Mediastinal Nodes Research Articles

The triple radiologic asthma phenotype is associated with worse disease control

BackgroundEfforts have been made to combine radiographical biomarkers such as bronchiectasis or bronchial wall thickness (BWT) to identify asthma sub-phenotypes and their clinical implications. ObjectiveTo assess whether a composite triple radiological phenotype measured by high resolution computed tomography comprising BWT, mucus plug score (MPS) and mediastinal lymph node (MLN) size might provide a better insight into sub-phenotypes in persistent asthma. MethodsOne hundred and twelve patients with moderate-to-severe asthma were included in this retrospective observational study. A binary method was used to classify patients according to median values for: pooled MLN≥3.6mm; BWT as pooled wall area ≥50% of the total airway area; and MPS≥1 where a mucus plug was considered positive if complete bronchial obstruction was imaged more than 2 cm from a pleural surface. ResultsPatients with the triple imaging phenotype exhibited significantly worse asthma control questionnaire scores exceeding minimal clinical important difference, a higher prevalence of concomitant chronic rhinosinusitis with nasal polyposis and a greater total IgE level. ConclusionWe have demonstrated an association between poorer symptom control and the triple radiological asthma phenotype.

Robot-assisted cervical esophagectomy with simultaneous transhiatal abdominal procedure for thoracic esophageal carcinoma

BackgroundMinimally invasive robot-assisted cervical esophagectomy has been sporadically reported as a novel thoracic esophagectomy technique for patients with thoracic esophageal carcinoma. Most reports indicate that the abdominal component of robot-assisted cervical esophagectomy is performed sequentially after the cervical phase. However, if the cervical and abdominal phases are performed simultaneously using a nerve integrity monitoring system with no administration of muscle relaxants, there are two major advantages: a reduced risk of recurrent nerve palsy and a shorter operative time. We herein report our experience performing novel robot-assisted transcervical esophagectomy with a simultaneous transhiatal abdominal approach using a nerve integrity monitoring system.MethodsThirty cases of robot-assisted cervical esophagectomy performed from 2023 to April 2024 were reviewed. The operative and short-term surgical outcomes of this procedure were compared with those of robot-assisted cervical esophagectomy using a sequential abdominal approach, and the feasibility and efficacy of the simultaneous procedure were analyzed.ResultsAll patients successfully underwent robot-assisted cervical esophagectomy with no intraoperative adverse events. There were no differences in the patients’ demographic or operative data between the two groups. There was no difference in the mean operation time for the cervical procedure (p = 0.23). However, there was a significant difference in the total time for the whole procedure (sequential group: 453.8 ± 26.8 min, simultaneous group: 291.2 ± 36.1 min; p < 0.01). There were no differences in postoperative surgical complications between the groups. There was also no difference in the total number of surgically harvested mediastinal lymph nodes (p = 0.33).ConclusionsRobot-assisted transcervical esophagectomy, a new technique for thoracic esophageal cancer, was safe and feasible under intraoperative management using nerve integrity monitoring without muscle relaxants. This procedure facilitates intraoperative monitoring of recurrent laryngeal nerve activity, significantly shortening the total operative time.

Study protocol for Near-infrared molecular imaging for lung cancer detection and treatment during mini-invasive surgery (phase II Trial) - (the RECOGNISE study)

Introduction. To date, radical surgery remains the best curative option in patients with early-stage lung cancer. In patients with small lung lesions, video-assisted thoracic surgery (VATS) should be increasingly chosen as a fundamental alternative to thoracotomy as it is associated with less postoperative pain and better quality of life. This scenario necessarily increases the need for thoracic surgeons to implement new localization techniques. The conventional near-infrared (NIR) indocyanine green (ICG) method demonstrated a significant limitation in deep cancer recognition, principally due to its intrinsic low-depth tissue penetration. Similarly, the lymph-node sentinel approach conducted by the ICG method was demonstrated to be inefficient, mainly due to the non-specificity of the tracker and the irregular pathway of pulmonary lymph node drainage. Our study aims to evaluate the effectiveness of Cetuximab- IRDye800CW in marking lung nodules and mediastinal lymph nodes. Methods and analysis. This study is defined as an open-label, single-arm, single-stage phase II trial evaluating the effectiveness of Cetuximab-IRDye800CW in detecting tumors and lymph-node metastases in patients with lung cancer who are undergoing video-assisted thoracic surgery (VATS). Cetuximab is a monoclonal antibody that binds, inhibits, and degrade the EGFR. The IRDye® 800CW, an indocyanine-type NIR fluorophore, demonstrated enhanced tissue penetration compared to other NIR dyes. The combination with the clinical approved monoclonal antibody anti-epidermal growth factor EGFR Cetuximab (Cetuximab-IRDye800) has shown promising results as a specific tracker in different cancer types (i.e., brain, pancreas, head, and neck). The study’s primary outcome is focused on the proportion of patients with lung nodules detected during surgery using an NIR camera. The secondary outcomes include a broad spectrum of items, including the proportion of patients with detection of unexpected cancer localization during surgery by NIR camera and the proportion of patients with negative surgical margins, the evaluation of the time spawns between the insertion of the NIR camera and the visualization of the nodule and the possible morbidity of the drug assessed during and after the drug infusion. Ethics and dissemination. This trial has been approved by the Ethical Committee of Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino (Torino, Italy) and by the Italian Medicines Agency (AIFA). Findings will be written as methodology papers for conference presentations and published in peer-reviewed journals. The Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, the University of Torino, and the AIRC Public Engagement Divisions will help identify how best to publicize the findings.Trial registration EudraCT 202,100,645,430. ClinicalTrials.gov NCT06101394 (October 23, 2023).

