Early-stage Esophageal Cancer Research Articles

A Novel Prediction Model to Identify Patients with Early-Stage Esophageal Cancer

Esophageal cancer has an insidious presentation with more than half of patients presenting with late-stage disease not amenable to potentially curative chemoradiotherapy or surgery. While screening high risk individuals with endoscopy can provide a survival benefit, screening the general unselected population is not currently recommended. This project used a machine learning approach to create an early prediction model drawing on the content of patients’ electronic health records (EHRs). We identified Medicare beneficiaries diagnosed with esophageal cancer between 2004 and 2013, and classified patients into early-stage esophageal cancer (n = 3,062) and late-stage esophageal cancer (n = 2,359) groups. Early-stage esophageal cancer cases were matched to a cohort of non-esophageal cancer controls in a 16:1 ratio, and this cohort was divided into a training (70%) and test (30%) dataset. From this training cohort we constructed a prediction model to identify individuals with early-stage disease using an eXtreme Gradient Boosting machine learning algorithm that incorporated features including patient demographics, procedure and clinical diagnosis codes, outpatient and PCP visit counts, and an inpatient visit indicator. Model discrimination was assessed with sensitivity, specificity, positive predictive value (PPV), and area under the receiver operating characteristic curve (AUC) with a score of 1.0 indicating perfect prediction. The final predictive model to identify patients with early-stage esophageal cancer included 202 features of which 127 (62.9%) were procedure codes, 67 (33.2%) were diagnosis codes, 6 (3.0%) were demographic features, and 2 (1%) were provider visit counts. The final predictive model had an AUC of 0.776. We evaluated model performance at varying classification thresholds and among different patient populations. When applied to patients over 65, a threshold with a sensitivity of 20.7% produced a specificity of 96.7% and a PPV of 0.068%. Late-stage esophageal cancer patients identified by the model would have been detected a median of 24 months before their actual diagnosis, with three quarters of these patients identified at least 9 months earlier than their recorded diagnosis date. Using EHR data to identify early-stage esophageal cancer patients shows promise, with potential for significantly earlier detection. While widespread use of this approach on an unselected population would produce high rates of false positives, this technique could be employed among high risk patients, or paired with other screening tools.

Endoscopic resection versus esophagectomy for patients with small-sized T1N0 esophageal cancer: A propensity-matched study

Endoscopic resection (ER) has been rapidly adopted in the treatment of early-stage esophageal cancer. We aimed to compare the outcomes of ER with esophagectomy for patients with small-sized (≤2 cm) stage T1a and T1b esophageal cancer in a population-based cohort. We queried the Surveillance, Epidemiology, and End Results database for patients with T1N0M0 esophageal cancer who underwent ER or esophagectomy and generated a balanced cohort with 217 matched pairs using propensity score matching (PSM). Kaplan-Meier method and multivariable Cox regression analysis were employed to investigate the matched cohort. Subgroup analyses of T stage were also performed. We identified 702 patients; 309 (44.0 %) underwent ER, and 393 (56.0 %) underwent esophagectomy. In the unmatched cohort, patients who underwent ER were older, more likely to have a T1a stage, and less likely to receive lymph node sampling. In the entire matched cohort, multivariate analysis found esophagectomy were associated with better overall survival (OS) (HR: 0.62, 95 % CI: 0.40-0.96, p = 0.032) than ER, but no significant difference in esophageal cancer-specific survival (ECSS) (HR: 1.37, 95 % CI: 0.64-2.96, p = 0.420) between the two procedures. The results were similar for subgroup analyses of stage T1b patients. However, ER and esophagectomy were associated with similar OS (HR: 0.74, 95 % CI: 0.41-1.36; p = 0.334) and ECSS (HR: 3.69, 95 % CI: 0.95-14.39; p = 0.060) in patients with stage T1a disease. In patients with stage T1 esophageal cancer, ER was similar to esophagectomy in terms of oncologic outcomes. More prospective studies should be implemented to determine the optimal treatment for T1b esophageal cancer patients with risk factors.

