Middle Thoracic Esophageal Cancer Research Articles

Comparison of Postoperative Outcomes Between Near-Infrared Fluorescent Imaging-Guided Mediastinal Lymphadenectomy and Conventional Surgery for Esophageal Cancer.

The study aimed to evaluate the efficacy of using near-infrared fluorescent imaging (NIRF) imaging with indocyanine green as an intraoperative tool for achieving complete mediastinal lymph node (LN) resection. Between September 2019 and July 2021, patients with potential for esophagectomy due to middle and lower thoracic esophageal cancer were enrolled in this study. All patients were scheduled for NIRF-guided mediastinal lymphadenectomy during esophageal cancer surgery and were appropriately assigned to the NIRF group. Patients who underwent esophagectomy between September 2017 and September 2019 were assigned to the historical control group upon satisfying the inclusion/exclusion criteria. Surgical outcomes and the number of removed LNs were compared between the two groups using 1:1 propensity score matching. Of 67 eligible patients, 59 patients were included in the NIRF group after postsurgical exclusions. The operative time was significantly shorter in the NIRF group than in the historical control group [180 (140-420)min versus 202 (137-338)min; P < 0.001]. The incidence of postoperative chylothorax and hoarseness were significantly lower in the NIRF group than in the historical control group (0% versus 10.2 %; P = 0.036, 3.4% versus 13.6%; P = 0.047). The number of dissected total LNs, mediastinal LNs, and negative LNs was significantly larger in the NIRF group than in the historical control group. The number of overall metastatic LNs and abdominal LNs was comparable between the two groups. NIRF imaging can assist in the thorough and complete mediastinal LNs dissections without increasing complications in patients undergoing esophagectomy.

Study on the Dynamic Changes of Myocardial Injury Markers in Radiotherapy for Esophageal Carcinoma and Its Correlation with Cardiac Dosimetry

It was hypothesized that radiotherapy for esophageal cancer could cause radiation-induced heart damage. To investigate the dynamic changes of myocardial enzyme, high-sensitive troponin T (hs-TnT), N-terminal pro-brain natriuretic peptide precursors (PRO-BNP) and left ventricular ejection fraction (LVEF) during radiotherapy and six months after radiotherapy for middle and lower thoracic squamous cell carcinoma, and to analyze the correlation between these indicators and dose-volume histogram (DVH) parameters of the heart. A total of 35 patients with thoracic esophageal squamous cell carcinoma who underwent radical concurrent chemoradiotherapy were enrolled in the study. Radiation therapy was performed for up to 6 weeks. All patients received Intensity modulated radiation therapy (IMRT). Total radiation dose was from 50.4Gy to 60 Gy in each patient with a dose of 1.8-2.0 Gy per fraction. Blood samples to determine creatine kinase (CK), creatine kinase isoenzyme MB (CK-MB), lactic dehydrogenase (LDH), alpha-hydroxybutyric dehydrogenase (α-HBDH), hs-TnT, PRO-BNP and LVEF were measured before radiotherapy, during (10th -20th fraction), at the end of radiotherapy, 1, 3, 6 months after radiotherapy. The dynamic changes of the above indexes were analyzed. The correlation between the above indexes and the mean heart dose (Dmean), V5-V60 (dose-volume histograms data were recorded in discrete 5Gy dose levels) of the heart in the course of radiotherapy was also analyzed. The Serum hs-TNT and LVEF show an upward trend during radiotherapy, at the end of radiotherapy and 6 months after radiotherapy for esophageal cancer. The hs-TnT of patients before, during, at the end of radiotherapy and 1, 3, and 6 months after radiotherapy were 7.2pg/ml, 9.1pg/ml, 9.1pg/ml, 9.0pg/ml, 9.4pg/ml, and 8.1pg/ml, respectively (p<0.05). The LVEF were 63.7%, 62.4%, 62.0%, 62.5%, 62.2%, 61.9% respectively (p<0.05). The pro-BNP showed an upward trend during radiotherapy and gradually returned to normal after radiotherapy. The CK and CK-MB showed a downward trend during radiotherapy and 1 month after radiotherapy, and gradually returned to normal 3 months after radiotherapy. Compared with the low dose group (the average dose of heart < 2000cGy), the high dose group (≥2000cGy) had a greater increase in hs-TNT, pro-BNP and LVEF, and a slower recovery time. There was no correlation between the changes of myocardial enzyme, hs-TnT, PRO-BNP, LVEF and the heart mean dose, V5-V60 during radiotherapy (p>0.05). Cardiac injury induced by concurrent chemoradiotherapy for middle and lower thoracic esophageal cancer can lead to the increase of serum hs-TNT and pro-BNP and the increase of LVEF in the early stage of treatment, and this phenomenon is more obvious in the high-dose group. The hs-TnT and PRO-BNP are sensitive parameters to reflect the heart damage in esophageal cancer radiotherapy, which may provide reference for the heart protection during radiotherapy.