645. CLINICAL SIGNIFICANCE OF LOCAL TREATMENT FOR RECURRENCE WITHIN THE SURGICAL FIELD AFTER RADICAL ESOPHAGECTOMY

Abstract Background In recent years, more aggressive multidisciplinary treatment and minimally invasive approaches with meticulous lymph node dissection have become the standard in esophageal cancer surgery, but recurrence cases within the surgical field after radical resection are unfortunately frequently observed. We will compare the clinicopathological characteristics of the cases of intra-sugical field recurrence with those of extra-surgical and both intra- and extra-surgical field recurrence and discuss their significance in light of the results of local treatment for intra-surgical field recurrence. Subjects The study included 130 cases of intra-surgical field recurrence among 490 esophageal cancer patients who underwent radical subtotal esophagectomy and cervical anastomosis (Mckeown-esophagectomy) with right thoracic approach between January 2013 and April 2019. Results The 130 cases of recurrence were categorized as intra-surgical field recurrence (Group I)/extra-surgical field (Group O)/intra- and extra-surgical field (Group I+O): 19/86/25. Preoperative factors: Tumor localization tended to be more common in Ut in group I (p=0.078), but there were no other differences such as cStage or preoperative treatment. Intraoperative/postoperative factors: I+O group had significantly more blood loss (p=0.045), but there were no other differences in the range of lymph node dissected field, number of dissected lymph nodes, combined resection of the thoracic duct, postoperative complications, hospital stay, or histological therapeutic effect. 19 patients in group I had 17 patients (89.5%) who received initial local treatment (surgery/CRT/RT: 4/7/6). The response rate (R0 resection or CR+PR) was 58.8%. Compared to cervical and upper mediastinal lymph node recurrence, the response rate to initial local treatment tended to be lower in patients with middle and lower mediastinal lymph node and anastomotic recurrence (80%/43%, p=0.145). Discussion Intra-surgical field recurrence after radical resection tended to be more common in the primary site of Ut. Recurrence in the upper mediastinal lymph nodes in the cervical region shows a relatively high response rate to local treatment, and long-term recurrence-free ("cure") is achieved. On the other hand, mid and lower mediastinal lymph node and anastomotic recurrences have a low response rate to local treatment and should be complemented with more systemic treatment, such as sequential ICI to initial treatment.

559. SURGICAL PROCEDURE AND CLINICAL OUTCOME OF TRANSMEDIASTINAL ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Abstract Background We started performing esophagectomy by a laparoscopic transhiatal approach in 2009, and 577 patients had undergone to date. Furthermore, we started performing single-port mediastinoscopic cervical approach in 2014, and developed a technique for total mediastinal lymph node dissection (390 patients). Methods The upper and middle mediastinal lymph node dissection including lymph nodes along the left recurrent laryngeal nerve, using a left cervical approach, was performed with a single-port mediastinoscopic technique. This approach with pneumomediastinum by AirSeal System improved the visibility and handling in the deep mediastinum around the aortic arch. We recently performed intraoperative monitoring of the recurrent laryngeal nerve using Nerve Integrity Monitor system. For dissection of upper and middle mediastinal lymph nodes, the left recurrent laryngeal nerve was sometimes compressed by the shaft of the sealing device or the retractor. We used continuous monitoring with the Automatic Periodic Stimulation electrode for the left recurrent laryngeal nerve, and immediately recognized dangerous procedures. Frequency of recurrent laryngeal nerve palsy was dramatically reduced to half by the introduction of Nerve Integrity Monitor system. Furthermore, to understand the anatomy of bilateral bronchial arteries, we performed 3-dimensional computed tomography angiography preoperatively, which was crucial to avoid intraoperative bleeding. Results The outcome of patients performed transmediastinal radical esophagectomy was compared with those performed the right thoracotomy by using propensity score matching. The operative time, the operative bleeding, and postoperative respiratory complications were significantly decreased by transmediastinal radical esophagectomy. Conclusion Our surgical procedure resulted in a good surgical view, safe en-bloc mediastinal lymph node dissection, and the decrease of postoperative respiratory complications. https://intconferenceservices-my.sharepoint.com/:v:/g/personal/barbarav_icsevents_com/ER9oAGbon3xJvdMGlJ2EUbIBgaq_8XDlKNA-wzVH3-7Hcg?nav=eyJyZWZlcnJhbEluZm8iOnsicmVmZXJyYWxBcHAiOiJPbmVEcml2ZUZvckJ1c2luZXNzIiwicmVmZXJyYWxBcHBQbGF0Zm9ybSI6IldlYiIsInJlZmVycmFsTW9kZSI6InZpZXciLCJyZWZlcnJhbFZpZXciOiJNeUZpbGVzTGlua0NvcHkifX0&amp;e=KbAfDr