Adenocarcinoma originating from long-segment Barrett's esophagus over 15\xa0cm: a series of 3 cases

BackgroundBarrett's esophagus (BE) is characterized by presence of columnar epithelium in the lower esophageal mucosa, which originally comprises stratified squamous epithelium. Gastroesophageal reflux disease causes BE and BE adenocarcinoma (BEAC); further, the incidence of BEAC is increasing, especially in developed countries. Long-segment BE (LSBE) has a particularly high carcinogenic potential and necessitates treatment, surveillance, and prevention.Case presentationHerein, we report three cases of BEAC originating from LSBE larger than 15 cm. All three patients underwent surgery for the diagnosis of BEAC. A 66-year-old man with advanced esophageal cancer underwent neoadjuvant chemotherapy and subsequent subtotal esophagectomy. The postoperative pathological diagnosis was of poorly differentiated adenocarcinoma with lymph node metastasis (pT3 pN3 pM0 pStage III based on the Union for International Cancer Control TNM Classification 8th edition). Two years after the operation, the patient was diagnosed with recurrence around the celiac artery and underwent chemotherapy. An 83-year-old woman with advanced esophageal cancer underwent subtotal esophagectomy. The postoperative pathological diagnosis was of well-differentiated adenocarcinoma with supraclavicular lymph node metastasis (pT3 pN3 pM1 pStage IV). Two months after the operation, the patient was diagnosed with recurrence in the neck lymph nodes and underwent chemotherapy; however, she died. A 66-year-old man with early-stage esophageal cancer underwent subtotal esophagectomy. A superficial early cancerous lesion was seen over BE. The postoperative pathological diagnosis was of well-differentiated adenocarcinoma without lymph node metastasis (pT1a pN0 pM0 pStage 0). The patient was found to be alive and recurrence-free 3 months after the operation.ConclusionsBEAC might show good prognosis if detected and treated early. Extremely LSBE is associated with a high incidence of BEAC; therefore, early detection and treatment with close surveillance is essential.

A prospective analysis of the diagnostic accuracy of 3\u2009T MRI, CT and endoscopic ultrasound for preoperative T staging of potentially resectable esophageal cancer

BackgroundPatients with esophageal cancer (EC) undergo endoscopic ultrasound and CT based cancer staging. Recent technical developments allow improved MRI quality with diminished motion artifact that may allow MRI to compare favorable to CT for noninvasive staging. Hence the purpose of the study was to assess image quality and diagnostic accuracy of 3 T MRI versus CT and EUS for preoperative T-staging of potentially resectable esophageal cancer.MethodsBetween October-2014 and December-2017, esophageal cancer patients with T-staging by EUS were enrolled in this prospective study. Post-operative histopathologic T-staging was the reference standard. All participants underwent MRI [T2- multi-shot turbo spin echo sequence (msTSE), diffusion-weighted imaging (DWI), and 3D gradient-echo based sequence (3D-GRE)] and CT [non-contrast and multiphase contrast-enhanced CT scanning] 5.6 + 3.6 days after endoscopy. Surgery was performed within 3.6 + 3.5 days after imaging. Two blinded endoscopists (reader 1 and 2) and radiologists (reader 3 and 4) independently evaluated EUS and CT/MRI, respectively. Considering the clinical relevance, patients were dichotomized into early (T1 and T2) vs late (T3 and T4) stage cancer before assessment. For statistical purpose, the binary decision was defined as the ability of the imaging technique to diagnose early stage/not early stage esophageal cancer. Diagnostic performance of EUS, MRI and CT was compared using McNemar’s test with Bonferroni correction; kappa values were assessed for reader performance.Results74 study participants (60 ± 8 yrs.; 56 men) with esophageal cancer were evaluated, of whom 85%(63/74) had squamous cell carcinoma, 61%(45/74) were at early stage and 39%(29/74) were at late stage cancer, as determined by histopathology. Intra- and Inter-reader agreement for pre-operative vs post-operative T-staging was excellent for all imaging modalities. Compared to CT, MRI showed significantly higher accuracy for both the readers (reader3: 96% vs 82%, p = 0.0038, reader4: 95% vs 80%, p = 0.0076, for MRI vs CT, respectively). Further, MRI outperformed EUS with higher specificity (reader 1 vs 3: 59% vs 93%, p = 0.0015, reader 2 vs 4: 66% vs 93%, p = 0.0081, for EUS vs MRI respectively), and accuracy (reader 1 vs 3: 81% vs 96%, p = 0.0022, reader 2 vs 4: 85% vs 95%, p = 0.057, for EUS vs MRI, respectively).ConclusionFor resectable esophageal cancer, MRI had better diagnostic performance for tumor staging compared to CT and EUS.Trial registrationChiCTR, ChiCTR-DOD, Registered 2nd October 2014, http://www.chictr.org.cn/showproj.aspx?proj=9620