Comparison of Clinical Efficacy Between Da Vinci Robot-Assisted Ivor Lewis Esophagectomy and McKeown Esophagectomy for Middle and Lower Thoracic Esophageal Cancer: A Multicenter Propensity Score-Matched Study.

We compared the perioperative efficacy and safety of da Vinci robot-assisted Ivor Lewis esophagectomy and McKeown esophagectomy for middle and lower thoracic esophageal cancer. A retrospective case-control study method was used. A total of 181 patients with esophageal cancer admitted to three medical centers in China from February 2018 to October 2022 were collected and divided into two groups according to surgical method: da Vinci robot-assisted thoracic surgery (RATS) Ivor Lewis esophagectomy (Ivor Lewis group) and RATS McKeown esophagectomy (McKeown group), respectively. Propensity score matching (PSM) analysis was used to reduce selection bias caused by confounding factors. The perioperative indicators of the two groups were compared and analyzed. There was a statistically significant difference in age and tumor location between the Ivor Lewis group and the McKeown group. After PSM, the above factors were no longer statistically significant. There were 80 patients in each group after PSM. In terms of operative time (P = 0.005), anastomotic leakage (P = 0.029), and pulmonary infection (P = 0.035), the Ivor Lewis group has significant advantages; in terms of the number of lymph nodes dissected around the recurrent laryngeal nerve (P = 0.010), the McKeown group has significant advantages. Both RATS Ivor Lewis esophagectomy and McKeown esophagectomy are safe and effective for treatment of middle and lower thoracic esophageal cancer. Ivor Lewis has advantages in operative time, anastomotic leakage, and pulmonary infection, while McKeown has advantage in lymph node dissection around the recurrent laryngeal nerve.

A multicenter randomized controlled trial of esophagectomy with or without prophylactic supraclavicular node dissection: a phase 3 trial (JCOG2013, MODERN3)

Abstract The need for prophylactic supraclavicular lymph node dissection during esophagectomy with radical lymphadenectomy remains controversial. A randomized phase III trial was launched in August 2022 to confirm the non-inferiority of esophagectomy with D2 lymphadenectomy except for supraclavicular lymph node dissection to standard D2 lymphadenectomy in terms of overall survival for patients with resectable upper or middle thoracic esophageal cancer. This study will enroll 480 patients from 54 Japanese institutions over 5 years. The primary endpoint includes overall survival, and the secondary endpoints include relapse-free survival, perioperative and late complication incidences, supraclavicular lymph node recurrence, salvage cervical treatment incidence, synchronous cervical and abdominal procedure proportion, operation time and the number of operating surgeons. This trial has been registered at the Japan Registry of Clinical Trials under study number jRCT1030220248.

A multicenter randomized controlled trial of esophagectomy with or without prophylactic supraclavicular node dissection: A phase III trial (JCOG2013, MODERN3).

TPS474 Background: Supraclavicular lymph nodes (SCLN) have been regarded as regional nodes of thoracic esophageal cancer in Japan and resected along with cervical paraesophageal lymph nodes as a cervical part of the standard three-field dissection, while the involvement of SCLN is regarded as distant metastasis in Western countries. However, there is no clear evidence that supports or rejects prophylactic SCLN dissection. As postoperative SCLN metastasis can often be managed by either surgery or chemoradiotherapy at the time of relapse, routine prophylactic SCLN dissection may not be essential. Here we conduct the clinical trial to confirm the non-inferiority of esophagectomy with D2 lymphadenectomy except for SCLN to standard D2 lymphadenectomy in terms of overall survival (OS) for patients with resectable upper or middle thoracic esophageal cancer. Methods: Eligibility criteria include the followings; upper or middle thoracic esophageal squamous cell carcinoma, adenosquamous carcinoma, or basaloid cell carcinoma with clinical stage I, II, III, or IVA (except for T4) based on the 8th UICC-TNM, age 18 to 80, ECOG performance status 0 or 1, and adequate organ function. Neoadjuvant chemotherapy (cisplatin plus 5- fluorouracil or docetaxel plus cisplatin plus 5-fluorouracil) is allowed, but preoperative chemoradiotherapy is not allowed. Patients are randomly assigned to the following two arms using the minimization method with a random component to balance institution, clinical stage (Stage I (T1N0M0) versus Stage I (T1N1M0)/II/III/IVA), age (76 or older versus 75 or younger), and tumor location (upper thoracic versus middle thoracic). Patients undergo either esophagectomy with standard D2 dissection (Arm A) or esophagectomy with D2 lymphadenectomy except for SCLN (Arm B). The primary endpoint is OS in all randomized patients. The secondary endpoints are relapse-free survival, the incidence of perioperative and delayed complications, the incidence of SCLN recurrence, the incidence of salvage cervical treatment, the proportion of synchronous cervical and abdominal procedure, and operation time and the number of operating surgeons. A sample size of 456 patients would be required to observe 147 events to demonstrate the non-inferiority of Arm B in terms of OS, with a one-sided alpha of 5%, power of 70%, an accrual period of 5 years, a follow-up period of 3 years, and a non-inferiority margin of 6% at 3-year OS, assuming the expected 3-year OS of Arm A and Arm B are 80% and 81%, respectively. The planned sample size was set at 480 patients (240 patients per arm). This trial was registered at the Japan Registry of Clinical Trials (jRCT) as study number jRCT1030220248 and started in August 2022. Clinical trial information: jRCT1030220248 .

