Robot-assisted surgery outperforms video-assisted thoracoscopic surgery for anterior mediastinal disease: a multi-institutional study.

Anterior mediastinal procedures are increasingly being performed using robot-assisted thoracic surgery (RATS) or video-assisted thoracoscopic surgery (VATS). While both approaches have shown superior outcomes compared to open surgery, their comparative benefits are not as distinct. The aim of this retrospective study was to bridge this knowledge gap using a multicenter dataset. Patients who underwent elective minimally invasive surgery for anterior mediastinal disease between 2015 and 2022 were deemed eligible. The study participants were grouped based on whether a robot was used or not, and perioperative outcomes were compared. To mitigate selection bias, inverse probability of treatment weighting (ITPW) was applied using the propensity score. The final analysis included 312 patients (RATS = 120; VATS = 192). Following the application of IPTW, RATS was found to be associated with a longer operating time (215.3 versus 139.31 min, P < 0.001), fewer days with a chest tube (1.96 versus 2.61 days, P = 0.047), and a shorter hospital stay (3.03 versus 3.91 days, P = 0.041) compared to VATS. Subgroup analyses indicated that the benefit of RATS in reducing the length of hospital stay was particularly pronounced in patients with tumors larger than 6 cm (mean difference [MD] = - 2.28 days, P = 0.033), those diagnosed with myasthenia gravis (MD = - 3.84 days, P = 0.002), and those who underwent a trans-subxiphoid surgical approach (MD = - 0.81 days, P = 0.04). Both VATS and RATS are safe and effective approaches for treating anterior mediastinal disease. However, RATS holds distinct advantages over VATS including shorter hospital stays and reduced chest tube drainage periods.

Effect of peroral endoscopic myotomy on growth and esophageal motility for pediatric esophageal achalasia.

BACKGROUND/PURPOSE: Peroral endoscopic myotomy (POEM), a novel minimally invasive treatment for esophageal achalasia, has been shown to be effective and safe for both adult and pediatric patients. However, studies on its application in children in Taiwan and its impact on growth and esophageal motility are lacking. METHODS: We conducted a retrospective study on consecutive pediatric patients who were diagnosed with esophageal achalasia at National Taiwan University Hospital and underwent POEM during 2015-2022. Disease characteristics and treatment outcomes were analyzed. RESULTS: Ten patients (age 16.9 ± 3.1 years), nine newly diagnosed and one previously treated with pneumatic dilatation, underwent POEM for achalasia (type I/II/III: 3/7/0). Average symptom duration before diagnosis was 19.4 ± 19.9 months, mean POEM procedure time was 83.6 ± 30.7 min, and clinical success (Eckardt score ≤3) was achieved in all patients. Eight patients experienced mild adverse events during POEM, but none required further endoscopic or surgical intervention. Over a mean follow-up period of 3.7 ± 1.6 years, mean Eckardt score decreased significantly from 5.7 ± 2.4 to 1.1 ± 0.7 (p = 0.0001). The BMI z-score also increased significantly after POEM (p = 0.023). Five patients received follow-up high-resolution impedance manometry (HRIM), and all had improved lower esophageal sphincter resting pressures (p = 0.011), body contractility, and bolus transit (p = 0.019). CONCLUSION: POEM is an effective and safe treatment for pediatric achalasia in Taiwan. Early diagnosis and treatment with POEM may help to restore esophageal function and nutrition status in children.

Prognostication and optimal criteria of circumferential margin involvement for esophageal cancer after chemoradiation and esophagectomy.

