During follow-up (median, 86 months; range, 24-160 months), the 5- and 10-year disease-free survival (DFS) rates were 84.0% and 73.0%, respectively, and the 5- and 10-year overall survival (OS) rates were 91.0% and 74.0%, respectively. Masaoka stage (P < 0.001), World Health Organization (WHO) histological classification (P < 0.001), and postoperative radiotherapy after initial resection (P = 0.006) were associated with recurrence (52/307, 16.9%). Multivariate analysis revealed that, after initial resection, WHO histological classification and Masaoka stage were independent predictors of DFS and OS. The pleura (25/52, 48.0%) were the most common site of recurrence, and locoregional recurrence (41/52, 79.0%) was the most common recurrence pattern. The recurrence pattern was an independent predictor of post-recurrence survival. Patients with recurrent thymoma who underwent repeated resection had increased post-recurrence survival rates compared with those who underwent therapies other than surgery (P = 0.017). CONCLUSIONS: Masaoka stage and WHO histological classification were independent prognostic factors of thymoma after initial complete resection. The recurrence pattern was an independent predictor of post-recurrence survival. Locoregional recurrence and repeated resection of the recurrent tumor were associated with favorable prognosis.

A Model Predicting Lymph Node Status for Patients with Clinical Stage T1aN0-2M0 Nonsmall Cell Lung Cancer.

BACKGROUND: Lymph node status of patients with early-stage nonsmall cell lung cancer has an influence on the choice of surgery. To assess the lymph node status more correspondingly and accurately, we evaluated the relationship between the preoperative clinical variables and lymph node status and developed one model for predicting lymph node involvement. METHODS: We collected clinical and dissected lymph node information of 474 patients with clinical stage T1aN0-2M0 nonsmall cell lung cancer (NSCLC). Logistic regression analysis of clinical characteristics was used to estimate independent predictors of lymph node metastasis. The prediction model was validated by another group. RESULTS: Eighty-two patients were diagnosed with positive lymph nodes (17.3%), and four independent predictors of lymph node disease were identified: larger consolidation size (odds ratio [OR] = 2.356, 95% confidence interval [CI]: 1.517-3.658, P < 0.001,), central tumor location (OR = 2.810, 95% CI: 1.545-5.109, P = 0.001), abnormal status of tumor marker (OR = 3.190, 95% CI: 1.797-5.661, P < 0.001), and clinical N1-N2 stage (OR = 6.518, 95% CI: 3.242-11.697, P < 0.001). The model showed good calibration (Hosmer-Lemeshow goodness-of-fit, P < 0.766) with an area under the receiver operating characteristics curve (AUC) of 0.842 (95% [CI]: 0.797-0.886). For the validation group, the AUC was 0.810 (95% CI: 0.731-0.889). CONCLUSIONS: The model can assess the lymph node status of patients with clinical stage T1aN0-2M0 NSCLC, enable surgeons perform an individualized prediction preoperatively, and assist the clinical decision-making procedure.

Comparison of short-term outcomes and three yearsurvival between total minimally invasive McKeown and dual-incision esophagectomy.

BACKGROUND: The aim of this study was to compare the short-term outcomes and three-year survival between dual-incision esophagectomy (DIE) and total minimally invasive McKeown esophagectomy (MIME) for esophageal cancer patients with negative upper mediastinal lymph nodes requiring esophagectomy and neck anastomosis. METHODS: One hundred and fifty patients underwent DIE, while 361 patients received total MIME. Perioperative outcomes and three-year survival were compared in unmatched and propensity score matched data between two groups. RESULTS: Both unmatched and matched analysis demonstrated that there were no significant differences in the number of lymph nodes harvested, or major or minor complication rates between the DIE and MIME groups. Compared with patients who underwent DIE, patients who underwent total MIME had longer operation duration (310 minutes vs. 345 minutes; P = 0.002). However, there was significantly less intraoperative blood loss in the total MIME compared with the DIE group (191 mL vs. 287 mL, respectively; P < 0.001). Kaplan-Meier analysis demonstrated a trend that patients who underwent MIME had longer overall (79.5% vs. 64.1%; P = 0.063) and disease-free three-year survival (65.3% vs. 82.8%; P = 0.058) compared with patients who underwent DIE. CONCLUSIONS: Both total MIME and DIE are feasible for the surgical treatment of esophageal cancer patients with negative upper mediastinal lymph nodes requiring esophagectomy and neck anastomosis. However, MIME was associated with better overall and disease-free three-year survival compared with DIE.