647. A CASE OF ACUTE GASTRIC TUBE ULCER BLEEDING SAVED BY EMERGENCY SURGERY

Abstract Gastric tube ulcer is recognized as one of the complications after esophageal cancer surgery. When a ulcer bleeds, or penetrates to the pericardial space, or perforates, it often follows a fatal course due to its anatomical position and the complexity of surgical treatment. We report a case of persistent bleeding from a gastric tube ulcer after esophageal cancer operation, which was unable to treat endoscopically. The case was a 67-year-old man. Thoracoscopic subtotal esophagectomy and posterior mediastinal route subtotal gastric reconstruction were performed for middle thoracic esophageal cancer. His fifth-year regular endoscopy revealed a gastric tube ulcer. As a cause of myalgia, the patient was prescribed NSAIDs every day by a nearby doctor. Initially, no bleeding was observed, and discontinuance of NSAIDs and conservative treatment with PPI was continued. However, five months later, sudden hematemesis was observed at night, and he was transferred to a nearby doctor. Emergency endoscopy revealed gastric tube ulcer bleeding. And he was transferred to our hospital in an emergency. However, two days later, hematemesis and persistent ulcer hemorrhage were observed. Due to the difficulty of cauterizing to heartbeat, emergency surgery was performed. The first attempt was made to approach by a posterior mediastinal route, but it was difficult to confirm the ulcer and it was difficult to control bleeding without compression. Adding the thoracotomy, the ulcer was confirmed under direct vision. An ulcer defect was about 5 cm, bleeding was from the ulcer margin. Barbed suture closure and the omental patch were performed. The postoperative course was uneventful and discharged from the hospital 21 days after the operation. We experienced a rare case of acute hemorrhagic gastric tube ulcer that was difficult to treat conservatively and was saved by emergency surgery. After reconstruction of esophageal cancer, there are complicated situations such as the route of the elevated gastric tube, the position of the ulcer, and the risk of perforation to the pericardial space. Prompt and accurate medical care is required.

Efficacy and safety of esophagectomy via left thoracic approach versus via right thoracic approach for middle and lower thoracic esophageal cancer: a multicenter randomized clinical trial (NST1501).

BackgroundLeft thoracic approach (LTA) has been a favorable selection in surgical treatment for esophageal cancer (EC) patients in China before minimally invasive esophagectomy (MIE) is popular. This study aimed to demonstrate whether right thoracic approach (RTA) is superior to LTA in the surgical treatment of middle and lower thoracic esophageal squamous cell carcinoma (TESCC).MethodsSuperiority clinical trial design was used for this multicenter randomized controlled two-parallel group study. Between April 2015 and December 2018, cT1b-3N0-1M0 TESCC patients from 14 centers were recruited and randomized by a central stratified block randomization program into LTA or RTA groups. All enrolled patients were followed up every three months after surgery. The software SPSS 20.0 and R 3.6.2. were used for statistical analysis. Efficacy and safety outcomes, 3-year overall survival (OS) and disease-free survival (DFS) were calculated and compared using the Kaplan-Meier method and the log-rank test.ResultsA total of 861 patients without suspected upper mediastinal lymph nodes (umLN) were finally enrolled in the study after 95 ineligible patients were excluded. 833 cases (98.7%) were successfully followed up until June 1, 2020. Esophagectomies were performed via LTA in 453 cases, and via RTA in 408 cases. Compared with the LTA group, the RTA group required longer operating time (274.48±78.92 vs. 205.34±51.47 min, P<0.001); had more complications (33.8% vs. 26.3% P=0.016); harvested more lymph nodes (LNs) (23.61±10.09 vs. 21.92±10.26, P=0.015); achieved a significantly improved OS in stage IIIa patients (67.8% vs. 51.8%, P=0.022). The 3-year OS and DFS were 68.7% and 64.3% in LTA arm versus 71.3% and 63.7% in RTA arm (P=0.20; P=0.96).ConclusionsEsophagectomies via both LTA and RTA can achieve similar outcomes in middle or lower TESCC patients without suspected umLN. RTA is superior to LTA and recommended for the surgical treatment of more advanced stage TESCC due to more complete lymphadenectomy.Trial RegistrationClinicalTrials.gov NCT02448979.

