Curative Treatment For Esophageal Cancer Research Articles

OGC O01 Delayed surgical Intervention after Chemoradiotherapy in Esophageal cancer (DICE) study

Abstract Background Chemoradiotherapy (CRT) is a core component of curative treatment for esophageal cancer for locally advanced esophageal cancer. Salvage esophagectomy is undertaken in patients who experience recurrent or residual cancer post-CRT. This study aims determine the impact of delayed surgical intervention following chemoradiotherapy on survival from oesophageal cancer. Methods This was an international, multi-center, retrospective cohort study involving seventeen tertiary international centers, including patients who received CRT followed by surgery between 2010–2020. In the main analysis patients were divided into four groups based upon the interval between chemoradiotherapy and surgery (0–50, 51–100, 101–200 and >200 days) to assess the impact upon 90-day mortality and 5-year overall survival (OS). Multivariable logistic and Cox regression provided hazard rations (HRs) with 95% confidence intervals (95%CI) adjusted for relevant patient, oncological and pathological confounding factors. Results 2,867 patients who underwent oesophagectomy after CRT were included. The mean age of the cohort was 63.2 (9.47) years. 79.7% were male; and 87.2% had an ASA grade ≥2. After adjustment for relevant confounders, prolonged interval following CRT was associated with an increased 90-day mortality; compared to 0–50 (reference), 51–100 days (HR=1.54, 95%CI 1.04–2.29), 101–200 days (HR=2.14, 95%CI 1.37–3.35) and >200 days (HR=3.06, 95%CI 1.64–5.69). Similarly, a poorer 5-year survival was also observed with prolonged interval following CRT compared to 0–50 (reference), 101–200 days (HR=1.41, 95%CI 1.17–1.70) and >200 days (HR=1.64, 95%CI 1.24–2.17). Conclusions Prolonged interval following CRT and esophagectomy is associated with increased 90-day mortality and poorer long-term survival. Patients must be carefully considered and counselled regarding surveillance and salvage esophagectomy following CRT.

The Clinical Impact of Other Primary Cancer in Patients Who Received Curative Treatment for Esophageal Cancer.

The present study evaluated the clinical impact of other metachronous or synchronous primary cancer (OPC) in patients who received curative treatment for esophageal cancer. The present study included 168 patients who underwent curative treatment for esophageal cancer between 2005 and 2018. Prognosis and differences between the OPC status (metachronous/synchronous) and clinic pathological parameters was analyzed. A total of 168 patients were included in this study. Forty patients were diagnosed with metachronous/synchronous OPC. When comparing the clinicopathological factors between the patients with and without OPC, the patients' background and postoperative clinical courses were very similar between the two groups. The 3- and 5-year overall survival rates in patients with esophageal cancer with OPC were 66.0% and 54.5%, respectively, while those in patients without OPC were 50.1% and 41.4%, respectively. There was no statistically significant difference in these rates (p=0.156). The OPC status was not included in the final multivariate analysis model. The OPC status was not found to be a prognostic factor for patients who received curative treatment for esophageal cancer. Therefore, it is not necessary to avoid performing curative treatment for esophageal cancer because of a patient's OPC status.

406. COMPARISON OF OUTCOMES BETWEEN SALVAGE OESOPHAGECTOMY AFTER DEFINITIVE CHEMORADIOTHERAPY WITH PLANNED OESOPHAGECTOMY AFTER NEOADJUVANT CHEMORADIOTHERAPY