Role of radiation therapy in node-negative esophageal cancer: A propensity-matched analysis.

BackgroundThis study investigated the prognostic impact of (neo‐)adjuvant radiation therapies in early stage esophageal cancer.MethodsA retrospective analysis using the Surveillance, Epidemiology, and End Results (SEER) database was conducted from 2004 to 2016. Patients with pathologically staged T1‐4N0M0 esophageal cancer were divided into two treatment groups: (i) neoadjuvant radiotherapy followed by surgery; and (ii) upfront esophagectomy followed by adjuvant radiotherapy. Propensity scored match and Cox proportional hazards model were used to identify covariates associated with overall survival and cancer‐specific survival.ResultsThere were 821 patients selected, of whom 588 (71.6%) received neoadjuvant radiotherapy and 233 (28.4%) received adjuvant radiotherapy. For the entire cohort, neoadjuvant radiotherapy was associated with a significantly benefit in five‐year survival outcomes compared with adjuvant radiotherapy (P < 0.01). After matching, the survival outcomes were still better for neoadjuvant radiotherapy than that of adjuvant treatment. Stratifying based on pathologic tumor status, neoadjuvant radiation was associated with improved CSS (five‐year survival 73.7% vs. 42.1%; P = 0.014) for localized (pT3‐4N0) disease. The Cox multivariate regression analysis revealed that the addition of neoadjuvant radiation for pT3‐4N0 diseases with tumor length ≥ 5 cm and squamous cell carcinoma, was a powerful prognostic factor for improved cancer‐specific survival (P < 0.01).ConclusionsCompared with adjuvant radiotherapy, the addition of neoadjuvant radiation for pT3‐4N0 diseases has been associated with improved cancer‐specific survival in high‐risk patients. Studies on preoperative neoadjuvant therapies would be plausible in high‐risk esophageal cancer patients.

Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for clinical node-negative esophageal carcinoma.

BackgroundThe impact of neoadjuvant chemoradiotherapy (nCRT) on early stage esophageal cancer is unknown. Here, we compared the outcomes after esophagectomy alone or nCRT plus surgery for clinically staged node‐negative esophageal cancer.MethodsWe searched the Surveillance, Epidemiology, and End Results database for patients with clinically node‐negative (cN0) esophageal cancer from 2004 to 2016 who underwent surgery alone or nCRT plus surgery. Propensity score matching and Cox regression analysis were used to identify covariates associated with overall survival and cancer‐specific survival.ResultsA total of 1587 patients were retrospectively identified, of whom 49.8% (n = 791) received nCRT and 80.2% (n = 1273) were truly node‐negative diseases. For the entire cohort, surgery alone was associated with a statistically significant but modest absolute increase in survival outcomes (P < 0.01). After matching, nCRT was associated with improved five‐year overall survival for pT3‐4N0 (localized) disease (59.6% vs. 37.7%; P < 0.001) and pathological node‐positive disease (60.5% vs. 40.7%; P = 0.002). Cox multivariate regression analysis revealed that the addition of nCRT for truly node‐negative patients with tumor length ≥ 3 cm, pT1‐2N0 (early‐staged) and localized disease were independent risk factors for survival than surgery alone (P < 0.01).ConclusionsCompared with surgery alone, patients with cN0 esophageal cancer with pathological node‐positive or localized true node‐negative disease gain a significant survival benefit from nCRT. However, nCRT plus surgery was associated with decreased survival for early‐staged true node‐negative patients. This finding may have significant implications on the use of neoadjuvant chemoradiation in patients with cN0 disease.