The association between preoperative plasma D-dimer levels and early postoperative outcomes in patients with esophageal cancer

Background: The present study aimed to evaluate the efficacy of plasma D-dimer levels in predicting early morbidity and mortality in patients with esophageal cancer. Methods: for this purpose, 60 patients who did surgery for middle- (n=35) and lower-thoracic esophageal cancer (n=25) were recruited. Then, preoperative plasma D-dimer levels were measured in a quantitative and qualitative manner and their relation with postoperative outcomes in each type of cancer was assessed for six months. Results: With regard to the middle-thoracic esophageal cancer, complications were observed in 14 cases and deaths were reported in six individuals. Considering the lower type, morbidity was found in 11 cases and mortality was seen in five patients. In both types of cancer, plasma D-dimer levels were significantly higher in patients with complications or deaths compared with those who were not. Sensitivity, specificity, as well as positive and negative predictive value (P/NPV) of plasma D-dimer levels were 90.91%, 78.57%, 76.92%, and 91.67% for diagnosing morbidity of the lower-thoracic esophageal cancer and 80%, 85%, 57.14, 94.44% for predicting mortality in this type of cancer. Moreover, the given values were equal to 71.43%, 76.19%, 66.67%, and 80% for diagnosing complications of the middle-thoracic esophageal cancer and 83.3%, 72.41%, 38.46%, 95.45% in predicting deaths induced by this type of cancer. Conclusion: It was concluded that elevated plasma D-dimer levels could be accompanied by adverse events and early poor postoperative outcomes for esophageal cancer.

142 A RANDOMIZED TRIAL: THREE-FILED LYMPHADENECTOMY COMPARED WITH TWO-FIELD LYMPHADENECTOMY FOR MIDDLE AND LOWER THORACIC ESOPHAGEAL CANCER

Abstract Esophagectomy combined with radical lymphadenectomy is widely accepted, but the role of three-field lymphadenectomy (3-FLD) remains unclear. Methods We performed an open-label, randomized, controlled trial involving patients with resectable cancer of the middle or lower third of the esophagus. Patients were randomly assigned to undergo esophagectomy with either 3-FLD (cervical-thoracic-abdominal lymphadenectomy) or two-field lymphadenectomy (thoracic-abdominal lymphadenectomy, 2-FLD) at a 1:1 ratio. The primary endpoint was overall survival (OS). Analysis were done according to the intent-to-treat principle. Results Postoperative complications were similar in the two arms. More lymph nodes were resected in 3-field arm (Median, 37 vs. 24 [2-FLD], P &amp;lt; 0.001), 43 (21.5%) patients had cervical LNM. More pN3 patients were identified in the 3-FLD arm (10.5%, 21/200 vs. 5.0%, 10/200 [2-FLD], P = 0.040). The cumulative probability of disease-free survival (DFS) was comparable between the two arms (HR, 1.021, 95%CI, 0.735–1.417, P = 0.903), as well as the OS (HR, 1.026, 95%CI, 0.694–1.515, P = 0.899). The cumulative 5-year DFS was 52% in the 3-FLD arm, as compared with 53% in the 2-FLD arm; 5-year OS rates were 64% and 62%. Conclusion Three-field lymphadenectomy offered more accurate nodal staging without increasing the surgical complications. Comparing with radical 2-FLD, there was no improvement in OS or DFS after 3-FLD for patients with middle and lower thoracic esophageal cancer. .

Near-infrared fluorescence imaging-guided lymphatic mapping in thoracic esophageal cancer surgery

Identifying the lymphatic drainage pathway is important for accurate lymph node (LN) dissection in esophageal cancer (EC). This study aimed to assess lymphatic drainage mapping in thoracic EC using near-infrared fluorescent (NIRF) imaging with indocyanine green (ICG) and identify its feasibility for intraoperative LN drainage visualization and dissection. From November 2019 to August 2020, esophagectomy was performed using intraoperative NIRF navigation with ICG injected into the esophageal submucosa by endoscopy. All LNs were divided into four groups according to the NIRF status and presence of metastasis: NIRF+LN+, NIRF+LN-, NIRF-LN+, and NIRF-LN-. Regional LNs were detected in all 84 enrolled patients with thoracic EC. A total of 2164 LNs were removed, and the mean number of dissected LNs was 25.68 ± 12.00. NIRF+ LNs were observed in all patients and distributed at 19 LN stations, which formed lymphatic drainage maps. The top five LN stations of NIRF+ probability in upper thoracic EC were No. 7, 106ecR, 107, 1, and 106recL; in middle thoracic EC, they were No. 107, 7, 110, 1, and 105; and in lower thoracic EC, they were No. 107, 7, 110, 106recR, and 1. There were no cases of ICG-related adverse events or chylothorax. The 30-day mortality rate was 0%. Major complications included anastomotic fistula (7.14%), pneumonia (4.76%), pleural effusion (13.10%), atelectasis (3.75%), hoarseness (8.33%), and arrhythmia (4.76%). Regional LN mapping of thoracic EC was performed using ICG/NIRF imaging, which showed different preferred LN drainage stations in various anatomical locations of the thoracic esophagus. ICG/NIRF imaging is feasible for intraoperative LN drainage visualization and dissection. The clinical trial registration number is NCT04173676 ( http://www. gov/ ).