745. A CASE OF ESOPHAGEAL METASTATIC STRICTURE 9 YEARS AFTER BREAST CANCER SURGERY

Abstract Background Oesophageal metastasis of breast cancer is relatively rare. In this report, we describe our experience of a case in which dysphagia was the main complaint, leading to the diagnosis of esophageal metastasis. Method A 63-year-old woman who had undergone partial mastectomy and sentinel lymph node removal in 20xx with a diagnosis of breast cancer presented 9 years after surgery with dysphagia. The postoperative pathological diagnosis of breast cancer was invasive ductal carcinoma, T2, N0, M0, ly1. She had previously received chemotherapy for recurrent bone metastases and mediastinal lymph node metastases 7 years post-operatively, and RT and chemotherapy for a diagnosis of SVC syndrome due to mediastinal lymph nodes 8 years post-operatively. In the present case, upper gastrointestinal endoscopy showed oesophageal stricture and biopsy showed ER+ and PgR- from oesophageal mucosa. Radiotherapy and chemotherapy were administered for the diagnosis of oesophageal metastasis of breast cancer, and the patient's symptoms improved. Conclusion In the case of oesophageal stricture with dysphagia after breast cancer surgery, it is essential to consider oesophageal metastases of breast cancer as a differential, although rare, in addition to benign and primary disease.

Antimoniosis: Radiological Insights into a Rare Pneumoconiosis in Miners.

Pneumoconiosis describes diseases caused by the accumulation of inorganic dust particles in the lungs, leading to tissue damage. The diagnosis relies on a history of exposure and compatible radiological findings. We aimed to investigate the radiological findings in individuals exposed to antimony-inert dust relative to their working periods. Fifty-six symptomatic male antimony miners were retrospectively evaluated for demographics and chest computed tomography (CT) scans. The demographic and radiological data of patients with a history of antimony mining, who presented at our pulmonary clinic between June 2017 and June 2023, were analyzed according to the duration of exposure. The study included 56 male patients with a mean age of 58.5±13.02 years and a mean exposure duration of 13.63 ± 6.82 years. CT scans showed that 73.2% (n=41) had upper and middle lung zone involvement, and 55.4% (n=31) had extensive involvement. Micronodules with centriacinar ground-glass opacities were the most common finding (n=37, 66.1%), followed by nodular opacities with irregular margins (n=22, 39.3%) and solid micronodules (n=20, 35.7%). Patients with over 20 years of exposure had significantly higher rates of respiratory and cardiovascular disease (p<0.05). Increased exposure time correlated with more extensive parenchymal involvement and higher rates of calcification in mediastinal lymph nodes, solid micronodules, nodular opacities with irregular margins, honeycombing, and conglomerate mass appearance. Radiological findings in pneumoconiosis generally worsen with longer exposure. Given the scarcity of up-to-date information on antimony pneumoconiosis, further studies focusing on radiological findings and chemical analyses of those exposed to antimony mine dust are essential to identify related pathologies.

329. PREDICTION OF MEDIASTINAL LYMPH NODE METASTASIS IN SIEWERT TYPE I/II ESOPHAGOGASTRIC JUNCTION CANCER WITH ESOPHAGEAL INVASION

Abstract Background Mediastinal lymph node dissection (LND) is a critical factor to decide the surgical strategy for Esophagogastric junction (EGJ) cancers. As a result of a prospective multicenter study in Japan, surgical algorithm including the extent of LND for EGJ cancers has recently been proposed according to the length of esophageal invasion. However, preoperative measure predicting upper mediastinal LN metastasis is still lacking, and the oncologic efficacy of mediastinal LND remain unknown. Methods The aim of this study was to identify preoperative factors predicting mediastinal LN metastasis, and we hypothesized that preoperative CT image would be of utility. Patients who underwent surgical treatment for Siewert Type I/II EGJ cancer with esophageal invasion with curative intent between 2000 and 2022 at the Tokai University Hospital were retrospectively reviewed. Results A total of 103 patients were enrolled. Among them, 55, 74, and 74 patients underwent upper, middle, and lower mediastinal LND, respectively. Upper/middle/lower mediastinal LN metastasis was observed in 14/13/23 of those patients, respectively, with lower thoracic paraesophageal LNs (29%), middle thoracic paraesophageal LNs (18%), and right recurrent nerve LNs (16%) being the three most common metastatic sites. Estimated invasion depth of the primary lesion≧cT3 (p≦0.007), tumor size≧4cm (p≦0.002), esophageal invasion length≧4cm (p≦0.007) and minor axis of the LN≧5mm by preoperative CT image (p&amp;lt;0.001) were significant preoperative factors related to mediastinal LN metastasis. Conclusion Clinical T factor, tumor size, the size of mediastinal LN by CT image, as well as esophageal invasion length, were important preoperative factors to predict mediastinal LN metastasis, and those factors should be taken into consideration to decide the surgical strategy for EGJ cancers with esophageal invasion. Survival impact of mediastinal LND still remain unclear, and further accumulation of cases and prospective studies are awaited.