Abstract Definitive chemoradiotherapy (dCRT) for oesophageal cancer is recommended in selected patients who are unfit for surgery, or where doctor and/or patient prefers to surgery. Salvage oesophagectomy after dCRT is reportedly a morbid procedure compared to oesophagectomy following neoadjuvant chemoradiotherapy (nCRT). If indications for dCRT expand, there will be a larger pool of patients requiring salvage oesophagectomy. We aimed to assess the post-operative clinical outcomes of patients who had dCRT compared with nCRT in our unit. Data were obtained from a prospectively maintained database of patients receiving curative treatment for oesophageal cancer from January 2010 until February 2022. Patients receiving a salvage oesophagectomy after dCRT were compared to those receiving nCRT and planned oesophagectomy. An comparison of differences in group characteristics, post-operative outcomes and survival rates was made. Analysis was completed using t-test, chi-square, log rank and Kaplan–Meier methods. 216 patients had dCRT with 24 undergoing salvage oesophagectomy. 228 had nCRT followed by surgery. The salvage group had more SCC (47% versus 16%; p = 0.002), higher blood loss (434 versus 280 mL; p = 0.033) and more surgeon-rated technical problems (e.g. pleural adhesions or mediastinal fibrosis) (30% versus 11%; p = 0.010). Operative times were not significantly different (357 versus 330 minutes; p = 0.232). There was a trend towards higher complications in the dCRT group (83 versus 63%; p = 0.057). Operative mortality was 0% in both groups. As expected the median survival was worse in the dCRT group (26 versus 66 months; p = 0.040). Patients selected to dCRT who require and are fit for salvage oesophagectomy have worse outcomes compared with those who have nCRT. However, this subgroup still have a modest potential for cancer survival. Our dataset adds to the existing literature and will help to counsel patients being considered for salvage oesophagectomy. The possible future increase in number of patients being offered dCRT makes improving the understanding of peri-operative and cancer-specific outcomes after salvage oesophagectomy a priority.

Quality of Life after Minimally Invasive Esophagectomy: A Cross-Sectional Study

Introduction: Surgery remains essential in the curative treatment of esophageal cancer (EC), but it is known for its high morbidity and impaired health-related QoL. Minimally invasive esophagectomy (MIE) was introduced to reduce surgical trauma and improve QoL. Methods: This cross-sectional study aimed to evaluate long-term HRQoL after MIE in comparison with the general population. HRQoL assessment was based on three questionnaires: the European Organisation for Research and Treatment of Cancer (EORTC) Core 30 (QLQ-C30, version 3), the EORTC QLQ Oesophago Gastric 25 (QLQ-OG25), and the Supportive Care Needs Survey-Short Form 34 (SCNS-SF34). Results were compared to a healthy reference population. Results: One hundred and forty eligible MIE patients were identified, of whom met the inclusion criteria, and 49 completed all questionnaires. Patients reported a significantly better mean score on the global health status and QoL than the healthy reference population (71.5 ± 15.1 vs. 66.1 ± 21.7; p = 0.016). However, patients scored significantly worse about functioning (physical, role, and social) (p < 0.05), fatigue (p = 0.021), eating, dysphagia, pain and discomfort, reflux, appetite loss, weight loss, coughing, and taste (p < 0.001). Discussion/Conclusion: EC survivors can reach a high global health status and QoL at least 1 year after MIE, despite long-term functional, nutritional, and gastrointestinal complaints. Patients provided written informed consent, and the study protocol was approved by the Ethics Committee of Ghent University Hospital (identifier: ID B670201940737).

Home-based physical activity after treatment for esophageal cancer-A randomized controlled trial.

The treatment of most esophageal cancer patients includes chemo(radio)therapy and extensive surgery, causing physical decline with loss of muscles. This trial aimed to test the hypothesis that a tailored home-based physical activity (PA) intervention improves muscle strength and mass in patients having undergone curative treatment for esophageal cancer. Patients operated for esophageal cancer 1year earlier were included in a nationwide randomized controlled trial in Sweden in 2016-2020. The intervention group was randomized to a 12-week home-based exercise program, while the control group was encouraged to maintain routine daily PA. The primary outcomes were changes in maximal/average hand grip strength measured with hand grip dynamometer and lower extremity strength measured using 30-second chair stand test and muscle mass measured using a portable bio-impedance analysis monitor. Intention-to-treat analysis was used, and results were presented as mean differences (MDs) with 95% confidence intervals (CIs). Among 161 randomized patients, 134 completed the study, 64 in the intervention group and 70 in the control group. Compared with the control group (MD 2.73; 95% CI 1.75-3.71), patients in the intervention group (MD 4.48; 95% CI 3.18-5.80) had statistically significantly (p=0.03) improved lower extremity strength. No differences were seen for hand grip strength or muscle mass. A home-based PA intervention 1year after surgery for esophageal cancer improves lower extremity muscle strength.