Esophagectomy With Three-Field Versus Two-Field Lymphadenectomy for Middle and Lower Thoracic Esophageal Cancer: Long-Term Outcomes of a Randomized Clinical Trial.

The optimal extent of lymphadenectomy during esophagectomy remains unclear. In this trial, we aim to clarify whether three-field (cervical-thoracic-abdominal) lymphadenectomy improved patient survival over two-field (thoracic-abdominal) lymphadenectomy for esophageal cancer. Between March 2013 and November 2016, a total of 400 patients with middle and lower thoracic esophageal cancer were included and randomly assigned to undergo esophagectomy with either three- or two-field lymphadenectomy at a 1:1 ratio. Analyses were done according to the intention-to-treat principle. The primary end point was overall survival (OS), calculated from the date of randomization to the date of death from any cause. Demographic characteristics were similar in the two arms. The median follow-up time was 55 months (95% confidence interval [CI]: 52-58). OS (hazard ratio [HR]= 1.019, 95% CI: 0.727-1.428, p= 0.912) and the disease-free survival (DFS) (HR= 0.868, 95% CI: 0.636-1.184, p= 0.371) were comparable between the two arms. The cumulative 5-year OS was 63% in the three-field arm, as compared with 63% in the two-field arm; 5-year DFS was 59% and 53%, respectively. On the basis of whether the patients had mediastinal or abdominal lymph node metastasis or not, OS was also comparable between the two arms. In this cohort, only advanced tumor stage (pathologic TNM stages III-IV) was identified as the risk factor associated with reduced OS (HR= 3.330, 95% CI: 2.140-5.183, p<0.001). For patients with middle and lower thoracic esophageal cancer, there was no improvement in OS or DFS after esophagectomy with three-field lymphadenectomy over two-field lymphadenectomy.

Successful surgical treatment for nonocclusive mesenteric ischemia of a wide area of the intestine accompanied by gastric conduit necrosis after esophagectomy for esophageal cancer: a case report and review of the literature

BackgroundNonocclusive mesenteric ischemia (NOMI) has been reported to be a life-threating disease. Gastric conduit necrosis is known as a critical postoperative complication after esophagectomy for esophageal cancer. We encountered a rare case of NOMI of a wide area of the intestine accompanied by gastric conduit necrosis after esophagectomy, which was successfully treated with an emergency operation.Case presentationA 67-year-old man presented with dysphagia. He was diagnosed with middle thoracic advanced esophageal cancer. After neoadjuvant chemotherapy, he underwent subtotal esophagectomy with lymphadenectomy and gastric conduit reconstruction. On postoperative day (POD) 2, he had diarrhea, high fever, and low blood pressure, which were treated with catecholamines. Laboratory data revealed acidosis and severe sepsis with multi-organ failure, including the kidneys. Although enhanced computed tomography did not exhibit definite findings of bowel ischemia, upper gastrointestinal endoscopy revealed necrotic mucosal changes in the whole gastric conduit. Therefore, we made a diagnosis of septic shock caused by gastric conduit necrosis and performed an emergency operation. When we explored the abdominal cavity, we found not only gastric conduit necrosis but also intermittent necrotic changes in the intestinal wall from the jejunum to the rectum. Therefore, NOMI was diagnosed. We performed an excision of the gastric conduit and 2 m of the small intestine, as well as total colectomy. After the second operation, prostaglandin E1 was administered intravenously as the treatment for NOMI, and sepsis was improved. On POD 122, he was self-discharged. He died of recurrence of lung metastasis from the esophageal cancer 9 months after the first operation.ConclusionWhen a patient has a critical status, including severe sepsis or severe acidosis, after esophagectomy, we should consider the possibility of NOMI in addition to gastric conduit necrosis and aim to diagnose and treat it immediately with an urgent operation.

Cardiotoxicity after chemoradiation for locally advanced esophageal cancer: Contributions of substructure and whole heart dose-volume parameters to risk prediction.