Submucosal tumor-like stomach cancer without morphological change for over 10 years

The patient was a 66-year-old man with a history of hepatitis B, hepatocellular carcinoma, and early-stage esophageal cancer. Although gastric submucosal tumor in the greater curvature of the upper stomach was suspected at upper gastrointestinal endoscopy over 10 years ago, biopsy was not performed because of unchanged tumor size and morphology. Endoscopy performed 1 year before visiting our hospital revealed the morphology of a submucosal tumor, which transformed to a type 3 lesion the following year. Moderately-to-poorly differentiated adenocarcinoma (stage I, T2N0M0) was diagnosed with biopsy, and open total gastrectomy with D2 lymph node dissection was performed.

Chemoradiotherapy vs radiotherapy for nonoperative early stage esophageal cancer: A seer data analysis.

BackgroundThe benefit of endoscopic treatment (ET) and esophagectomy for early esophageal cancer (EC) has been sufficiently recognized. Radiotherapy (RT) is the main treatment modality for patients who do not undergo surgery. The effectiveness of adding chemotherapy (CT) to RT remains unclear. This study aimed to evaluate the impact of chemoradiotherapy (CRT) and RT alone on overall survival (OS) and cancer‐specific survival (CSS) in early EC patients not undergoing surgery.MethodsData collected between 2004 and 2015 were obtained from the national Surveillance, Epidemiology, and End Results (SEER) database. All the samples were randomly grouped into the training cohort or the verification cohort. The training cohort was split into subgroups by stage, age, and histology. Stage was based on the American Joint Committee on Cancer (AJCC) 6th edition published in 2004. The Kaplan‐Meier method and Cox proportional hazards modeling were used to compare OS and CSS. The performance of the nomogram was measured by a concordance index (C‐index) and the calibration curve.ResultsData for a total of 5332 patients were obtained from the SEER database. A total of 3736 patients (stage I: n = 1277; stage IIA: n = 1484; stage IIB: n = 975) were used for the training cohort. Multivariate Cox regression analysis showed that age, sex, histology, grade, therapy, reasons for no surgery, and year of diagnosis were independent predictors of OS. The survival curve of patients treated with CRT showed a significant survival benefit compared to that in patients treated by RT alone in stage I, stage IIA, and stage IIB. CRT was also found to be related to better survival than RT in patients at a younger age (<65) and an older age (≥65) with squamous cell carcinoma or adenocarcinoma.ConclusionsCompared with RT, CRT results in better OS and CSS in early EC patients who do not undergo surgery.

Development of a predictive nomogram for cause-specific mortality in surgically resected early-stage oesophageal cancer: a Surveillance, Epidemiology, and End Results (SEER) analysis.

BackgroundThe aim of this population-based study was to perform competing risk analysis and estimate cancer- and other cause-specific mortality in patients who underwent oesophagectomy with pT1N0M0 oesophageal cancer (EC). A competing risks nomogram was also developed to predict the proportional of death from each specific cause.MethodsA total of 1,144 patients who received oesophagectomy for pT1N0M0 EC between 2010 and 2015 from SEER database were included. The cumulative incidence function was used to evaluate each cause of death, and the significant difference was assessed by the Grey’s test. A nomogram was established using the proportional subdistribution hazard analysis to identify predictors for each cause-specific death.ResultsThe 5-year cumulative incidence of cancer-specific death for surgically resected pT1N0M0 EC was 15.7%, and the incidence was 11.2% for other cause-specific death. Age, tumour length, pT1 substage, grade, history and primary site were identified as predictive factors for EC-specific death, but only age, tumor length and pT1 substage were associated with death from other cause. Our nomograms showed a relative good discriminative ability, with c-index of 0.663 for the EC-specific mortality model and 0.699 for the other cause-specific mortality model. The calibration curves showed a good match between the nomogram-predicted probabilities and the actual probabilities.ConclusionsIn patients who underwent curative-intent resection for pT1N0M0 EC, death from other causes was an important competing event. During clinical decision making and patient-clinician communication, our quantifiable nomograms could provide a rapid and precise judgement of the risk of death from each cause.