Purpose: Circumferential radial margin (CRM) involvement by tumor after resection for esophageal cancer has been suggested as a significant prognostic factor. However, the prognostic value of CRM involvement after surgery with neoadjuvant concurrent chemoradiotherapy (CCRT) is unclear. This study aimed to evaluate the prognostic value of and survival outcomes in CRM involvement as defined by the Royal College of Pathologists (RCP) and the College of American Pathologists (CAP) for patients with esophageal cancer undergoing neoadjuvant CCRT and esophagectomy. Methods: A total of 299 patients with esophageal cancer who underwent neoadjuvant CCRT followed by esophagectomy between 2006 and 2016 were enrolled in our study. The CRM status of the specimens obtained was determined pathologically according to both the CAP and RCP criteria. Survival analyses were performed and compared according to the two criteria. Results: Positive CRM was found in 102 (34.1%) and 40 (13.3%) patients according to RCP and CAP criteria, respectively. The overall and progression-free survival rates were significantly lower in the CRM-positive group than in the CRM-negative group according to both the RCP and CAP criteria. However, under multivariate analysis, in addition to pathological T and N staging of the tumor, only CAP-defined CRM positivity was a significant prognostic factor with adjusted hazard ratios of 2.64 (1.56-4.46) and 2.25 (1.34-3.78) for overall and progression-free survival, respectively (P < 0.001). Conclusion: In patients with esophageal cancer undergoing neoadjuvant CRT followed by esophagectomy, CAP-defined CRM positivity is an independent predictor of survival. Adjuvant therapy should be offered to patients with positive CRM.

Defining conversion therapy for esophageal squamous cell carcinoma.

A multimodality treatment conference with experts from across East Asia was held to establish a consensus for conversion therapy. An agreement was reached that conversion therapy was defined as surgery or chemoradiotherapy (CRT) aiming at cure after initial treatment for tumors that were initially unresectable due to adjacent organ invasion or distant metastasis.

Secular Trends in Incidence of Esophageal Cancer in Taiwan from 1985 to 2019: An Age-Period-Cohort Analysis.

In Taiwan, the age-standardized incidence of EC, especially esophageal squamous cell carcinoma (ESCC), has increased substantially during the past thirty years. We described the incidence trends of EC from 1985−2019 by an average annual percentage change (AAPC) and age-period-cohort model by using Taiwan Cancer Registry data. Age-period-cohort modeling was used to estimate the period and cohort effects of ESCC and esophageal adenocarcinoma (EAC). The Spearman's correlation coefficient was used to analyze the correlation between age-adjusted incidence rates of EC and the prevalence of risk factors from national surveys. The results showed the incidence rate of ESCC in men (AAPC = 4.2, 95% CI = 3.1−5.4, p < 0.001) increased prominently from 1985−1989 to 2015−2019 while that of EAC in men (AAPC = 1.2, 95% CI = 0.9−1.5, p < 0.001) and ESCC in women (AAPC = 1.7, 95% CI = 1.4−2.1, p < 0.001) increased to a lesser degree. Increased period effects were observed in ESCC in men, ESCC in women, and EAC in men. High correlations were found between the risk factors and the increased birth-cohort effects of ESCC (p < 0.05). To conclude, the incidence of ESCC in both sex and EAC in men increased with statistical significance in recent decades. The increased prevalence of risk factors from approximately 1970−1995 could explain the increased cohort effects of ESCC.

Robotic-Assisted Thoracoscopic (RATS) Enucleation of Esophageal Mesenchymal Tumors and Foregut Cysts.

Background: Esophageal mesenchymal tumors and foregut cysts are mostly benign lesions of the esophagus. Tumor enucleation is recommended for lesions with a risk of malignancy, or for the relief of clinical symptoms. Although robotic-assisted thoracoscopic enucleation of esophageal tumors and cysts has been demonstrated in sporadic case reports, its clinical role is yet to be elucidated. Methods: This study aimed to present the first case series in the literature for the perioperative and long-term clinical outcomes of robotic-assisted thoracoscopic enucleation. Results: A total of 19 patients who underwent robotic-assisted thoracoscopic enucleation of esophageal tumors and cysts from 2012 to 2019 were included in the study. The mean tumor/cyst size was 5.5 cm (1.5-22 cm). There were two cases shifting to minimally invasive esophagectomy (10.5%) due to intraoperative pathological confirmation of malignant gastrointestinal stromal tumors with mucosal invasion. Perioperative complication was detected in three (15.8%) cases, without 30-day or surgical mortality. There was no recurrence of tumor or symptoms in all patients during the clinical follow-up period (mean = 35 months). Conclusions: Robotic-assisted thoracoscopic enucleation of esophageal submucosal benign tumors is technically feasible and effective. Given its advantage in overcoming spatial limitations, it can become a widely accepted surgical option for such diseases.