e16576 Background: To investigate the predictive value of substructure and whole heart dosimetric parameters for cardiotoxicity and overall survival (OS) in patients with esophageal cancer receiving concurrent chemoradiation (cCRT). Methods: We retrospectively reviewed the records of 125 patients with stage Ⅲ middle and lower thoracic esophageal cancer treated with cCRT from 2011 to 2015. The primary endpoint was grade ≥ 2 cardiac events and the second endpoint was OS. Dose-volume histogram parameters for whole heart, left atrium (LA), left ventricle (LV), right atrium (RA), right ventricle (RV), right coronary artery (RCA), left anterior descending (LAD), left circumflex (LCX), and pericardium were extracted. Automated multivariable logistic regression model selection using the MATLAB-based Dose Response Explorer System was performed. Models were evaluated by Spearman correlation coefficient (Rs) and ROC area. Cox regressions analysis was performed to evaluate the association between covariates and OS. Results: Median follow-up was 32 months. The prescribed dose was 60 Gy. Forty patients (32.0%) developed 44 grade ≥ 2 cardiac events, at a median of 14.5 months to first event. The most frequently observed cardiac events were pericardial effusion or pericarditis (n = 13), arrhythmia (n = 12), acute coronary syndrome (ACS, n = 10), and congestive heart failure (CHF, n = 5). Variables included in the models most frequently selected by bootstrap were age, WHO/International Society of Hypertension (ISH) risk score and mean LA dose (Rs = 0.36, AUC = 0.796, p &lt; 0.001) for all cardiac events; age, WHO/ISH risk score and pericardium volume receiving ≥ 20 Gy (Rs = 0.33, AUC = 0.771, p &lt; 0.001) for pericardial events; age, mean LA dose and RA volume receiving ≥ 5 Gy (Rs = 0.31, AUC = 0.754, p &lt; 0.001) for arrhythmic events; and WHO/ISH risk score, mean LA dose and LCX volume receiving ≥ 30 Gy (Rs = 0.37, AUC = 0.812, p &lt; 0.001) for ACS/CHF events. On multivariable analysis, disease progression, Eastern Cooperative Oncology Group (ECOG) performance status, mean LA dose, and gross tumor volume were significant predictors of OS. Conclusions: Whether for whole cardiac, pericardial, arrhythmic or ischemic events, models including corresponding substructure dose outperformed those with whole heart dose in risk prediction. High cardiac substructure dose was associated with a worse OS.

Successful preservation of the proximal stomach tube by evaluating blood flow using indocyanine green for gastric tube cancer: a case report

BackgroundThere have been two reports on preserving the proximal gastric tube by using intraoperative indocyanine green (ICG)-based photodynamic detection to evaluate blood flow through the anastomosis for gastric tube cancer after esophagectomy. However, in those cases, the period since the first operation was > 3 years 11 months, and there have been no reports of cases with < 1-year periods after the first operation.Case presentationA 59-year-old man underwent video-assisted thoracic subtotal esophagectomy and gastric tube reconstruction after two courses of preoperative chemotherapy for middle thoracic esophageal cancer. After half a year, follow-up upper gastrointestinal endoscopy showed a submucosal tumor in the posterior wall of the pre-pyloric region. We performed a biopsy, and the results led to a diagnosis of gastric cancer (moderately differentiated adenocarcinoma: tub2). Clinically, the patient was described as having stage IB (cT2N0M0) gastric cancer of the reconstructed gastric tube. To avoid total gastrectomy, we tried to evaluate the blood flow of the proximal part of the gastric tube by intraoperative ICG-based photodynamic detection. Intraoperative findings confirmed neo-vascularization from the remnant cervical esophagus to the upper region of the gastric tube approximately 7 cm through the esophagogastric anastomosis. Therefore, we dissected the distal part of the gastric tube approximately 4 cm from the esophagogastric anastomosis and then performed Roux-en-Y gastro-jejunostomy via the ante-sternum route. The postoperative course was stable, and the patient was discharged on the 14th postoperative day.ConclusionsICG-based photodynamic diagnosis was found to be simple and less invasive. Therefore, even if the postoperative period is short, this method should be considered for evaluation of blood flow prior to performing less invasive surgery.

Comparison of nodal irradiation dose using radiotherapy for patients with thoracic esophageal cancer.

The present study aimed to compare incidental nodal irradiation (INI) doses using volume-modulated arc therapy (VMAT), 5-field intensity-modulated radiotherapy (5F-IMRT) and 3D-conformal radiotherapy (3D-CRT) treatment plans for patients with thoracic esophageal cancer (EC). A total of 15 patients with thoracic EC were selected for participation between October 2016 and July 2017 at the Hangzhou Cancer Hospital. Regional lymph nodal stations were contoured according to 3D CT-based images of the Japan Esophageal Society Guidelines. All patients were treated with 60 Gy using VMAT, 5F-IMRT and 3D-CRT plans. Dose-volume histograms of planning target volume (PTV), lung, heart, spinal cord and incidental nodal irradiation were compared between the three plans. 5F-IMRT was superior in PTV_V95% (the volume of the PTV receiving 95% of the prescription dose, P=0.003) and the VMAT plan was best in terms of conformal index (P=0.005). V20 and V30 were reduced by 10.7-22.6% (P=0.002) and 12.8-21% (P=0.026), respectively, in normal lung tissue using the VMAT plan. 5F-IMRT demonstrated the lowest maximum dose (Dmax) for the spinal cord (P=0.037). For the INI, 3D-CRT exhibited the highest equivalent uniform dose (EUD) values for 106pre (P=0.014) and 106tb-L (P=0.03) in upper-thoracic EC. The mean EUD of all lymph nodal regions in middle-thoracic EC were >40 Gy in VMAT and 5F-IMRT plans; the VMAT plan had higher EUD values in lower-thoracic EC compared with 5F-IMRT, 3D-CRT plans for INI. VMAT were comparable to the 5F-IMRT plan with respect to dosimetric characteristics for planning and INI doses to thoracic nodal levels NO 105-112 are considerable for thoracic EC.