Clinicopathological features and prognosis of patients with esophageal cancer as the second primary cancer: a large population-based analysis using the SEER program [2000-2015

BackgroundThis study used the Surveillance, Epidemiology, and End Results (SEER) data to investigate clinicopathological characteristics and prognoses of patients with esophageal cancer as a second primary cancer from 2000 to 2015.MethodsEsophageal cancer as the second primary cancer (SEPC) patient information collected from the SEER database were extracted, evaluated, and compared with only primary esophageal cancer (OPEC) patient data. Overall survival (OS) was evaluated by the Kaplan-Meier method. Univariate analysis (UVA) and multivariate analysis (MVA) by the Cox proportional hazards regression identified risk factors that predicted OS and the results were used to construct a nomogram to predict OS in SEPC patients.ResultsA total of 7,161 esophageal cancer patients were identified from the SEER registry, which included 813 patients (11.4%) with SEPC in the patient history. The most common cancer for the first primary cancer prior to esophageal cancer (FPC) was genital system cancer (43.5%). The median OS was 7 (95% CI: 6.69–11.31) months and was not significantly different from that of patients with OPEC. The patients with SEPC appeared with unique clinical pathological features compared with OPEC, including older age, more squamous cell carcinoma, and early stage esophageal cancer, and less lower third of esophageal cancer (P<0.001). UVA and MVA identified M stage, surgery, and chemotherapy as independent risk factors. The nomogram had a calibration index of 0.682.ConclusionsSEPC had unique clinicopathological characteristics. M stage, surgery, and chemotherapy were independently associated with OS. The nomogram accurately predicted OS.

Efficacy of hydrocortisone sodium succinate and aluminum phosphate gel for stricture prevention after ≥3/4 circumferential endoscopic submucosal dissection.

ObjectiveEndoscopic submucosal dissection (ESD) is widely used in early-stage esophageal cancer, but the quality of life of patients with postoperative stricture is markedly reduced, requiring long-term repeat, periodic endoscopic balloon dilatation. We evaluated the combination of hydrocortisone sodium succinate and aluminum phosphate gel administered orally for stricture prevention.MethodsWe retrospectively assigned 27 patients who underwent ≥3/4 circular ESD for esophageal superficial squamous cell cancer to one of two groups according to the preventative strategy: endoscopic intralesional steroid injection and systemic steroid (IT+ST group) and oral combination of hydrocortisone sodium succinate and aluminum phosphate gel (OHA group). Stricture rate was compared between the two groups.ResultsThere were six and seven complete and ≥3/4 circular ESD cases, respectively, in the IT+ST group and four and ten cases in the OHA group. Stricture rates in the IT+ST and OHA groups were 53.8% and 7.1%, respectively. Nine patients in each group developed hypokalemia after glucocorticoid administration.ConclusionsOHA is a promising treatment strategy for stricture prevention following large-circumference ESD in patients with early stage esophageal carcinoma.

P178 SYNCHRONOUS TRIPLE CANCER OF THE ESOPHAGUS, GASTRIC CARDIA AND GIST OF THE STOMACH: A CASE REPORT AND REVIEW OF THE LITERATURE