Prognostic value of preoperative serum lactate dehydrogenase in thymic carcinoma.

BACKGROUND: The prognostic value of serum lactate dehydrogenase (LDH) has been demonstrated in various solid tumors. We attempted to determine whether serum LDH was predictive of survival in thymic carcinoma after surgical resection. METHODS: Ninety-five patients with thymic carcinoma treated in our hospital between January 2005 and December 2015 were retrospectively enrolled. Serum LDH was measured before surgery and categorized as low or high relative to the upper limit of normal (ULN) (225 U/L). The relationships of serum LDH level and other clinical variables with survival were estimated by Cox regression and Kaplan-Meier survival analysis. RESULTS: Serum LDH levels were found to be significantly associated with overall survival (OS) and progression-free survival (PFS) of these patients. The 1-, 3-, and 5-year PFS were 76%, 51%, and 38%, and the 1-, 3- and 5-year OS were 97%, 75%, and 46%, respectively. Univariate analysis found that high serum LDH (>225 U/L) was associated with both lower OS [hazard ratio (HR) =2.710; 95% confidence interval (CI): 1.363-1.5.391; P=0.004] and PFS (HR =3.365; 95% CI: 1.776-6.374; P<0.001). Multivariate analysis found that high serum LDH was associated with lower PFS (HR =2.122; 95% CI: 1.056-4.267; P=0.035). Moreover, high LDH was significantly associated with advanced Masaoka stage (P=0.001). CONCLUSIONS: High serum LDH (>225 U/L) was an independent predictor of decreased PFS in thymic carcinoma patients. It was also significantly associated with reduced OS, but was not an independent predictor of death in those patients.

Unilateral absence of pulmonary artery associated with contralateral lung cancer.

Unilateral absence of a pulmonary artery (UAPA) is a rare congenital cardiac malformation that is often associated with other cardiovascular deformities. Surgical repair of this rare condition is usually performed only on the abnormal lung. The occurrence of lung cancer in association with UAPA is even rarer and clinical experience is very limited. This report aims to describe a case of unilateral absence of right pulmonary artery that was complicated by primary carcinoma of the contralateral lung. A left lower lobectomy was performed despite the absence of the right pulmonary artery and repeated decreases in the arterial oxygen saturation (SaO2) were encountered intraoperatively. The current case provides insights into the operative tolerability and the foreseeable ominous prognosis after excision of the normal lung in patients with UAPA and highlights the importance of the clinical awareness of this potentially lethal congenital anomaly in light of its extreme rarity, which may facilitate better diagnosis and treatment of such patients.

A propensity matched comparison of effects between video assisted thoracoscopic single-port, two-port and three-port pulmonary resection on lung cancer.

BACKGROUND: To summarize our experiences of single-port, two-port vs. three-port VATS pulmonary resection for lung cancer patients. METHODS: Data of consecutive 1,553 patients who underwent video assisted thoracoscopic surgery (VATS) pulmonary resection for lung cancer in the Department of Thoracic Surgery of Cancer Hospital of Chinese Academy of Medical Sciences and Peking Union Medical College between November 2014 and January 2016 were prospectively collected and analyzed. A propensity-matched analysis was used to compare the short-term outcomes of lung cancer patients who received VATS single-port, two-port and three-port pulmonary resection. RESULTS: There were 716 males and 837 females. The mean age was 58.90 years (range, 25-82 years) and the conversion rate was 2.7% (42/1,553) in this cohort. After propensity score matching, there were 207 patients in single-port and two-port group, and 680 patients in three-port group. Propensity-matched analysis demonstrated that there were no significant differences in duration of operation (129 vs. 131 min, P=0.689), intra-operative blood loss (63 vs. 70 mL, P=0.175), number of dissected lymph nodes (12 vs. 13, P=0.074), total hospital expense (﹩9,928 vs. ﹩9,956, P=0.884) and cost of operation (﹩536 vs. ﹩535, P=0.879) between VATS single-port, two-port and conventional three-port pulmonary resection groups. There was no significant difference in the complication rate between two groups (5.3% vs. 4.7%, P=0.220). However, compared with three-port group, patients who underwent single port and two-port experienced shorter postoperative length of stay (6.24 vs. 5.61 d, P=0.033), shorter duration of chest tube (4.92 vs. 4.25 d, P=0.008), and decreased volume of drainage (926 vs. 791 d, P=0.003). CONCLUSIONS: The short term outcomes between VATS single-port, two-port and conventional three-port groups for the surgical treatment of lung cancer were comparable. However, compared with three-port VATS pulmonary resection, single-port and two-port were associated with shorter postoperative length of stay, shorter duration of chest tube, and decreased volume of drainage.