Dosimetric and Radiobiological Comparison of External Beam Radiotherapy Using Simultaneous Integrated Boost Technique for Esophageal Cancer in Different Location.

Objectives: To compare treatment plans of intensity modulated radiotherapy (IMRT), volumetric modulated arc radiotherapy (VMAT), and helical tomotherapy (HT) with simultaneous integrated boost (SIB) technique for esophageal cancer (EC) of different locations using dosimetry and radiobiology.Methods: Forty EC patients were planned for IMRT, VMAT, and HT plans, including 10 cases located in the cervix, upper, middle, and lower thorax, respectively. Dose-volume metrics, conformity index (CI), homogeneity index (HI), tumor control probability (TCP), and normal tissue complication probability (NTCP) were analyzed to evaluate treatment plans.Results: HT showed significant improvement over IMRT and VMAT in terms of CI (p = 0.007), HI (p < 0.001), and TCP (p < 0.001) in cervical EC. IMRT yielded more superior CI, HI and TCP compared with VMAT and HT in upper and middle thoracic EC (all p < 0.05). Additionally, V30 (27.72 ± 8.67%), mean dose (1801.47 ± 989.58cGy), and NTCP (Niemierko model: 0.44 ± 0.55%; Lyman-Kutcher-Burman model: 0.61 ± 0.59%) of heart in IMRT were sharply reduced than VMAT and HT in middle thoracic EC. For lower thoracic EC, the three techniques offered similar CI and HI (all p > 0.05). But VMAT dramatically lowered liver V30 (9.97 ± 2.84%), and reduced NTCP of lungs (Niemierko model: 0.47 ± 0.48%; Lyman-Kutcher-Burman model: 1.41 ± 1.07%) and liver (Niemierko model: 0.10 ± 0.08%; Lyman-Kutcher-Burman model: 0.17 ± 0.17%).Conclusions: HT was a good option for cervical EC with complex target coverage but little lungs and heart involvement as it achieved superior dose conformity and uniformity. Due to potentially improving tumor control and reducing heart dose with acceptable lungs sparing, IMRT was a preferred choice for upper and middle thoracic EC with large lungs involvement. VMAT could ameliorate therapeutic ratio and lower lungs and liver toxicity, which was beneficial for lower thoracic EC with little thoracic involvement but being closer to heart and liver. Individually choosing optimal technique for EC in different location will be warranted.

Dosimetric and radiobiological comparison of external beam radiotherapy using simultaneous integrated boost technique for esophageal cancer in different location.

e15505 Background: Based on dosimetry and radiobiology to compare treatment plans for esophageal cancer (EC) in different location using intensity modulated radiotherapy (IMRT), volumetric modulated arc radiotherapy (VMAT) and helical tomotherapy(HT) with simultaneous integrated boost (SIB) technique. Methods: A total of 20 patients including 5 cases respectively located in the cervix, upper, middle and lower thorax were generated for IMRT, VMAT and HT plans. The dose volume histogram statistics, conformity index (CI), homogeneity index (HI), tumor control probability (TCP) and normal tissues control probability (NTCP) were analyzed to evaluate treatment plans. Results: HT showed significantly improvement over IMRT and VMAT in terms of CI(0.93±0.03), HI(0.07±0.03) and TCP(88.08±0.82%) in cervical EC(p&lt;0.05). IMRT greatly developed TCP(88.29±1.79%;85.11±0.79%), and offered superior CIs (0.87±0.04;0.90±0.01) and HIs(0.10±0.01; 0.06±0.01) compared with VMAT and HT in upper and middle thoracic EC(p&lt;0.05). Meanwhile, the V30(33.30±6.49%), mean dose (2559.00±219.64cGy) and NTCP(0.50±0.61%) of heart for IMRT were significantly reduced than other two techniques in middle thoracic EC. Patients with lower thoracic EC yielded the similar CIs and HIs(all p&gt;0.05) for the 3 techniques, but VMAT showed the lowest NTCP of lungs (0.01±0.01%) with improved TCP (84.84±1.13%). Conclusions: HT was a good option with little lung and heart involvement as it achieved superior dose conformality and uniformity. IMRT was a perfect strategy with large thoracic involvement. It significantly improved tumor local control and reduced heart dose and complications with acceptable dose to lungs. VMAT was preferred with a smaller target volume but surrounded by more heart and less lungs. Individually choosing optimal technique for EC in different location will be warranted.