Abstract Background A 82-year old man was admitted to our hospital in February 2019 for a thorough investigation to determine an incidential finding of a tumor of the stomach in a CT-Scan. He had no history of previous abdominal surgery or of serious illness. The initial symptoms were slight dysphagia, deterioriation in general condition and weight loss in the last months. Endoscopy of the stomach confirmed a poorly differentiated adenocarcinoma of the gastric cardia (intestinal type, Siewert Type II AEG) with the suspicion of paragastric lymph node metastasis. The consensus of our Comprehensive Cancer Center was a neoadjuvant FLOT-chemotherapy followed by radical resection. The Patient presented again during chemotherapy in April 2019 complaining of discomfort and epigastric pain. Endoscopy showed a partial regress of the primary tumor and on CT scan a progress of the potential lymph node metastases. Due to the symptoms and findings early resection was recommended. On surgery extensive tumor masses were found around the lesser curve and around the peritoneal cavity not like lymph node metastases. An radical resection with intrathoracic anastomoses with gastric pull up was performed. The patient was discharged 4 weeks postoperatively. The histopathological findings showed 2 other synchronous cancers besides the adenocarcinoma of the gastric cardia (ypT1b, L0;V1,G3,R0, HER2-negative, no microsatellite instability). It showed an early stage of squamous cell carcinoma of the esophagus (pT1a (m3-Type), Gn0 (0/21), L0, V0, G1, R0) and the potential paragastric lymphnode metastasis revealed to be a rare high-risk wild-type GIST of the stomach which showed a high mitotic index (&gt; 120 mitoses/15 high-power fields). The patient was readmitted to our hospital because of severe epigastric pain. A CT-Scan showed a massive progress and local recurrence of the GIST with a diameter of 7cm and infiltration into the portal vein and ascites with suspicion on peritoneal carcinomatosis. Despite the attempt of a sunitinib therapy the patient died in the beginning of May 2019 in a palliative setting . Conclusion There have only been few reports in the literature of synchronous triple cancer of gastric GIST, esophageal squamous cell carcinoma, and gastric adenocarcinoma. In our case we considered the gastric adenocarcinoma to be a middle stage cancer and the squamous cell carcinoma an early stage esophageal cancer. The incidental finding of the high-grade gastric GIST with a high mitotic index and unfavorable histopathological features as the wild-type confirmation was probably the cause of death of the patient.

Comparison of Short-Term Efficacy Between Endoscopic Submucosal Tunnel Dissection and Endoscopic Submucosal Dissection in Treatment of Wide Esophageal Squamous Cell Carcinoma of Early Stage.

The goal of this study was to compare the efficacy and safety of endoscopic submucosal tunnel dissection (ESTD) with endoscopic submucosal dissection (ESD) for the removal of early-stage esophageal squamous cancer wider than or equal to one half the circumference of the esophagus. Although ESD has been successfully applied for resection of early-stage esophageal cancer, there are still technical challenges and postoperative stenosis when it is applied to treat large lesions. A total of 40 patients with early-stage esophageal cancer wider than or equal to one half its circumference were enrolled in this study and randomly assigned to an ESTD or ESD group for treatment of esophageal superficial squamous cell carcinoma. All of the patients received oral steroids after endoscopic dissection. We then compared the 2 groups in terms of average operating time, dissection speed, en bloc resection rate, R0 resection rate, and complications during a 1-year follow-up period. The dissection speed in the ESTD group was significantly faster than that in the ESD group (P=0.047). There were no significant differences in operating time, en bloc resection rates, or R0 resection rates between the ESTD and ESD group (P=0.319, 1.000, 1.000, respectively). There were also no significant differences in perforation, bleeding, or stenosis rates between the ESTD and ESD group (P=1.000, 0.748, 1.000, respectively). Both ESTD and ESD are safe and effective therapies for early-stage esophageal cancer wider than or equal to one half the esophageal circumference. The dissection speed of ESTD is faster than that of ESD.

Treatments and outcomes of older patients with esophageal cancer: Comparison with younger patients.

The number of older patients with esophageal cancer (EC) is increasing due to the population aging and increasing life expectancy. However, no optimal treatment strategy for older patients with EC has been established to date. The aim of the present study was to review and compare the treatment modalities and outcomes of 990 younger and older patients diagnosed with EC in our institution. The patients were divided into younger (≤74 years) and older (≥75 years) groups. The majority of the patients in both groups had early-stage EC and were treated by endoscopic submucosal dissection (ESD). The older patients with locally advanced (stage II and III) EC were more likely to undergo chemoradiotherapy rather than esophagectomy. Among the older patients, 22% selected best supportive care. The disease-specific survival rate of the older patients was significantly lower compared with that of the younger patients, which was likely due to the less intense treatment modalities applied. The prognosis following esophagectomy was significantly better compared with that of chemoradiotherapy in the younger, but not in the older patients. In conclusion, the poorer prognosis of older patients (aged ≥75 years) with stage I EC may improve with multidisciplinary treatment after ESD. Although CRT is currently considered the optimal treatment for older patients with stage II/III EC, more efficient treatment modalities are urgently required.