Selection of minimally invasive surgical approaches for treating esophageal cancer.

Minimally invasive esophagectomy has gradually been accepted as an active treatment option for surgery of esophageal cancer. However, there is no consensus about how to perform the procedures in the thoracic and abdominal phase including anastomosis in the neck (McKeown) or chest (Ivor Lewis), VATS, robotic-assisted or reduced port approaches or various endoscopic abrasion techniques. Further studies to investigate the roles of these novel techniques are required to treat the various patient populations.

Clinical outcomes for patients with thymoma and thymic carcinoma after undergoing different front-line chemotherapy regimens.

BACKGROUND: Front-line platinum-base chemotherapy for advanced thymoma and thymic carcinoma (TC) improves resectability and prolongs patients' overall survival (OS). In this study, we evaluated patients' outcomes given different front-line regimens: cisplatin, doxorubicin, and cyclophosphamide (CAP); cisplatin and etoposide (EP); or cisplatin and paclitaxel (TP). MATERIALS AND METHODS: We retrospectively evaluated the medical records of patients with advanced thymoma and TC who were treated at our medical center between 2005 and 2015. We investigated objective response rates (ORRs), progression-free survival (PFS), and OS after undergoing different front-line regimens. RESULTS: Among the 108 enrolled patients, 37 (34%) had thymoma and 71 (66%) had TC; 45 received CAP, 36 received EP, and 27 received TP regimens. The ORRs of patients receiving CAP, EP, and TP were 51%, 50%, and 41%, respectively. For patients with stage III and IVA disease, the median PFS after CAP, EP, and TP were 34.5, 26.4, and 18.0 months (p = 0.424), respectively, and the 5-year OS rates were 84.9%, 70.6%, and 60.0% (p = 0.509). In patients with stage IVB disease, the median PFS were 9.4, 8.2, and 11.6 months after undergoing CAP, EP, and TP (p = 0.173), respectively, and the 5-year OS rates were 41.1%, 39.1%, and 14.3% (p = 0.788). TC pathology subtype and liver metastasis were associated with poor OS. Three patients with stage IVB TC had an OS of more than 5 years. CONCLUSION: Different front-line chemotherapy regimens may provide similar long-term PFS and OS in patients with advanced thymoma and TC. In addition to TC and liver metastasis were associated with poor OS, other potential prognostic factors are warranted for studying.

The Trajectory of Cancer-Related Fatigue and Its Associating Factors in Patients with Esophageal Cancer Receiving Treatments: A Prospective Longitudinal Study.

BACKGROUND: Cancer-related fatigue (CRF) is the most distressing symptom in the overall cancer population. For patients with esophageal cancer, CRF may even be harder to predict and control due to its complicated and prolonged treatment. Moreover, communication difficulties due to disease progression or treatment may further diminish esophageal cancer patients' ability to communicate about CRF. However, little research has addressed the trajectory and associating factors of CRF in this population, especially during the active treatment phase. The purpose of this study was (1) to evaluate and compare the level of CRF at three time points, namely before treatment, a month after concurrent chemoradiotherapy (CCRT), and a week after surgery, and (2) to identify associated factors of CRF. METHODS: This prospective cohort study used a questionnaire to evaluate esophageal cancer patients' CRF at three time points. Repeated measures ANOVA and linear regression were used to analyze the data. RESULTS: This study included 73 participants. The severity of all CRF aspects intensified significantly over the course of treatment, reaching the highest level after surgery (P < 0.001). Worries of physician invalidation at baseline (P < 0.05) and marital status associated with CRF after CCRT and after surgery. CONCLUSIONS: This is the first study to demonstrate the relationship between CRF and physician invalidation. Clinicians must be aware of the intensifying trend of CRF and provide timely intervention when caring for patients with esophageal cancer during cancer treatment. Reducing the worries of physician invalidation may alleviate CRF.

