Tumor regression grade combined with lymph node status in esophageal squamous cell carcinoma after neoadjuvant chemoradiotherapy.

INTRODUCTION: We aimed to elucidate the prognostic value of tumor regression grade (TRG) combined with lymph node status compared with the 8th edition of the ypTNM staging system in patients with advanced esophageal squamous cell cancer (ESCC) after neoadjuvant chemoradiotherapy (nCRT). METHODS: We enrolled 325 patients with ESCC who underwent nCRT followed by complete resection. We adopted the modified Schneider TRG system, with high (ypT0N0), mid (ypT0N+ or ypT + N0), and low (ypT + N+). After developing a multivariable Cox model, the discrimination ability of the ypStage and TRG systems was evaluated using the Akaike Information Criterion (AIC) and R2 measure. RESULTS: The mean duration of follow-up was 56.7 ± 43.3 months. The survival curves between the adjacent groups of TRG were significantly different for both overall survival (OS) and recurrence-free survival (RFS). However, there were no significant differences between ypStages II and III for OS (p = 0.683) or RFS (p = 0.760). The TRG system also had a discrimination ability in patients with ypStage I (p < 0.001 for both OS and RFS) and ypStage III (p = 0.045 for OS and 0.042 for RFS). Compared with the ypTNM staging system, the modified TRG had a lower AIC value (1835.99 vs. 1852.02) and a higher R2 (0.256 vs. 0.177), indicating better discrimination ability and prediction accuracy. CONCLUSIONS: For patients with ESCC who underwent esophagectomy following nCRT, the modified Schneider TRG system may complement the ypStage and help clinicians select the most appropriate postoperative treatment and surveillance.

Repair of challenging non-malignant tracheo- or broncho-oesophageal fistulas by extrathoracic muscle flaps.

OBJECTIVES: Evaluation of complex, acquired, non-malignant tracheo/broncho-oesophageal fistulas (TEF) repaired by extrathoracic pedicled muscle flaps that were, in addition to their interposition between the airways and the gastro-intestinal tract, patched into gastro-intestinal or airway defects if primary closure seemed risky. METHODS: A single institution experience of patients treated between 2003 and 2015. Twenty-two patients required TEF repair following oesophageal surgery (18), Boerhaave syndrome (1), chemotherapy for mediastinal lymphoma (1), carinal resection and irradiation (1) and laryngectomy (1); 64% of them underwent prior radio- or chemotherapy and 50% prior airway or oesophageal stenting. RESULTS: Airway defects were closed by muscle flap patch ( n = 12), lobectomy ( n = 4), airway resection/anastomosis ( n = 2), pneumonectomy ( n = 1), segmentectomy ( n = 2) or primary suture ( n = 1). Gastro-intestinal defects were repaired by oesophageal diversion ( n = 9), muscle flap patch ( n = 8) or primary suture ( n = 5). A muscle flap patch was used to close airway and gastro-intestinal defects in 55% and 36% of cases, respectively. The 90-day postoperative mortality and TEF recurrence rates were 18% and 4.5%. Airway healing and breathing without tracheal appliance was obtained in 95% of patients and gastro-intestinal healing in 77% of those without oesophageal diversion. Five of nine patients with oesophageal diversion underwent intestinal restoration by retrosternal colon transplants. CONCLUSIONS: Complex TEF arising after oesophageal surgery, radio-chemotherapy or failed stenting can be successfully closed using extrathoracic muscle flaps that can, in addition to their interposition between the airway and the gastro-intestinal tract, also be patched into gastro-oesophageal or airway defects if primary closure seems hazardous.