395. SUPERIOR PERFORMANCE OF ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY OVER THORACOSCOPIC APPROACH: A MULTI-INSTITUTIONAL STUDY ON SHORT-TERM OUTCOMES

Abstract Background Robot-assisted minimally invasive esophagectomy (RAMIE) and conventional minimally invasive esophagectomy (CMIE) are superior to open techniques. However, few studies have directly compared the outcomes of these two approaches. Methods A retrospective study was conducted on a dataset from six medical centers, encompassing patients with esophageal squamous cell carcinoma (ESCC) who underwent minimally invasive esophagectomy between 2015 and 2022. Perioperative outcomes were compared after applying inverse probability of treatment weighting (IPTW). Results The study included 577 patients (RAMIE, 206; CMIE, 371). After applying IPTW, RAMIE was found to yield a higher number of mediastinal nodes compared to CMIE (14.86 versus 12.66, p=0.017). RAMIE was notably effective in retrieving upper mediastinal left RLN nodes, averaging 1.97 nodes versus 1.14 nodes harvested by CMIE (p&amp;lt;0.001). This was coupled by a significant decrease in nerve palsy rates (13.9% versus 22.8%, p=0.020). A significantly larger percentage of patients in the RAMIE group had an uncomplicated postoperative course (51.8% versus 34%, p&amp;lt;0.001). RAMIE also led to a reduction in pneumonia rates (8.6% versus 15.2%, p=0.041) and was linked to a shorter length of stay (LOS; 16.64 versus 21.14 days, p=0.007). The advantage of RAMIE in reducing LOS was especially pronounced in patients with a high Charlson comorbidity index (mean difference, 8.46 days; p=0.0069) and those who underwent preoperative therapy (mean difference, 5.63 days; p&amp;lt;0.001). Conclusion In ESCC, the use of RAMIE led to fewer pneumonia and faster recovery compared to CMIE. Additionally, RAMIE significantly improved the feasibility and safety of performing LND along the RLN.

Deep learning-based prediction of nodal metastasis in lung cancer using endobronchial ultrasound

ObjectiveEndobronchial ultrasound-guided transbronchial needle aspiration is a vital tool for mediastinal and hilar lymph node staging in patients with lung cancer. Despite its high diagnostic performance and safety, it has a limited negative predictive value. Our objective was to evaluate the diagnostic performance of deep learning-based prediction of lung cancer lymph node metastases using convolutional neural networks developed from automatically extracted images of endobronchial ultrasound videos without supervision of the lymph node location. MethodsPatient and lymph node data were collected from a single-center database. The diagnosis of metastasis was confirmed with endobronchial ultrasound-guided transbronchial needle aspiration and/or surgically resected specimens; the diagnosis of normal lymph node was confirmed with surgically resected specimens only. An annotation system facilitated automated image extraction from endobronchial ultrasound videos. Image frames were randomly selected and split into training and validation datasets on a per-patient basis. A deep learning model with convolutional neural networks, SqueezeNet, was used for image classification via transfer learning based on pretraining from ImageNet. Adaptive moment estimation and stochastic gradient descent were applied as optimizers. ResultsSqueezeNet, with adaptive moment estimation, achieved a sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 96.7% each after 300 epochs, whereas SqueezeNet with stochastic gradient descent achieved 91.1% each. However, SqueezeNet with stochastic gradient descent demonstrated more stable performance than with adaptive moment estimation. ConclusionsDeep learning-based image classification using convolutional neural networks showed promising diagnostic accuracy for lung cancer nodal metastasis. Future clinical trials are warranted to validate the algorithm's efficacy in a prospective, large-cohort study.

Effect of primary tumor volume on survival of concurrent chemoradiotherapy in stage IV non-small cell lung cancer.

To explore the survival effect of thoracic gross tumor volume (GTV) in three-dimensional (3D) radiotherapy for stage IV non-small cell lung cancer (NSCLC). The data cases were obtained from a single-center retrospective analysis. From May. From 2008 to August 2018, 377 treatment criteria were enrolled. GTV was defined as the volume of the primary lesion and the hilus as well as the mediastinal metastatic lymph node. Chemotherapy was a platinum-based combined regimen of two drugs. The number of median chemotherapy cycles was 4 (2-6), and the cut-off value of the planning target volume (PTV) dose of the primary tumor was 63 Gy (30-76.5 Gy). The cut-off value of GTV volume was 150 cm3 (5.83-3535.20 cm3). The survival rate of patients with GTV <150 cm3 is better than patients with GTV ≥150 cm3. Multivariate Cox regression analyses suggested that peripheral lung cancer, radiation dose ≥63 Gy, GTV <150 cm3, 4-6 cycles of chemotherapy, and CR + PR are good prognostic factors for patients with stage IV non-small cell lung cancer. The survival rate of patients with GTV <150 cm3 was longer than patients with ≥150 cm3 when they underwent 2 to 3 cycles of chemotherapy concurrent 3D radiotherapy (p < 0.05). When performing 4 to 6 cycles of chemotherapy concurrent 3D radiotherapy, there was no significant difference between <150 cm3 and ≥150 cm3. The volume of stage IV NSCLC primary tumor can affect the survival of patients. Appropriate treatment methods can be opted by considering the volume of tumors to extend patients' lifetime to the utmost.