Comparison of Clinical Outcomes between Salvage and Elective Thoracic Endovascular Aortic Repair in Patients with Advanced Esophageal Cancer with Aortic Invasion: A Retrospective Cohort Study.

Aortoesophageal fistula (AEF) caused by esophageal cancer (EC) is a rare but life-threatening complication. However, the optimal management strategy remains undetermined. Previous cases have demonstrated that thoracic endovascular aortic repair (TEVAR) is effective for prophylactic management. In our study, we evaluated the management of AEF with elective TEVAR over salvage TEVAR. In our single-center retrospective cohort study, forty-seven patients with cT4M0 EC were included in this study, and we divided them into salvage (Group S) and elective (Group E) groups based on whether TEVAR was performed before the hemorrhagic AEF occurred. Our study outcomes included survival and complication rate after TEVAR. Group E showed better overall 90-day survival and aortic-event-free survival in 90-day and 180-day over Group S. More patients in Group E could receive subsequent chemoradiotherapy or esophagectomy. Significantly fewer AEF-related complications, including recurrent hemorrhagic events after TEVAR, hypoperfusion-related organ injury, and bloodstream infection, were noted in Group E. In patients with advanced EC-invading aorta, elective TEVAR offered an early overall and aortic-event-free survival benefit compared to salvage TEVAR. By reducing the AEF-related complications, elective TEVAR could provide more patients receiving subsequent curative-intent treatment.

Drainless Thoracoscopic Lobectomy for Lung Cancer.

OBJECTIVES: Drainless video-assisted thoracoscopic (VATS) wedge resection has been demonstrated as feasible in treating various lung diseases. However, it remains unknown whether this surgical technique can be effectively applied to lobectomy. In the current study, we evaluated the perioperative outcome of drainless, minimally invasive lobectomy in patients with lung cancer. METHODS: A total of 26 lung cancer patients who received surgery-performed pulmonary lobectomy were enrolled. The perioperative outcomes were analyzed based on a propensity score matching a comparison with those who had chest drainage. RESULTS: No major surgical morbidity and mortality was noted during the perioperative period. The mean of postoperative hospital stay was 5.08 ± 2.48 days. There was no significant difference in postoperative hospital stay between the two groups of patients. However, the presence of significant postoperative pain (VAS score > 30) on the first day after surgery was less in the drainless group (34.6% vs. 3.8%; p = 0.005). CONCLUSIONS: Our results demonstrated that drainless, minimally invasive lobectomy for selected lung cancer patients is feasible. Further evaluation of its impact on short- and long-term surgical outcomes is required in the future.

Managing screening-detected subsolid nodules-the Asian perspective.

The broad application of low-dose computed tomography (CT) screening has resulted in the detection of many small pulmonary nodules. In Asia, a large number of these detected nodules with a radiological ground glass pattern are reported as lung adenocarcinomas or premalignant lesions, especially among female non-smokers. In this review article, we discuss controversial issues and conditions involving these subsolid pulmonary nodules that we often face in Asia, including a lack or insufficiency of current guidelines; the roles of preoperative biopsy and imaging; the location of lesions; appropriate selection of localization techniques; the roles of dissection and sampling of frozen sections and lymph nodes; multifocal lesions; and the roles of non-surgical treatment modalities. For these complex issues, we have tried to present up-to-date evidence and our own opinions regarding the management of subsolid nodules. It is our hope that this article helps surgeons and physicians to manage the complex issues involving ground glass nodules (GGNs) in a balanced manner in their daily practice and provokes further discussion towards better guidelines and/or algorithms.

The Long-Term Clinical Impact of Thoracic Endovascular Aortic Repair (TEVAR) for Advanced Esophageal Cancer Invading Aorta.