The influence of adjuvant radiation therapy after endoscopic resection on survival for early stage EC: an analysis of the surveillance epidemiology and end results (SEER) database.

Endoscopic resection (ER) followed by radiation therapy (RT) is a treatment option for early stage esophageal cancer (EC). We used the surveillance epidemiology and end results (SEER) database to investigate the influence of adjuvant RT after ER on survival for early stage EC. The SEER database [1998-2013] was queried for locoregional cases of EC. Tumor staging was redefined with the 8th Edition of the American Joint Committee on Cancer (AJCC)/Union for International Cancer Control tumor-node-metastasis (TNM) staging system. The T1-2 stage EC cases in which ER were followed by radiation or observation were included. Kaplan-Meier methods were performed to compare overall survival (OS) and cancer-specific survival (CSS) between the patients who received radiation and those who did not. Subgroup analysis was made according to AJCC stage. A multivariate Cox proportional-hazards regression model was used to identify independent covariates which may influence survival. The median survival of the no-radiation group was significantly longer than that of the radiation group [74 vs. 31 months; hazard risk (HR), 2.39; 95% confidence interval (CI), 1.782-3.197; P<0.001]. In T1a stage subgroup, patients who did not receive RT had significantly better OS and CSS outcomes (OS: 90 vs. 31 months; HR, 2.90; 95% CI, 1.766-4.773; P<0.001; CSS: 105 vs. 48 months; HR, 5.40; 95% CI, 2.636-8.226; P<0.001). In the T1b and T2 subgroup analyses, both the OS and CSS were not significantly different between the radiation group and the no-radiation group (all P>0.05). In multivariate regression analysis, radiation was not a significant factor for OS and CSS after adjustment for confounding factors (P>0.05). Using SEER data, we revealed that RT after ER did not improve survival in early stage EC patients; specifically, RT did not benefit T1b and T2 patients and may lead to poorer survival in T1a patients. Our findings do not support the addition of RT after ER for early stage EC, especially T1a EC.

Patients younger than 45 years of age have superior 5-year survival in advanced esophageal cancer

Background: Esophageal cancer is an aggressive malignancy that most commonly presents in the sixth and seventh decade of life. However, there are a subset of patients that present with esophageal cancer at a very young age ( Methods: This study was performed through a retrospective review of patients who underwent esophageal resection performed at our institution from 1985 to 2014 identified 82 patients who were under the age of 45 when they underwent surgical resection for esophageal cancer. This cohort of patients were matched to a cohort of patients who had the same stage, sex, neoadjuvant therapy, pathology, and year of diagnosis within 5 years but were older than 45 years old when they underwent esophageal resection. Results: There was no significant difference in survival between the younger and older cohort of patients with stage I or II disease. Patients with stage III/IV esophageal cancer under the age of 45 had 1-, 3-, and 5-year survival of 88.6%, 31.8% and 24.2%, while in the older matched cohort 1-, 3-, and 5-year survival was 58.3%, 20.6%, 8.8% [P=0.04, hazard ratio (HR) 1.72]. Conclusions: While age doesn’t affect overall survival of early-stage esophageal cancer, patients under the age of 45 with advanced esophageal cancer have superior overall survival compared to older patients.

Innovative and Contemporary Interventional Therapies for Esophageal Diseases.

Esophageal surgery has become quite specialized, and both dedicated diagnostic and refined surgical techniques are required to deliver state-of-the-art care. The field has evolved to include endoscopic mucosal resection and radiofrequency ablation for early-stage esophageal cancer and minimally invasive esophagectomy with the reconstruction of a gastric conduit for carefully selected patients with esophageal cancer or those with "end-stage" esophagus from benign diseases. Reoperative esophageal surgery after esophagectomy deserves special mention given that these patients, with improved survival, are presenting years after esophagectomy with functional and anatomic disorders that sometimes require surgical intervention. Different diagnostic modalities are essential for assessing patients and planning surgical treatment. Recognizing early and late postoperative complications on imaging may expedite and improve patient outcomes. Finally, endoscopic management of achalasia with peroral endoscopic myotomy and the use of the LINX device for gastroesophageal reflux disease are highly effective and minimally invasive treatments that may reduce complications, costs, and length of hospital stay.