807. A REVISED APPROACH TO THE ESOPHAGOGASTRIC JUNCTION: A MODIFIED SIEWERT CLASSIFICATION

Abstract Background Esophagogastric junction (EGJ) adenocarcinomas are challenging due to their anatomical and histopathological features and treated either as part of the esophagus or stomach cancers. Siewert (S) and Nishi classifications rely on the tumor’s epicenter to guide treatment decisions, which can lead to diagnostic and therapeutic inconsistencies. Moreover, recent studies helped define the optimal extent of lymphadenectomy for EGJ cancers. Here we present our standardized approach to EGJ cancers that integrates these insights, providing a framework to guide clinical decision-making. Methods Our modified classification relies on tumor extent rather than the epicentre, based on endoscopic measurement of the proximal and the distal limits, and the exact location of the EGJ. This approach classifies tumors based on their extent which results into six categories: SI, SI/II, SII, SII/III, SIII, and SI/II/III. Lower esophageal tumors whose distal limit lies between + 1cm and -2cm are classified as I/II. Cardia tumors whose proximal limit falls between those boundaries are II/III. Tumors that span more cephalad than + 1cm and more distally than – 2cm, are I/II/III. For Siewert I, I/II and II tumors, surgical management depends on the extent of esophageal involvement, mainly dictated by the probability of mediastinal basement nodal involvement, as defined by Kurokawa et al (2019). Additionally, a 3-field lymphadenectomy is performed when there is involvement of the cervical or recurrent laryngeal nerve lymph node stations. Results In SI, SI/II, and SI/II/III, with esophageal involvement exceeding 4 cm we favor a transthoracic esophagectomy (TTE) with total thoracic lymphadenectomy. If the involvement is between 1-4 cm, a transhiatal esophagectomy (THE) with lower mediastinal lymphadenectomy is performed. In SII, THE is done for 0-1 cm of involvement; absence of esophageal involvement permits a transhiatal extended total gastrectomy (eTG) with abdominal D2 lymphadenectomy and intra-operative margin status assessment via frozen sections. In SI/II/III and esophageal involvement of more than 4 cm, TTE is required; for esophageal involvement of 1-4 cm, we perform a THE and total gastrectomy with abdominal D2 lymphadenectomy based on distal margin findings. Conclusion This proposed modification to the classification of EGJ adenocarcinomas introduces a comprehensive framework that is tailored to the extent of tumor involvement. By addressing the limitations of existing systems and incorporating current insights, this updated classification aims to improve patient categorization and standardize treatment protocols, potentially leading to enhanced clinical outcomes.

The role of wedge resection and lymph node examination in stage IA lung carcinoid tumors.

Current guidelines recommend anatomical resection and mediastinal lymph node resection for stage I to IIIA pulmonary carcinoids (PCs). The role of wedge resection in stage IA PCs remains controversial, previous studies focused on typical carcinoids (TCs) while differentiating histological subtypes preoperatively is not easy. We aimed to study the effect of wedge resection and lymph node examination (LNE) in patients with stage IA PCs. Patients who underwent anatomical and wedge resection for stage T1N0M0 lung carcinoid tumors between 2004 and 2019 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Patients were also divided into a non-LNE group and an LNE group. Kaplan-Meier analysis and the log-rank test were used to calculate and compare overall survival (OS). Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were used to balance the variables between groups. Univariate and multivariate Cox proportional hazard models were developed to determine prognostic factors. A total of 2,029 patients with bronchopulmonary carcinoid tumors were included in this study, 1,450 underwent lobectomy, 147 underwent segmentectomy and 432 underwent wedge resection. Initially, 5-year survival differed marginally between wedge and anatomical resection (91% vs. 95%, P=0.051), but lost significance after adjustment. LNE improved 5-year survival (95% vs. 89%, P=0.003), and this remained significant after adjustment. In multivariate cox analysis, LNE remained a significant variable while extent of resection was not. This result also remained consistent after adjustment. OS was comparable between wedge resection and anatomical resection when at least 1 lymph node was examined. For early-stage PC, wedge resection was not inferior to anatomical resection in terms of OS, while LNE significantly increased the survival in both multivariate and matched studies. The relationship between surgical extent and survival in the unadjusted study may be attributed to the lower rate of LNE in wedge resection. Our findings support wedge resection with emphasis on LNE in early-stage PCs.