Clinical Impact of the Location of Lymph Node Metastases After Neoadjuvant Chemotherapy for Middle and Lower Thoracic Esophageal Cancer

In the current cancer staging systems, the location of lymph node (LN) metastases is not considered, although LN status is defined according to the number of LN metastases. This study aimed to investigate the clinical impact of the location of LN metastases in esophageal cancer and to evaluate the relevance of minimizing the extent of lymphadenectomy after neoadjuvant therapy. In 561 patients with esophageal cancer who underwent neoadjuvant chemotherapy, the therapeutic value of each LN dissection was estimated by multiplying the incidence of metastasis by the 5-year survival rate of patients with positive nodes. In addition, we examined whether the value was affected by the response to neoadjuvant therapy. Metastasis to the celiac LN and middle mediastinal LN regions was identified as an independent prognostic factor by multivariate analysis, together with the number of LN metastases; however metastasis to the cervical LN and upper mediastinal LN regions was not identified as an independent prognostic factor. The therapeutic value was high in recurrent nerve LNs, paraesophageal LNs, paracardial LNs, and left gastric LNs. The therapeutic value for each LN dissection did not change according to the response to neoadjuvant therapy, excluding the lower mediastinal LN and perigastric LN stations for which the value was relatively high in patients with a poor response. The present study shows that the location and number of LN metastases have a prognostic impact in patients with esophageal cancer undergoing neoadjuvant chemotherapy. Limited lymphadenectomy according to the response to neoadjuvant therapy cannot be justified.

Incidence of Regional Recurrence Outside of Radiation Fields in Patients with or without Elective Nodal Irradiation for Stage I Middle Thoracic Esophageal Cancer

The appropriate field of elective nodal irradiation (ENI) for middle thoracic (Mt) esophageal cancer is still unclear. To evaluate the efficacy of ENI for stage I Mt esophageal cancer treated with radiotherapy (RT), we researched the incidence of recurrence outside of radiation fields in patients with and without ENI. From April 2006 to December 2014, 55 patients with stage I esophageal cancer mainly located at Mt received definitive RT with or without concurrent chemotherapy in our institution. Of these, 52 patients followed up for more than six months were examined in this study (age, 51-89, median 70; male/female = 46/6; chemoradiotherapy/RT alone = 43/9). Because of the change of institutional policy, ENI became to be performed in principle from 2013. Seventeen patients (33%) received ENI to the mediastinum with or without the supraclavicular region and the upper abdomen. Remaining 35 patients received irradiation only to the range where the margin of 3-4 cm was added above and below the gross tumor volumes. The median follow-up time was 51.8 months (2.5 to 126.5 months). A total of 11 patients (21%) relapsed: 4 (8.0%) developed local, 6 (12%) developed regional and 1 (2.0%) developed loco-regional. The regional recurrence outside of radiation fields occurred in two patients with ENI (12%) and in three patients without ENI (9%) (p=0.71). For patients with ENI, sites of regional recurrences were recurrent nerve lymph nodes (#106rec) in one case and lymph nodes along the lesser curvatures (#3) in one. For patients without ENI, sites of regional recurrences were #106rec in two cases, right cardiac lymph nodes (#2) in one, lymph nodes along the celiac artery in one and left cervical lymph nodes in one. Three-year overall survival rates (OS) and progression free survival rates (PFS) for all patients were 83% and 73%, respectively. Three-year OS for patients with and without ENI were 88% and 80%, respectively (p=0.52). Three-year PFS for patients with and without ENI were 77% and 71%, respectively (p=0.32). Incidence of lymph node recurrence outside of radiation fields did not differ significantly between patient with and without ENI for stage I Mt esophageal cancer. In addition, ENI did not improve OS and PFS significantly.

PS01.220: COMPARISON OF SHORT-TERM OUTCOMES BETWEEN RAMIE AND VAMIE IN TREATMENT MIDDLE THORACIC ESOPHAGEAL CANCER

Abstract Background Whether robot-assisted minimally invasive esophagectomy (RAMIE) has any advantages over video-assisted minimally invasive esophagectomy (VAMIE) remains controversial. In this study, we tried to compare the short-term outcomes of RAMIE with that of VAMIE in treating middle thoracic esophageal cancer from a single medical center. Methods Consecutive patients undergoing RAMIE or VAMIE for middle thoracic esophageal cancer from April 2016 to April 2017 were prospectively included for analysis. Baseline data and pathological findings as well as short-term outcomes of these two group (RAMIE group and VAMIE group) patients were collected and compared. A total of 84 patients (RAMIE group: 42 patients, VAMIE group: 42 patients) were included for analysis. Results The baseline characteristics between the two groups were comparable. RAMIE yielded significantly larger numbers of total dissected lymph nodes (21.9 and 17.8, respectively; P = 0.042) and right recurrent laryngeal nerve (RLN) lymph nodes (2.1 and 1.2, respectively; P = 0.033) as well as abdominal lymph nodes (10.8 and 7.7, respectively; P = 0.041) than VAMIE. Even though RAMIE may consume more overall operation time, it could significant decrease total blood loss compared to VAMIE (97 and 161 ml, respectively; P = 0.015). Postoperatively, no difference of the risk of major complications or hospital stay was observed between the two groups. Conclusion RAMIE had significant advantage of lymphadenectomy especially for dissecting RLN lymph nodes over VAMIE with comparable rate of postoperative complications. Further randomized controlled trials are badly needed to confirm and update our conclusions. Disclosure All authors have declared no conflicts of interest.