Abstract 2616: Stemness factors nanog and oct4 contribute to epithelial-to-mesenchymal transition and are predictive for outcome in esophageal adenocarcinoma

Abstract Background and Aims: The incidence of esophageal adenocarcinoma (EAC) has increased six-fold in Western countries over the last decades, and 5-year survival rates remain low at 5-20%. While multimodality treatment strategies for curative treatment of esophageal cancer, including the CROSS regimen (chemoradiotherapy followed by surgery) have increased median overall survival, the majority of patients develop recurrences after several months. Epithelial to mesenchymal transition (EMT) has been recently shown by our group to be one of the major underlying mechanisms of resistance to therapy. Paradoxically, therapeutic pressure of effective therapies such as the CROSS regimen are found to instruct a mesenchymal, resistant phenotype in models for EAC. In this study, the aim was to delineate the heterogeneity for the propensity to undergo EMT after chemoradiation and which mechanisms underpin this propensity. Methods: A panel of 8 EAC cell lines (5 primary and 3 ATCC cell lines) were treated with chemoradiotherapy and ranked by their propensity to undergo EMT, based on morphology when EMT occurred and protein marker expression. Next, the cell line panel as well as 44 pre-treated esophageal biopsies were RNA-sequenced. Expression data of the cell line panel were linked to their ranked in vitro EMT response. By means of Leave-one-out cross validation with Ridge Regression, EMT score prediction in pre-treated biopsies was validated. Gene expression profiles were related to clinical outcome data to identify markers that associated with propensity for EMT in patients. Results: In the panel of in vitro EAC models, a strong heterogeneity was observed for the propensity to EMT after chemoradiation. For each marker, Ridge regression analysis identified the top 50 highly correlating genes. Combining all positively correlating genes of days to EMT, NCAD and ZEB1, known key transcription factors of pluripotency including NANOG and OCT4 emerged. Expression of NANOG and OCT4 in pre-treatment biopsies was highly predictive for response to neoadjuvant chemoradiation, occurrence of recurrences, and survival in patients. Genetic perturbation by knockout and inhibition of NANOG and OCT4 reduced the onset of EMT and sensitized cells for chemoradiation. Conclusions: In conclusion, we were able to identify patients who are disproportionally prone to develop EMT in response to chemoradiation. Moreover, stemness factors NANOG and OCT4 are crucial regulators in plasticity of EAC and are promising predictive markers in pre-treatment biopsies of patients. By targeting NANOG and OCT4 in vitro, cells were sensitized to chemoradiation, holding promise for stemness inhibition to prevent therapy resistance in EAC. Citation Format: Amber Perenna van der Zalm, Mark P. Dings, Reimer Janssen, Peter Bailey, Jan Koster, Danny Zwijnenburg, Richard Volckmann, Cynthia Waasdorp, Jeroen Blokhuis, César Oyarce, Gerrit Hooijer, Sybren L. Meijer, Jan Paul Medema, Hanneke W. van Laarhoven, Maarten F. Bijlsma. Stemness factors nanog and oct4 contribute to epithelial-to-mesenchymal transition and are predictive for outcome in esophageal adenocarcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2616.

Improved Clinical and Survival Outcomes After Esophagectomy for Cancer Over 25 Years

BackgroundIn recent decades, there have been major developments in the curative treatment of esophageal cancer, such as the implementation of positron emission tomography with computed tomography, neoadjuvant chemoradiotherapy, minimally invasive surgery, and postoperative care programs. This observational study examined clinical and survival outcomes after esophagectomy for cancer over 25 years. MethodsConsecutive patients who underwent esophagectomy for cancer at a tertiary referral center between 1993 and 2018 were selected from a prospectively maintained database. Patients were assigned to 5 periods: 1993 to 1997, 1998 to 2002, 2003 to 2007, 2008 to 2012, and 2013 to 2017. The primary outcome was 5-year overall survival by using Kaplan–Meier log-rank tests for trends. ResultsA total of 1616 patients were analyzed. The median follow-up of surviving patients was 91.0 months (interquartile range [IQR], 62.6-127.5 months).The 5-year overall survival improved gradually from 32.8% to 48.2% over 25 years (P < .001). Hospital length of stay decreased from 16 days (median IQR, 14-24 days) in 1993 to 1997 to 11 days (IQR, 8-18 days) in 2013 to 2017 (P < .001). No decrease in mortality was encountered over 25 years, although over the last 5 years, in-hospital and 90-day mortality dropped from 4.2% and 8.3% in 2013 to 0% in 2017 (P < .05). Anastomotic leakages decreased from 26.4% to 9.7% between 2013 and 2017 (P < .001). ConclusionsOver the last 25 years, clinical outcomes and 5-year overall survival significantly improved in patients who underwent esophagectomy for cancer at this tertiary referral center.