Prognostic value of preoperative neutrophil-lymphocyte ratio is superior to platelet-lymphocyte ratio for survival in patients who underwent complete resection of thymic carcinoma.

BACKGROUND: Preoperative neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) have prognostic value in patients with various operable tumors. The aim of our study was to determine whether NLR and PLR are predictive of survival in thymic carcinoma patients after complete resection. METHODS: A total of seventy-nine patients who underwent complete resection of thymic carcinoma at our hospital between January 2005 and December 2015 were retrospectively enrolled. Differential leukocyte counts were collected before surgery, and the relationships of NLR, PLR, and other patient clinical variables with survival were estimated by Cox regression analysis and Kaplan-Meier survival analysis. RESULTS: Univariate analysis found that a high level of NLR was associated with lower disease-free survival (DFS) (HR: 3.385, 95% CI: 1.073-10.678, P=0.037) and lower overall survival (OS) (HR: 12.836, 95% CI: 1.615-101.990, P=0.016). The optimal NLR threshold of 4.1 could stratify the patients with high risk of recurrence or metastasis (P=0.026) and death (P=0.006). Meanwhile, the NLR value of >4.1 in those patients was associated with bigger tumor size (P=0.035) and more advanced Masaoka stages (P=0.040) compared with NLR ≤4.1. However, the PLR and other variables were not significantly associated with survival in thymic carcinoma patients. CONCLUSIONS: The preoperative NLR of >4.1 was significantly associated with larger tumor size, more advanced Masaoka stages and reduced DFS and OS, but was not an independent predictor of survival in thymic carcinoma patients after complete resection.

The impact of operative approaches on outcomes of middle and lower third esophageal squamous cell carcinoma.

BACKGROUND: The aim of this study was to investigate the perioperative outcomes and 3-year overall survival (OS) of 2 approaches including Sweet and open Ivor Lewis esophagectomy in the surgical treatment of middle and lower third esophageal squamous cell carcinoma. METHODS: The medical records of 1,746 consecutive patients who underwent esophagectomy for middle and lower esophageal cancer between January 2009 and September 2015 at the First Department of Thoracic Oncologic Surgery of Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College were retrospectively reviewed. The clinical variables and 3-year survival were compared between Sweet (n=1,701) and open Ivor Lewis (n=45) approaches in unmatched and propensity score matching analysis. RESULTS: Patients who received esophagectomy by Sweet approach had shorter duration of surgery (mean 212 vs. 390 min; P<0.001), more lymph nodes removed (mean 24 vs. 19; P=0.005), lower overall complications rate (24.4% vs. 11.7%; P=0.009), lower total hospital cost (¥77,200 vs. 106,000; P=0.045) compared with patients who received open Ivor Lewis approach. After propensity score matching analysis, Sweet approach was still associated with decreased duration of surgery (mean 210 vs. 390 min; P<0.001), more lymph nodes removed (mean 24 vs. 19; P=0.050), and lower total hospital cost (¥86,800 vs. 106,000; P=0.045) compared with Ivor Lewis approach. However, there were no significant differences in overall complication rates (24.4% vs. 24.4%; P=1.000) between two approaches. There was no significant difference in 3-year OS between Sweet and open Ivor Lewis approaches (59.9% vs. 61.4%; P=0.637) in unmatched analysis and in matched analysis (77.8% vs. 61.4%; P=0.264). CONCLUSIONS: In this cohort, for middle and lower third esophageal squamous cell carcinoma patients, both Sweet and open Ivor Lewis approaches are feasible in terms of perioperative outcomes and 3-year OS.