453. ROBOT ESOPHAGECTOMY WITH EXTENDED MEDIASTINAL LYMPH NODE DISSECTION FOR ESOPHAGEAL SQUAMOUS CELL CARCINOMA

Abstract Background Radical surgical resection may play role in prognosis improvement of the esophageal squamous cell carcinoma (ESCC) patients. Because esophagectomy with radical lymphadenectomy is highly invasive, we introduced thoracoscopic esophagectomy in 1999, and have performed over 600 cases. In 2009, we developed a hybrid of the prone and left lateral decubitus positions for thoracoscopic esophagectomy with extended LN dissection and reported good long-term outcomes especially in cT1bN0M0 ESCC patients. We reported 3y and 5y RFS was 96% and 96%, and 3y and 5y OS was 94% and 92% in those patients. We introduced robot-assisted esophagectomy (RMIE) using daVinci Xi system in June 2018 and have performed for 80 cases. We perform RMIE with the prone position instead of the hybrid position with same concept of thoracoscopic esophagectomy with extended LN dissection. Thanks to a three-dimensional magnified view, fully wristed dexterity and tremor filtration of da Vinci Xi system, the robotic system facilitates precise dissection especial for upper mediastinal lymph node dissection. We show safety introduction and technical pitfalls of robot-assisted esophagectomy with extended LN dissection. Methods: The patient is fixed on prone position. We use Monopolar curved scissors for superficial layer, bipolar cut for dissection with maryland bipolar forceps for deeper layer around Aorta and trachea, and Sharp dissection with Potts scissors around recurrent laryngeal nerves. After esophageal mobilization and mediastinal lymphadenectomy were completed, bilateral recurrent laryngeal nerve, bilateral subclavian artery, trachea, bilateral bronchus, aorta, left pulmonary artery and vein, left pleura, pericardium and hiatus are all skeletonized. Results: We could standardize surgical procedure in first 20 cases. Average operation time in the thoracic procedure is 234.4min and 190.2min in last 30 cases. Median blood loss is 0ml. Postoperative pneumonia and vocal cord palsy were occurred only 6 case in 80 cases. Conclusion: Robot assisted esophagectomy with extended LN dissection was safely introduced in our facility and it is feasible and beneficial for the lymph node dissection especially for lymph node dissection around the recurrent laryngeal nerve. https://www.dropbox.com/scl/fi/w8na39w6bo9ivwwz7x2rh/Hirofumi-Kawakubo-ISDE-2024.mp4?rlkey=p9mvt7dotyeaj6xfwvud8vcmr&amp;dl=0

346. ESOPHAGOGASTRIC JUNCTION SIEWERT II TUMORS, A CHALLENGE FOR THE SURGEON: RESULTS OF TRANSHIATAL EXTENDED GASTRECTOMY VS. IVOR LEWIS ESOPHAGECTOMY

Abstract Background Esophagogastric junction (EGJ) Siewert type II tumors pose unique challenges in terms of adequate surgical treatment due to their anatomical location and potential for abdominal and mediastinal lymph node metastasis. The optimal surgical approach for these tumors remains a topic of debate, with options including transhiatal extended gastrectomy or transthoracic esophagectomy. Understanding the different outcomes associated with these surgical interventions is crucial for informed decision-making and patient-tailored management. The aim of this study was to compare the perioperative and oncological outcomes of these two surgical technique to access which could be the treatment of choice for Siewert II type tumours. Methods This study is a retrospective non-randomized cohort study from a single center. We reviewed the data of all the patients who underwent surgery for EGJ Siewert type II tumors between December 2014 and February 2023. The patients were divided into two groups: those who underwent transthoracic esophagectomy were assigned to “TE group” (72 patients) and those who underwent transhiatal extended gastrectomy were assigned to “TEG group” (21 patients). Results Patients in the TEG group were older (p=0.011) and in worst clinical condition (Charlson Comorbidity Index 4.15±1.78 vs. 4.95±1.46, p=0.064). The tumour stage at the diagnosis was more advanced in the TE group (p=0.004), and upfront surgery was infrequent in this group (p&amp;lt;0.001). The average duration of surgery was higher in the TE group (p&amp;lt;0.001). No difference was seen in the tumour length (p=0.924), implying a statistically significant difference in the proximal margin length (p&amp;lt;0.001), and distal margin length (p&amp;lt;0.001), with a R0 resection rate higher in the TE group (93.1% vs. 66.7%, p=0.002). The higher rate of R1 resection in the TEG group was mainly due to proximal margin infiltration. No difference was seen in the number of harvested lymph nodes (p=0.339). Overall postoperative complications rates were similar (p=0.144). No differences were found in the length of ICU stay (p=0.676) and in hospital stay (p=0.075). At a median follow up of 20 months, there were no statistical differences in Overall Survival and Disease-Free Survival at 5 years. Conclusion Our data suggests that transthoracic esophagectomy for EGJ Siewert type II tumors should be the treatment of choice for patients in good clinical condition, but transhiatal extended gastrectomy could be a good choice for patients presenting in worse clinical condition. A multidisciplinary approach is essential for optimal patient care, and the selection of the surgical technique should be based on a thorough evaluation of the patient's condition and tumor characteristics

510. INNOVATIVE ROBOTIC-ASSISTED ESOPHAGECTOMY WITH THREE-FIELD LYMPHADENECTOMY: A NOVEL APPROACH TO ESOPHAGEAL CANCER SURGERY