The impact of jejunostomy feeding on nutritional outcomes after oesophagectomy

Oesophagectomy is the mainstay of curative treatment for oesophageal cancer; however nutritional status is compromised in the months and years post-operatively1. Controversy surrounds the optimal route for post-operative nutrition support and there is wide variation in the use of feeding jejunostomy in different centres across the UK2,3. The aim of this study was to evaluate whether patients who received jejunostomy feeding post-oesophagectomy had improved nutritional and clinical outcomes within the first post-operative year, compared to those without jejunostomy.

Minimally Invasive Cervical Esophagectomy (MICE), radical esophagectomy and 3-field lymphadenectomy without thoracic access.

Background: Radical esophagectomy combined with two field lymph node dissection is the cornerstone for curative treatment of esophageal cancer. Despite the employment of minimally invasive transthoracic approaches, pulmonary complications remain high (30%).

The impact of Nutrition and Gastrointestinal Symptoms on Health-related Quality of Life in Survivorship after Oesophageal Cancer Surgery

Background and AimsOesophagectomy is the primary curative treatment for oesophageal cancer but is associated with considerable postoperative morbidity and mortality. To better understand the aetiology of impaired health-related quality of life (HRQL) in oesophageal cancer survivors (OCS), this study sought to determine the longitudinal changes in nutritional status, nutrition-impact symptoms (NIS), and HRQL in this cohort, and to determine which variables have the greatest impact on postoperative HRQL decline.MethodsData, derived from St. James' Hospital, Dublin, included patients who underwent oesophagectomy from October 2017 to May 2019 and attended clinic preoperatively and 6 months postoperatively. A subset attended a further 12-month appointment. HRQL and symptom data were collected using validated questionnaires and anthropometric measures were completed by clinicians. Data were analysed using SPSS.ResultsA total of 66 patients were studied preoperatively and 6 months postoperatively, of whom 37 were studied at 12 months postoperatively. Malnutrition remained prevalent at each time-point, although rates did not significantly change longitudinally. Conversely, the prevalence of malabsorption (7.6%–14.3%, P<0.001) and dumping syndrome (67.7%–74.3%, P=0.003) significantly increased with increasing time postoperatively. NIS were significantly associated with impaired HRQL function scores and were independent predictors of global quality of life (gQOL) score postoperatively (P=0.004). A diagnostic threshold of gastrointestinal symptom severity (11.5) that identifies patients at risk of impaired gQOL was therefore reported.ConclusionMalnutrition and NIS are prevalent post-oesophagectomy, the latter significantly associated with reduced HRQL. Targeted intervention in those with severe NIS could be highly beneficial, highlighting the need for dietetic input in OCS. Oesophagectomy is the primary curative treatment for oesophageal cancer but is associated with considerable postoperative morbidity and mortality. To better understand the aetiology of impaired health-related quality of life (HRQL) in oesophageal cancer survivors (OCS), this study sought to determine the longitudinal changes in nutritional status, nutrition-impact symptoms (NIS), and HRQL in this cohort, and to determine which variables have the greatest impact on postoperative HRQL decline. Data, derived from St. James' Hospital, Dublin, included patients who underwent oesophagectomy from October 2017 to May 2019 and attended clinic preoperatively and 6 months postoperatively. A subset attended a further 12-month appointment. HRQL and symptom data were collected using validated questionnaires and anthropometric measures were completed by clinicians. Data were analysed using SPSS. A total of 66 patients were studied preoperatively and 6 months postoperatively, of whom 37 were studied at 12 months postoperatively. Malnutrition remained prevalent at each time-point, although rates did not significantly change longitudinally. Conversely, the prevalence of malabsorption (7.6%–14.3%, P<0.001) and dumping syndrome (67.7%–74.3%, P=0.003) significantly increased with increasing time postoperatively. NIS were significantly associated with impaired HRQL function scores and were independent predictors of global quality of life (gQOL) score postoperatively (P=0.004). A diagnostic threshold of gastrointestinal symptom severity (11.5) that identifies patients at risk of impaired gQOL was therefore reported. Malnutrition and NIS are prevalent post-oesophagectomy, the latter significantly associated with reduced HRQL. Targeted intervention in those with severe NIS could be highly beneficial, highlighting the need for dietetic input in OCS.