Sa1250 A COMPARISON OF ANATOMIC DISTRIBUTION, GRADE, AND LYMPH NODE SPREAD WITH EARLY-STAGE ESOPHAGEAL SQUAMOUS CELL CARCINOMA RELATIVE TO ESOPHAGEAL ADENOCARCINOMA

Endoscopic resection is increasingly being recommended for both squamous and adenocarcinoma early-stage esophageal cancers. Most analyses for early-stage cancers in the U.S. as well as the corresponding guidelines have been derived from data from the adenocarcinoma histology. Given that the tumor biology may differ considerably, we compared early-stage esophageal squamous cell carcinoma (ESCC) to early-stage adenocarcinoma (EAC) in a large, representative, U.S. population database containing data on both tumor subtypes.

Estimation of Cost for Endoscopic Screening for Esophageal Cancer in a High-Risk Population in Rural China: Results from a Population-Level Randomized Controlled Trial.

Population-level endoscopic screening for esophageal cancer has been conducted in China for years. In this study, we aim to provide an updated and precise cost estimation for esophageal cancer screening based on a randomized controlled trial in a high-risk area in China. We estimated the cost of esophageal cancer screening with chromoendoscopy using a micro-costing approach based on primary data of the ESECC (Endoscopic Screening for Esophageal Cancer in China) randomized controlled trial (NCT01688908) from a health sector perspective. Unit costs and quantities of resources were collected to obtain annual screening costs. The screening project was then theoretically expanded to a 10-year period to explore long-term trends of costs. Costs were adjusted to US dollars for the year 2018. In the ESECC trial, screening cost per endoscopy with a valid pathologic diagnosis was $196, accounting for 3.82% of the gross domestic product per capita in Hua County, and the costs for detecting one esophageal cancer and one early-stage esophageal cancer were $26,347 and $37,687, respectively. In conventional screening in which protocol-driven costs were excluded, costs as above were $134, $18,074, and $25,853. The cost for detecting one gastric cardia cancer or stomach cancer was nine times higher than detecting one esophageal cancer owing to low prevalences of the two cancers. In a simulated 10-year screening project, annual cost decreased notably over time. Despite the relatively low absolute cost, population-level endoscopic screening will still be a heavy burden on local government considering the socioeconomic conditions. Long-lasting programs would be less costly and population-level screening would make little sense in non-high-risk regions.

Somatic alterations in circulating cell-free DNA of oesophageal carcinoma patients during primary staging are indicative for post-surgical tumour recurrence

Oesophageal cancer (OC) has high mortality. This study aims at determining the feasibility of liquid biopsies for genomic profiling in early stage OC, comparing two different technologies for mutational analysis in circulating cell -free DNA (ccfDNA) and evaluating the clinical impact of these somatic alterations during primary staging. In 25 patients with locally advanced OC, endoscopic tumour biopsies and simultaneous blood samples were taken during primary staging. Genomic DNA from biopsies and ccfDNA were analysed for mutations using a 12 gene panel next-generation sequencing (NGS) assay as well as digital droplet PCR (ddPCR). Genetic data was correlated with patients’ outcome. In 21 of the tested biopsies (84%) at least one somatic mutation was detected by NGS. Mutations detected by NGS were detectable by ddPCR with similar allele frequencies. In three out of the 21 patients with proven mutations, the same mutations were also detectable in ccfDNA using NGS (14%). In contrast, ddPCR detected mutations in ccfDNA of five additional patients (8/21, 38%). Post-surgical outcome analysis was performed for those patients who had received complete tumour resection (n = 16). Five of them suffered from an early relapse within the first year after surgery, including four with detectable somatic mutations in ccfDNA during primary staging. Taken together, we showed a higher sensitivity for ddPCR compared to NGS in detecting mutated ccfDNA in OC. Detection of somatically altered ccfDNA during primary staging seems to be indicative for post-surgical tumour recurrence.