Abstract Background Esophageal squamous cell carcinoma, the predominant form of esophageal cancer in Thailand, often presents at advanced stages (III - IV), necessitating surgical intervention. Radical esophagectomy, including three-field lymphadenectomy, stands as one of the most invasive gastrointestinal surgeries. However, in the era of minimally invasive surgery (MIS), robotic systems have emerged as a formidable approach to achieve radical treatment goals while minimizing surgical invasiveness. This video showcases a novel surgical technique and its challenges. Methods A case of mid-thoracic esophageal squamous cell carcinoma, clinically staged III, treated via robotic-assisted esophagectomy and three-field lymphadenectomy using the Da Vinci Xi system. The operation encompassed three phases: Initially, the thoracic phase with patient in semi-prone position with three robotic and one assistant trocars for complete esophageal mobilization and mediastinal lymph node retrieval. The abdominal phase, followed by the cervical phase, utilized four robotic trocars and one assistant trocar in supine position with hyperextended neck, facilitating perigastric lymph node retrieval, gastric tube reconstruction via the posterior mediastinal route, and cervical esophago-gastric tube anastomosis using a circular stapler. Results The patient experienced an uneventful recovery. Postoperative esophagogastroduodenoscopy on day 1 revealed the integrity of the anastomosis and normal vocal cord function. Imaging conducted on day 7 confirmed that the anastomosis was patent without any leakage. Surgical outcomes included an operative time of 615 minutes, estimated blood loss of 150 ml, a 14-day hospital stay, and recovery without complications. This video highlights the intricacies of the procedure and the robotic system's ability to access anatomically challenging spaces, thereby minimizing surgical invasiveness and enhancing recovery. Conclusion The robotic system is capable of performing radical procedures in anatomically challenging areas, such as narrow spaces and areas requiring precise maneuverability among vital structures. It enables a comprehensive approach spanning from the upper to the lower thoracic regions and diversity of surgery in thoracic and abdominal cavity. Additionally, this presentation highlights unique surgical tips and techniques that enhance the safety and feasibility of robotic-assisted esophagectomy. By significantly reducing surgical errors and optimizing outcomes for both oncologic and minimally invasive surgeries, it thereby marks a significant leap forward in the field of esophageal surgery. https://drive.google.com/file/d/1vrmu2D8TGoetnplcREPWQocXJle4PrOX/view?usp=share_link

350. CONTINUOUS INTRAOPERATIVE NERVE MONITORING TO REDUCE THE LEFT RECURRENT LARYNGEAL NERVE PARALYSIS IN TRANSMEDIASTINAL ESOPHAGECTOMY

Abstract Introduction Transmediastinal esophagectomy (TME) is a curative option for esophageal cancer, and can achieve total mediastinal lymph node dissection (LND) with transcervical and transhiatal procedures. With the transcervical procedure, the upper mediastinal LND is highly associated with the risk of causing recurrent laryngeal nerve paralysis (RLNP). Continuous intraoperative nerve monitoring (CIONM) can visualize the risk procedure in real time, which may result in reducing postoperative RLNP. The aim of this study was to clarify the usefulness of CIONM in reducing postoperative left RLNP with TME. Material and methods A total of 227 patients who underwent TME for esophageal cancer (EC) or esophagogastric junction cancer (EGJC) between October 2017 and July 2022 at our institution were included in this study. Patients who did not undergo the upper and middle mediastinal LND (33 patients) and could not undergo CIONM (34 patients) were excluded from these 227 patients. Finally, we analyzed data on 160 patients. The clinicopathological data were reviewed from the medical record database of our institution. Results The technical implementation rate of CIONM was 87.4%. The diagnostic performance for RLNP with amplitude&amp;lt;100μV (LOS: loss of signal) at the end of transcervical procedure was as follows (sensitivity: 83.3%, specificity: 90.7%, positive diagnostic value: 88.8%). In the univariate analysis, the frequency of left RLNP was significantly higher in male, patients with primary tumor located at the upper thoracic esophagus, and patients with LOS (p&amp;lt;0.001, respectively). Moreover, the multivariate analysis identified patients with tumor located at the upper thoracic esophagus and patients with LOS (p&amp;lt;0.001) as independent risk factors for left RLNP. Conclusion In the present study, we showed the significant association between amplitude LOS and left RLNP. CIONM could contribute to reducing left RLNP by not only paying attention to amplitude reduction during surgery, but also learning the risk procedure that may cause nerve damage after surgery.

Mediastinal lymph node dissection in segmentectomy for peripheral c-stage IA (≤2 cm) non–small-cell lung cancer

ObjectiveAlthough recent trials on intentional segmentectomy have made mediastinal lymph node dissection (MLND) mandatory, the necessity of MLND in segmentectomy remains uncertain. We conducted a retrospective study to evaluate the necessity of MLND in segmentectomy for patients with peripheral stage IA (≤2 cm) non–small cell lung cancer. MethodsOf the 5222 surgical cases for non–small cell lung cancer from 3 institutions between 2010 and 2021, 1457 patients met the JCOG0802 trial eligibility criteria. Initially, we analyzed 574 patients who underwent lobectomy with MLND to identify preoperative risk factors for cN0-pN2 occurrence (cohort 1). Subsequently, we evaluated the relationship between these factors and the cumulative postoperative recurrence in 390 patients who underwent segmentectomy (cohort 2). ResultsIn cohort 1, risk factors for cN0-pN2 occurrence were consolidation-to-tumor ratio = 1.0 and maximum standardized uptake value ≥2.0. When classifying patients into 3 groups (group A, without any factors, group B, with either factor, and group C, with both factors), the occurrence of cN0-pN2 was significantly greater in group C than in the other groups (0.9%, 3.4%, and 8.4%, respectively, P = .005). When classifying patients in cohort 2 using the classification identified in cohort 1 (117, 131, and 142 were categorized into group A, group B, and group C, respectively), the 5-year cumulative incidence of recurrence rate was significantly greater in group C than in others (2.0%, 2.0%, and 15.9%, respectively, P < .001). ConclusionsMLND is unlikely to be beneficial in intentional segmentectomy for patients with tumors showing consolidation-to-tumor ratio <1.0 and maximum standardized uptake value <2.0.