627 PL11.02 ENSURE: AN INTERNATIONAL MULTICENTRE STUDY EXPLORING WHETHER SURVEILLANCE AFTER ESOPHAGEAL CANCER SURGERY IMPACTS ONCOLOGICAL AND QUALITY OF LIFE OUTCOMES

Abstract Although established and emerging therapies for recurrent esophageal cancer (EC) may impact on survival and health related quality of life (HR-QL), surveillance protocols after the primary curative treatment of EC are varied and inconsistent, reflecting a limited evidence-base to guide an optimum approach. Specifically, whether advantages exist for an intensive surveillance protocol is unknown and was the focus of this study. Methods ENSURE was an international multicentre observational study of consecutive patients undergoing surgery with curative intent for esophageal and junctional cancers (2009–2015) across 20 European and North American centers (NCT03461341). Intensive surveillance (IS) was defined as routine annual CT/PET-CT during the first three postoperative years, and compared with standard surveillance (SS) with investigation as clinically indicated. The primary outcome measure was overall survival (OS), secondary outcomes included treatment, disease-specific survival (DSS), disease-free survival (DFS), recurrence pattern, and HR-QL. Multivariable linear, logistic and Cox proportional hazards regression analyses were performed to determine the independent impact of surveillance on oncologic outcomes and HR-QL. Results 4,682 patients were studied, 45.5% underwent IS. At median follow-up of 60 months, 47.5% developed recurrence; oligometastatic in 39% of cases, with 31% receiving best supportive care, 60% chemotherapy and/or radiation, and 8% surgical resection. IS was associated with reduced symptomatic recurrence (OR0.17 [0.12–0.25]), increased tumor-directed therapy (OR2.09 [1.58–2.77]), and improved OS (HR0.90 [0.82–0.98], 5-year OS 47.9 ± 1.2% versus 43.2 ± 1.1%). On multivariable analysis, significantly improved OS with IS was maintained for patients who underwent surgery alone (HR0.60 [0.47–0.78]) and in those with lower pathological (y)pT stages (Tis-2, HR0.72 [0.58–0.89]). IS was associated with greater anxiety (P = 0.016), but similar overall HR-QL. Conclusion These data suggest that IS may improve oncologic outcomes, particularly in patients with early stage disease at presentation or with a favorable pathological stage post induction therapy. This may be relevant to guideline development and provide a framework and rationale for RCTs. It may also inform shared decision-making with patients at a time where therapeutic options for recurrence are expanding.

The Clinical Impacts of Neutrophil to Lymphocyte Ratio for Esophageal Cancer Patients Who Receive Curative Treatment

We investigated the impact of the neutrophil to lymphocyte ratio on esophageal cancer survival and recurrence after curative treatment. This study included 120 patients who underwent curative surgery followed by adjuvant treatment for esophageal cancer between 2008 and 2018. The risk factors for overall survival and recurrence-free survival (RFS) were identified. Neutrophil to lymphocyte ratio of 2.38 was regarded to be the optimal critical point of classification considering the 1-year, 3-year, and 5-year survival rate. The overall survival rates at 3 and 5 years after surgery were 70.5% and 63.0% in the neutrophil to lymphocyte ratio low group, respectively, and 41.0% and 29.7% in neutrophil to lymphocyte ratio high group, which amounted to a statistically significant difference (p=0.001). The recurrence-free survival rates at 3 and 5 years after surgery were 48.6% and 40.7% in the neutrophil to lymphocyte ratio low group, respectively, and 33.6% and 26.9% in neutrophil to lymphocyte ratio high group, which amounted to a statistically significant difference (p=0.046). A multivariate analysis demonstrated that the neutrophil to lymphocyte ratio was a significant independent risk factor for both the overall survival and recurrence-free survival. Neutrophil to lymphocyte ratio was a risk factor for survival in patients who underwent curative treatment for esophageal cancer. It is necessary to develop the effective plan of the perioperative care and the surgical strategy according to the neutrophil to lymphocyte ratio.

