Outcomes In Esophageal Cancer Research Articles

Absolute lymphocyte count and C-reactive protein-albumin ratio can predict prognosis and adverse events in patients with recurrent esophageal cancer treated with nivolumab therapy.

Predicting the prognosis and adverse events (AEs) of nivolumab therapy for recurrent esophageal cancer is very important. The present study investigated whether a simple blood biochemical examination could be used to predict prognosis and AEs following nivolumab treatment for relapse of esophageal cancer. A total of 41 patients who received nivolumab treatment for recurrent esophageal cancer after esophagectomy were analyzed. The absolute lymphocyte count (ALC), neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), monocyte-lymphocyte ratio (MLR) and C-reactive protein-albumin ratio (CAR) were assessed at the time of nivolumab induction as indices that can be calculated by blood biochemical examinations alone. Median values were 1,015 for ALC, 3.401 for NLR, 242.6 for PLR, 0.458 for MLR and 0.119 for CAR, and patients were divided into two groups according to values. A high ALC, low NLR, low PLR, low MLR and low CAR were associated with a better response to nivolumab. In addition, patients with the aforementioned indices, with the exception of low PLR, or better response were more likely to develop AEs in univariate analysis. In multivariate analysis, a high ALC [odds ratio (OR): 4.857, P=0.043] and low CAR (OR: 9.099, P=0.004) were identified as independent risk factors for AEs. Survival analysis revealed that overall survival and progression-free survival (PFS) rates after nivolumab treatment differed significantly between the high and low groups of ALC, NLR, PLR, MLR and CAR. The multivariate analysis identified a low ALC [hazard ratio (HR): 3.710, P=0.003] and high CAR (HR: 2.953, P=0.007) as independent poor prognostic factors of PFS. In conclusion, ALC and CAR have potential as biomarkers for outcomes of recurrent esophageal cancer following nivolumab treatment.

The effect of histologic grade on neoadjuvant treatment outcomes in esophageal cancer.

The gold standard for locoregional esophageal cancer (LEC) treatment includes preoperative chemoradiation and surgical resection, with possible perioperative or adjuvant systemic therapy. With few data associating histologic grade and prognosis in LEC patients receiving neoadjuvant chemoradiation followed by resection, we seek to evaluate this association. Our institutional esophagectomy database between 1999 and 2019 was queried, selecting esophageal adenocarcinoma patients who completed neoadjuvant therapy (NAT), followed by esophagectomy. Propensity-score matching of low- and high-histologic grade groups was performed to assess survival metrics using initial clinical grade (cG) and final pathologic grade (pG). We performed a multivariable logistic regression to study predictors of pathologic complete response as a secondary objective. A total of 518 patients met the inclusion criteria. Kaplan-Meier analysis of the matched dataset showed no difference in initial or 5-year recurrence-free survival or overall survival (OS) between cG1 and cG2 versus cG3 based on original grade. When matched according to pG, cG1-2 had improved median survival parameters compared to cG3, with 5-year OS for cG1-2 of 45% versus 27% (p = 0.001). Higher pG, pathologic N stage, and poor response to NAT are predictors of poor survival. Patients with post-NAT pG1-2 demonstrated improved survival. Integrating histologic grade into postneoadjuvant staging may be warranted.

Pan-immune-inflammation Value and Prognosis in Patients With Esophageal Cancer.

The pan-immune-inflammation value was associated with clinical outcomes and tumor-infiltrating lymphocytes in 866 esophageal cancers. Systemic immune competence may influence patient prognosis through local immune response. To examine the relationship between the pan-immune-inflammation value (PIV), tumor immunity, and clinical outcomes in 866 patients with esophageal cancer. The PIV, calculated from all immune-inflammatory cells in the peripheral blood count, is a recently proposed marker for clinical outcomes in some types of cancers. Nonetheless, the prognostic significance of PIV in esophageal cancer remains unclear. In the derivation cohort (n = 433), we set the optimal cutoff value using a time-dependent receiver operating characteristic (ROC) curve. In the validation cohort (n = 433), the relationships between the PIV, tumor-infiltrating lymphocytes (TILs), CD8 expression by immunohistochemical staining, and patient prognosis were examined. The area under the ROC curve for the PIV at 5 years was 0.631 in the derivation cohort. The validation cohort, divided into PIV-low cases (n = 223) and PIV-high cases (n = 210), showed significantly worse overall survival (log-rank P = 0.0065; hazard ratio [HR]: 1.48; 95% confidence interval [CI]: 1.12-1.98; P < 0.001; multivariate HR: 1.41; 95% CI: 1.05-1.90; P = 0.023). The prognostic effect of the PIV was not significantly modified by any clinical characteristics (P for interaction > 0.05). The PIV-high cases were significantly associated with a low TIL status (P < 0.001) and low CD8-positive cell counts (P = 0.011). The PIV was associated with clinical outcomes in esophageal cancer, supporting its role as a prognostic biomarker. Considering the relationship between the PIV and TILs, systemic immune competence may influence patient prognosis through a local immune response.