BACKGROUND: Advanced esophageal cancer invading the aorta is considered unsuitable for surgery with definitive chemotherapy or chemoradiation as the treatments of choice. In the current study, we evaluated the long-term clinical impact of combining thoracic endovascular aortic repair (TEVAR) with multimodality treatment in caring for such patients. METHODS: We evaluated 48 patients who had advanced esophageal cancer with aortic invasion. The oncological outcome, including overall survival (OS) and progression-free survival (PFS), after multimodality treatment with or without TEVAR is evaluated for these patients. RESULTS: Overall, 25/48 patients (52.1%) received a TEVAR procedure. There was no significant difference in OS (p = 0.223) between patients who did or did not receive TEVAR; however, patients who received TEVAR had significantly less local tumor recurrence (p = 0.020) and longer PFS (p = 0.019). This impact was most evident in patients who received both TEVAR and esophagectomy, with an incremental increase in hazard ratio (HR) for disease progression of 2.89 (95% confidence interval [CI] 0.86-9.96) and 4.37 (95% CI 1.33-14.33) observed under multivariable analysis, respectively, in comparison with patients who underwent only one or neither of these procedures (p = 0.005 for trend test). CONCLUSION: TEVAR is a feasible procedure for esophageal cancers invading the aorta and can be used for curative-intent resection to improve local tumor control and PFS.

The genetic effect and molecular function of the SOCS5 in the prognosis of esophageal squamous cell carcinoma.

Expression of cytokines and growth factors have been shown to be highly correlated with the prognosis of esophageal squamous cell carcinoma (ESCC), a deadly disease with poor prognosis. The suppressor of cytokine signaling (SOCS) family of proteins are key factors in regulating cytokines and growth factors. Yet the role of the SOCS proteins in ESCC is hardly investigated. We currently investigated the prognostic role of SOCS5 in ESCC. We analyzed the prognostic effects of 16 single nucleotide polymorphisms (SNPs) within the SOCS genes in 632 ESCC patients. We repeatedly observed that the 3 SNPs in SOCS5, SOCS5:rs3814039, SOCS5:rs3738890, and SOCS5: rs3768720, were significantly correlated with both overall (OS) and progression-free survival (PFS) of ESCC patients (rs3814039, p=0.032 for OS and p=0.009 for PFS; rs3738890, p=0.016 for OS, and p=0.008 for PFS; rs3768720, p=0.005 for OS and p=0.002 for PFS). SOCS5: rs3768720 was also significantly associated with distant metastasis (Ptrend=0.028). The luciferase assay revealed that SOCS5:rs3814039 and SOCS5: rs3768720 might influence the prognosis by regulating SOCS5 expression. Functional analysis demonstrated SOCS5 was able to regulate epidermal growth factor receptor (EGFR) expression and migration activity of ESCC cells. Furthermore, Patients with strong SOCS5 in normal tissues exhibited significantly better PFS (P=0.049) and reduced risk of distant metastasis (P=0.004) compared to those with weak SOCS5 expression. Overall, our study demonstrates the novel function of SOCS5 in ESCC prognosis. The genetic polymorphisms and expression of SOCS5 could serve as a novel therapeutic biomarker for improving the prognosis of ESCC.

Robotic-assisted single-incision gastric mobilization for minimally invasive oesophagectomy for oesophageal cancer: preliminary results.

OBJECTIVES: With the gradual acceptance of robotic-assisted surgery to treat oesophageal cancer and the application of a single-port approach in several abdominal procedures, we adopted a single-port technique in robotic-assisted minimally invasive oesophagectomy during the abdominal phase for gastric mobilization and abdominal lymph node dissection. METHODS: Robotic-assisted oesophagectomy and mediastinal lymph node dissection in the chest were followed by robotic-assisted gastric mobilization and conduit creation with abdominal lymph node dissection, which were performed via a periumbilicus single incision. The oesophagogastrostomy was accomplished either in the chest (Ivor Lewis procedure) or neck (McKeown procedure) depending on the status of the proximal resection margin. RESULTS: The procedure was successfully performed on 11 patients with oesophageal cancer from January 2017 to December 2018 in our institute. No surgical or in-hospital deaths occurred, though we had one case each of anastomotic leakage, pneumonia and hiatal hernia (9%). CONCLUSIONS: Robotic single-incision gastric mobilization for minimally invasive oesophagectomy for treating oesophageal cancer seems feasible. Its value in terms of perioperative outcome and long-term survival results awaits future evaluation.