Impact of Smoking Status on Perioperative Morbidity, Mortality, and Long-Term Survival Following Transthoracic Esophagectomy for Esophageal Cancer

IntroductionEsophagectomy is a key component in the curative treatment of esophageal cancer. Little is understood about the impact of smoking status on perioperative morbidity and mortality and the long-term outcome of patients following esophagectomy.ObjectiveThis study aimed to evaluate morbidity and mortality according to smoking status in patients undergoing esophagectomy for esophageal cancer.MethodsConsecutive patients undergoing two-stage transthoracic esophagectomy (TTE) for esophageal cancers (adenocarcinoma or squamous cell carcinoma) between January 1997 and December 2016 at the Northern Oesophagogastric Unit were included from a prospectively maintained database. The main explanatory variable was smoking status, defined as current smoker, ex-smoker, and non-smoker. The primary outcome was overall survival (OS), while secondary outcomes included perioperative complications (overall, anastomotic leaks, and pulmonary complications) and survival (cancer-specific survival [CSS], recurrence-free survival [RFS]).ResultsDuring the study period, 1168 patients underwent esophagectomy for cancer. Of these, 24% (n = 282) were current smokers and only 30% (n = 356) had never smoked. The median OS of current smokers was significantly shorter than ex-smokers and non-smokers (median 36 vs. 42 vs. 48 months; p = 0.015). However, on adjusted analysis, there was no significant difference in long-term OS between smoking status in the entire cohort. The overall complication rates were significantly higher with current smokers compared with ex-smokers or non-smokers (73% vs. 66% vs. 62%; p = 0.018), and there were no significant differences in anastomotic leaks and pulmonary complications between the groups. On subgroup analysis by receipt of neoadjuvant therapy and tumor histology, smoking status did not impact long-term survival in adjusted multivariable analyses.ConclusionAlthough smoking is associated with higher rates of short-term perioperative morbidity, it does not affect long-term OS, CSS, and RFS following esophagectomy for esophageal cancer. Therefore, implementation of perioperative pathways to optimize patients may help reduce the risk of complications.

Decrease of physical fitness during neoadjuvant chemoradiotherapy predicts the risk of pneumonia after esophagectomy.

Although neoadjuvant chemoradiotherapy (nCRT) is frequently used in esophageal cancer patients undergoing treatment with curative intent, it can negatively impact patients' physical fitness. A decline in physical fitness during chemoradiotherapy may be an indication of vulnerability. The aim of this study was to evaluate whether changes in physical fitness, weight, and fat-free mass index (FFMI) during nCRT can predict the risk of postoperative pneumonia. A retrospective longitudinal observational cohort study was performed in patients who received curative treatment for esophageal cancer between September 2016 and September 2018 in a high-volume center for esophageal cancer surgery. Physical fitness (handgrip strength, leg extension strength, and exercise capacity), weight, and FFMI were measured before and after chemoradiotherapy. To be included in the data analyses, pre- and post-nCRT data had to be available of at least one of the outcome measures. Logistic regression analyses were performed to evaluate the predictive value of changes in physical fitness, weight, and FFMI during nCRT on postoperative pneumonia, as defined by the Uniform Pneumonia Scale. In total, 91 patients were included in the data analyses. Significant associations were found between the changes in handgrip strength (odds ratio [OR] 0.880, 95% confidence interval [CI]: 0.813-0.952) and exercise capacity (OR 0.939, 95%CI: 0.887-0.993) and the occurrence of postoperative pneumonia. All pneumonias occurred in patients with declines in handgrip strength and exercise capacity after nCRT. A decrease of handgrip strength and exercise capacity during nCRT predicts the risk of pneumonia after esophagectomy for cancer. Measuring physical fitness before and after chemoradiotherapy seems an adequate method to identify patients at risk of postoperative pneumonia.

242 ABANDONING RESECTIONAL INTENT IN PATIENTS INITIALLY DEEMED SUITABLE FOR ESOPHAGECTOMY; A NATIONWIDE STUDY OF RISK FACTORS AND OUTCOMES

Abstract The main curative treatment for esophageal cancer is resection. In some cases, patients initially deemed suitable for resection become unsuitable, often due to signs of generalized disease or having become unfit for surgery. The aim of the present study was to assess frequency and risk factors for patients initially deemed suitable for esophagectomy becoming ineligible for resection. Methods All patients in the Swedish National Quality Register for Esophageal and Gastric Cancer from 2006 to 2016 were included and risk factors associated with becoming ineligible for resection were analyzed and adjusted in multivariable logistic regression analysis calculating Odds ratios (ORs) with 95% Confidence intervals (CIs). Results A total of 1792 patients were planned for resection, of these 303 (17%) became ineligible for resection (114 patients were non-resectable and 189 patients never progressed to surgery). High and intermediate educational level was associated with an increased probability of resection (OR 1.80 95% CI 1.21–2.66 and OR 1.49 95% CI 1.07–2.09, respectively) while patients with clinically advanced disease were more likely to become ineligible (cT4a: OR 0.34, 95%CI 0.14–0.0.87, cN3: OR 0.26, 95%CI 0.09–0.79 respectively). Patients given neoadjuvant treatment were also more likely to become ineligible for surgery (OR 0.62 95%CI 0.46–0.86). Conclusion Of those planned for resection for esophageal cancer, 17% never progressed to esophagectomy. High educational level was associated with an increased chance of undergoing resection whereas clinically advanced disease and neoadjuvant treatment were independent factors associated with increased risk of abandoning resectional intent.