525. PALLIATIVE MULTIMODALITY-THERAPY, EVEN WITH ABBREVIATED IMMUNOTHERAPY CAN MAKE CURATIVE SURGERY FOR SYNCHRONOUS LUNG AND ESOPHAGEAL CANCER POSSIBLE: A CASE REPORT

Abstract Background Synchronous lung and esophageal carcinomas are problematic. When both cancers are locally advanced, combined surgical treatment is rarely possible because of high-risk or insufficient respiratory reserve. Palliative treatment including immunotherapy can sometimes offer significant tumor response and potentially prolong survival in patients with PDL-1 tumor expression. However the place of immunotherapy for potentially rendering inoperable patients operable is still unknown. Methods Case report: A 78-year-old male with smoking history was diagnosed with synchronous locally advanced adenocarcinoma of the Gastroesophageal Junction (GEJ) cT3cN1cM0 and bilateral lung adenocarcinomas stage 4a, cT2cN1cM1a (right lower lobe 43mm confirmed by CT-guided biopsy, left upper lobe 32mm and additional S6 left lower lobe nodule). The patient was considered incurable by MDT and palliative treatment was offered as both cancers had significant PDL-1 expression (GEJ: CPS score &amp;gt;1, Lung: PDL-1 expression 90%). Pembrolizumab immunotherapy was started but poorly tolerated (severe myositis) and stopped again after only 6 weeks. The left-sided lung cancer had by then already regressed and stereotactic irradiation (SBRT 5x12Gy) of the right-side lung cancer was administered resulting in further local tumor control (figure). Endoscopic tumor re-evalution showed a Siewert type 2 tumor (uT3N1) similar to the initial endoscopy 15 months before. Both side lung adenocarcinomas remained regressed and the left lower lobe nodule was unchanged (6mm). Mediastinal lymph node staging by EBUS was negative. Thirteen months after initial diagnosis, 4 cycles of neo-adjuvant chemotherapy (FLOT) were administered. Combined synchronous surgery was finally done 16 months after initial diagnosis. A minimally invasive combined resection included a laparoscopic &amp; thoracoscopic Ivor-Lewis MIE, left thoracoscopic wedge of the lower lobe nodule and a right lower lobectomy with radical lymph node dissection. Post-operative course was smooth: Clavien-Dindo score 1, hospital stay 18 days. Final pathology Distal third adenocarcinoma (1.5x1.2cm above Z-line) with major partial response ypT2N0M0, R0, 0/43 lymph nodes (subcarinal signs of nodal response), right lower lobe tumor of 60x55mm with residual 1.2mm focus of residual viable adenocarcinoma (ypTisN0M0, R0) and left lower lobe hamartoma (6mm). Follow-up showed no recurrence 9 months after surgery (25 months from initial diagnosis). Conclusions: 1) Despite much abbreviated palliative immunotherapy (6 weeks), SBRT and FLOT our patient was down-staged within 16 months from an initially palliative situation to a potential cure with complete resection of all tumors. 2) Synchronous combined radical laparoscopic &amp; thoracoscopic Ivor-Lewis esophagectomy with lung lobectomy can be feasible after immuno-, chemo- and radiotherapy even in elderly patients.

552. COMPARING ROBOTIC ESOPHAGECTOMY TO VIDEO-ASSISTED THORACOSCOPIC ESOPHAGECTOMY FOR ESOPHAGEAL SQUAMOUS CELL CARCINOMA: RESULTS FROM THE REVATE RANDOMIZED CLINICAL TRIAL

Abstract Background The treatment of esophageal squamous cell carcinoma (ESCC) includes dissecting lymph nodes along the recurrent laryngeal nerve (RLN), which is oncologically important but is technical demanding. Vocal cord palsy as a result from RLN injury, carries significant morbidities. This randomized clinical trial (RCT) compared the efficacy and safety of robotic esophagectomy (RE) and video-assisted thoracoscopic esophagectomy (VATE) for performing RLN lymph node dissection (LND) Methods We conducted a multicenter RCT(NCT03713749) from November 2018 to March 2022, enrolling patients with ESCC who required McKeown esophagectomy. The primary endpoint was to determine the success rate of left RLN LND. Success was defined as the removal of lymph nodes confirmed by pathology, without causing permanent nerve palsy (duration &amp;gt; 6 months). Secondary endpoints encompassed perioperative and oncological outcomes. Results The per-protocol analysis included data from 203 patients (RE group: n=103; VATE group: n=100). The primary endpoint was achieved in 88.3% of the RE group and 69% of the VATE group (p&amp;lt;0.001). Additionally, the RE group had a higher mediastinal lymph node harvest (16 [12−22] versus 14 [10−20], p=0.04), shorter thoracic operating time (110 [89−137] min versus 124[103.5−154] min, p=0.004), and earlier drainage removal (4 [3−7] days versus 6 [4−9] days, p=0.007) compared to the VATE group. The two study arms exhibited comparable complication rates with no recorded in-hospital deaths in either group. Conclusion This multicenter trial demonstrates the effectiveness of RE in enhancing the feasibility and safety of RLN LND in ESCC. Additionally, RE leads to an improved mediastinal lymphadenectomy, shorter operating times, and earlier removal of drainage.