Thoracic cancer surgery during the COVID-19 pandemic: a consensus statement from the Thoracic Domain of the Asian Society for Cardiovascular and Thoracic Surgery.

OBJECTIVES: Healthcare resources have been mobilized to combat the COVID-19 pandemic of 2020. The Thoracic Domain of the Asian Society for Cardiovascular and Thoracic Surgery reports a consensus statement on the provision of thoracic cancer surgery during this pandemic. METHODS: A Thoracic Experts Panel was convened by the Society. A consensus on the provision, safety, and setting of thoracic cancer surgery during the pandemic was obtained through a Delphi process. RESULTS: Responses were received from 26 panel members (96% response rate) from 10 regions across Asia. The Society recommended that elective thoracic cancer surgery services may need to be reduced or postponed if medical resources were needed for COVID-19 patients, especially intensive care unit beds and ventilators. However, thoracic cancer surgery should proceed as normal for all solid tumors, without restrictions based on disease stage, availability of non-surgical treatment options, or patient condition (unless there is a high likelihood of postoperative intensive care unit stay). Aerosol-forming procedures should be avoided intra- and perioperatively. The surgical approach does not make a difference in terms of safety. Services for thoracic cancer patients should be offered only in hospitals that maintain isolation wards for patients with confirmed or suspected COVID-19. CONCLUSIONS: Services for patients with thoracic cancer should be maintained during the COVID-19 pandemic. The position of the Society is that thoracic surgeons have a responsibility to perform good surgical management of thoracic cancer during the pandemic, to advocate for patients' rights to receive it, and to safeguard patients and staff from infection.

General thoracic surgery services across Asia during the 2020 COVID-19 pandemic.

The COVID-19 pandemic of 2020 posed an historic challenge to healthcare systems around the world. Besides mounting a massive response to the viral outbreak, healthcare systems needed to consider provision of clinical services to other patients in need. Surgical services for patients with thoracic disease were maintained to different degrees across various regions of Asia, ranging from significant reductions to near-normal service. Key determinants of robust thoracic surgery service provision included: preexisting plans for an epidemic response, aggressive early action to "flatten the curve", ability to dedicate resources separately to COVID-19 and routine clinical services, prioritization of thoracic surgery, and the volume of COVID-19 cases in that region. The lessons learned can apply to other regions during this pandemic, and to the world, in preparation for the next one.

The Impact of Pretreatment PET/CT Nodal Status on Esophageal Squamous Cell Carcinoma After Neoadjuvant Chemoradiation.

BACKGROUND: For advanced esophageal cancer, the clinical significance of pretreatment nodal status (cN) as determined by different examinations remains unclear. PATIENTS AND METHODS: Patients with esophageal squamous cell carcinoma who underwent neoadjuvant chemoradiation and surgery were analyzed in this study. Pretreatment cN status assessed by CT, EUS, and PET/CT and clinicopathological features were used to evaluate tumor recurrence and long-term survival. RESULTS: Two hundred and twenty-two patients were identified in this study. Pretreatment PET/CT cN0 [odds ratio (OR) cN0 versus cN+, 5.316, p < 0.001] and pretreatment CT cN0 (OR 1.957, p = 0.032) both independently predicted ypN0. Pretreatment PET/CT cN0 was also associated with a lower recurrence rate and longer survival across the entire study group. Among patients with ypN0, pretreatment PET/CT cN+ indicated poor disease-free survival [hazard ratio (HR) 2.777, p = 0.001] and overall survival (HR 2.211, p = 0.034) compared with pretreatment PET/CT cN0, which predicted a favorable prognosis. CONCLUSIONS: Data from the current study suggest that pretreatment lymph node status as assessed by PET/CT is strongly correlated with survival outcomes after neoadjuvant chemoradiation and surgery in patients with esophageal squamous cell carcinoma. ypN0 patients can achieve better survival outcomes when pretreatment cN0 is assessed by PET/CT.