Protocol for LAsting Symptoms after Oesophageal Resectional Surgery (LASORS): multicentre validation cohort study.

IntroductionSurgery is the primary curative treatment for oesophageal cancer, with considerable recent improvements in long-term survival. However, surgery has a long-lasting impact on patient’s health-related quality of life (HRQOL). Through a multicentre European study, our research group was able to identify key symptoms that affect patient’s HRQOL. These symptoms were combined to produce a tool to identify poor HRQOL following oesophagectomy (LAsting Symptoms after Oesophageal Resection (LASOR) tool). The objective of this multicentre study is to validate a six-symptom clinical tool to identify patients with poor HRQOL for use in everyday clinical practice.Methods and analysisIncluded patients will: (1) be aged 18 years or older, (2) have undergone an oesophagectomy for cancer between 2015 and 2019, and (3) be at least 12 months after the completion of adjuvant oncological treatments. Patients will be given the previously created LASOR questionnaire. Each symptom from the LASOR questionnaire will be graded according to impact on quality of life and frequency of the symptom, with a composite score from 0 to 5. The previously developed LASOR symptom tool will be validated against HRQOL as measured by the European Organisation for Research and Treatment of Cancer QLQC30 and OG25.Sample sizeWith a predicted prevalence of poor HRQOL of 45%, based on the previously generated LASOR clinical symptom tool, to validate this tool with a sensitivity and specificity of 80%, respectively, a minimum of 640 patients will need to be recruited to the study.Ethics and disseminationNHS Health Research Authority (North East—York Research Ethics Committee) approval was gained 8 November 2019 (REC reference 19/NE/0352). Multiple platforms will be used for the dissemination of the research data, including international clinical and patient group presentations and publication of research outputs in a high impact clinical journal.

Factors related to the incidence of esophageal stenosis after treatment of advanced esophagus cancer.

e16561 Background: Esophageal stenosis after curative treatment of esophageal cancer (CE) by radiochemotherapy has a high incidence, causing great impact to the patient’s health. Identifying risk factors for this type of pathology may provide earlier diagnosis and more effective follow-up for patients with CE undergoing curative radiotherapy. The objective of this study was to determine the risk factors for esophageal stenosis in patients with complete regression of the tumor lesion after advanced CE treatment with radiotherapy associated or not with chemotherapy. The choice of the theme is justified because there are no studies on esophageal stenosis after radiotherapy associated or not with chemotherapy in esophageal cancer in the west. Methods: Retrospective observational study with 103 patients of both sexes who presented total regression of esophageal squamous cancer, confirmed by endoscopy and biopsies, after treatment with or without chemotherapy. The relationship between the sexes, age, tumor staging, involvement of the esophageal circumference, tumor location, isolated use of radiotherapy or associated chemotherapy, and tumor extension with or without stenosis and its degree after treatment with total regression of the tumor. Results: Most patients are male (58.3%). There was a direct relationship between the degree of circumference involvement and the degree of stenosis and a significant association between tumor location and degrees of stenosis (p &lt; 0.001). The higher the degree of posttreatment stenosis, the higher the percentage of more advanced tumors (p &lt; 0.001). Regarding tumor extension, the greater the degree of stenosis after treatment, the greater the proportion of tumors larger than 60 mm (p &lt; 0.001). T3 tumors increase in 23.77 chance of post-treatment stenosis compared to T2 tumors. T4 tumors, increase the chance of presenting post-treatment stenosis 23.94 times compared to T2 tumors. Conclusions: Our data show that impaired esophageal circunference, tumor extension, advanced stages, and pretreatment tumor stenosis are factors related to esophageal stenosis following treatment with advanced radiochemotherapy for esophageal cancer.

Thromboembolic and bleeding complications in patients with oesophageal cancer.

BackgroundIn patients who undergo curative treatment for oesophageal cancer, risk estimates of venous thromboembolism (VTE), arterial thromboembolism and bleeding are needed to guide decisions about thromboprophylaxis.MethodsThis was a single‐centre, retrospective cohort study of patients with stage I–III oesophageal cancer who received neoadjuvant chemoradiation followed by oesophagectomy. The outcomes VTE, arterial thromboembolism, major bleeding, clinically relevant non‐major bleeding and mortality were analysed for four consecutive cancer treatment stages (from diagnosis to neoadjuvant chemoradiotherapy, during neoadjuvant treatment, 30‐day postoperative period, and up to 6 months after postoperative period).ResultsSome 511 patients were included. The 2‐year survival rate was 67·3 (95 per cent c.i. 63·2 to 71·7) per cent. During the 2‐year follow‐up, 50 patients (9·8 per cent) developed VTE, 20 (3·9 per cent) arterial thromboembolism, 21 (4·1 per cent) major bleeding and 30 (5·9 per cent) clinically relevant non‐major bleeding. The risk of these events was substantial at all treatment stages. Despite 30‐day postoperative thromboprophylaxis, 17 patients (3·3 per cent) developed VTE after surgery. Patients with VTE had worse survival (time‐varying hazard ratio 1·81, 95 per cent c.i. 1·25 to 2·64). Most bleeding events occurred around the time of medical intervention, and approximately one‐half during concomitant use of prophylactic or therapeutic anticoagulation.ConclusionPatients with oesophageal cancer undergoing neoadjuvant chemoradiotherapy and surgery are at substantial risk of thromboembolic and bleeding events throughout all stages of treatment. Survival is worse in patients with thromboembolic events during follow‐up.

Current Surgical Treatment of Esophageal Cancer-Distal Adenocarcinoma, Multidisciplinary Approach, Evolving Minimal-Invasive Approach at High-Volume Centers

Even in 2020 esophageal cancer stays a severe disease and means a caesura in the life of the affected. Early carcinoma under strict indications and conditions can be safely resected by interventional endoscopy. In locally advanced esophageal cancer of the mid and lower third radical resection stays the gold-standard. The favored approach is the transthoracic esophagectomy with 2-field lymphadenectomy and reconstruction by gastric pullup. In recent years, progress resulted in a notable decrease in morbidity and mortality of these procedures and in an acceptable life quality despite resection and reconstruction. Additionally, multidisciplinary treatment-especially neoadjuvant chemo- and radiochemotherapy-improved long-term survival. Overall it is clear, that the treatment of esophageal cancer in high volume centers is safer and more effective. Challenges for the future are the further development of minimally invasive procedures by laparoscopic, thoracoscopic, or robot-assisted approaches, which results in minimizing the operative trauma and reducing pulmonary complications. With further progress in decoding the esophageal cancer gene, gene-products, and pathways more specific prevention and more targeted therapy could be applied. Standards of treatment of esophageal cancer differ from country to country. This lies mostly in the ethnic differences like incidence, the unequal distribution of squamous cell carcinoma and adenocarcinoma, and in broad differences in concepts and the capability of the health systems. This review focuses on the current surgical diagnostic and curative treatment of esophageal cancer at the majority of high volume centers in Germany by reviewing the associated literature and imbedded by the author's own clinical and academic experiences.

The Clinical Impact of the Age-adjusted Charlson Comorbidity Index on Esophageal Cancer Patients Who Receive Curative Treatment.

We investigated the impact of the age-adjusted Charlson comorbidity index (ACCI) on esophageal cancer survival and recurrence after curative treatment. This study included 122 patients who underwent curative surgery followed by adjuvant chemotherapy for esophageal cancer between 2005 and 2017. The risk factors for the overall survival (OS) and recurrence-free survival (RFS) were identified. An ACCI of 5 was regarded as the optimal critical point of classification considering the survival rates. The OS rates at 3 and 5 years after surgery were 64.2% and 54.4% in the low-ACCI group, respectively, and 42.3% and 29.2% in high-ACCI group, respectively (p=0.035). The RFS rates at 3 and 5 years after surgery were 50.2% and 43.6% in the low-ACCI group, respectively, and 28.5% and 21.3% in high-ACCI group, respectively (p=0.021). A multivariate analysis demonstrated that ACCI was a significant independent risk factor for both the OS and RFS. ACCI is a risk factor for survival in patients who undergo curative treatment for esophageal cancer. An effective plan for the perioperative care and surgical strategy should be developed according to ACCI.