Dose escalation not improving outcome in esophageal cancer—still far from conclusive

Dose escalation not improving outcome in esophageal cancer—still far from conclusive

Increasing Use of PET-CT, Neoadjuvant Treatment, Minimally Invasive Approach and Surgical Radicality in Esophageal Cancer Surgery are Associated with Improved Short- and Long-term Outcomes in Real-World Setting

BackgroundGuideline adherence has improved outcomes in several cancers. Our aim was to evaluate whether the rate of PET-CT, neoadjuvant treatment, minimally invasive approach, and surgical radicality, suggested also by recent guidelines, would improve short- and long-term operative outcomes in esophageal cancer in real-world setting. MethodsThis retrospective study in two Finnish Hospitals between 2010 and 2020 included 296 esophageal cancer patients. Grouping factors based on four factors with annual cut-offs by center were 90% rate in PET-CT-based staging, 70% in neoadjuvant therapy usage, 80% in minimally invasive approach, and 20 in annual mean lymph node yield. If none of factors were reached, all patients operated in that year were classified into group 1. With one to three cut-offs reached, grouping was into group 2. If all annual cut-offs were reached, patients were classified into group 3. Primary end points were major complication rate and overall 1-, 3-, and 5-year survival. ResultsMajor complication rate decreased significantly from 38.2% in group 1 (p < 0.001) and 34.2% in group 2 (p < 0.001) to 10.2% in group 3. Overall 1-, 3-, and 5-year survival rates between groups 1–3 were 77.9% vs. 80.3% vs. 94.2% (p = 0.004), 51.5% vs. 51.1% vs. 67.3% (p = 0.022), and 44.1% vs. 47.4% vs. 55.5% (p = 0.065), respectively. Adjusted 5-year overall mortality was reduced significantly in group 3 compared to group 1 (HR 0.46, 95% CI 0.28–0.75). ConclusionThis study suggests that increasing rate of PET-CT, neoadjuvant treatment, minimally invasive surgery, and surgical radicality improves short- and long-term outcomes in operated esophageal cancer patients.

Positive circumferential resection margin in locally advanced esophageal cancer: an updated systematic review and meta-analysis.

The impact of positive circumferential resection margin on prognosis in esophageal cancer is under controversy. Previous systematic reviews and meta-analyses had limitations. This updated systematic review and meta-analysis aimed to assess the prognostic impact of positive circumferential resection margin in esophageal cancer.PubMed and Web of Science were searched for studies investigating the association between circumferential resection margin status and prognosis in esophageal cancer. Study population were focused on T3 and/or T4a patients. Study selection was based on availability of survival information (Kaplan-Meier curves and adjusted analysis). Random-effects models were used to summarize hazard ratios for overall survival and disease-free survival.According to College of American Pathologists criteria, circumferential resection margin-positive patients had shorter median overall survival (P < 0.0001) and shorter median disease-free survival (P < 0.0001) compared with circumferential resection margin-negative patients. The pooled hazard ratios for overall survival and disease-free survival were 2.06 (95% confidence interval, 1.68-2.53; P < 0.0001) and 2.00 (95% confidence interval, 1.41-2.84; P < 0.0001), respectively. According to the Royal College of Pathologists criteria, circumferential resection margin-positive patients had shorter median overall survival (P < 0.0001) and shorter median disease-free survival (P < 0.0001) compared with circumferential resection margin-negative patients. The pooled hazard ratios for overall survival and disease-free survival were 1.31 (95% confidence interval, 1.16-1.48; P < 0.0001) and 1.31 (95% confidence interval, 1.09-1.57; P < 0.0001), respectively.ompared with negative circumferential resection margin, positive circumferential resection margin is associated with worse survival outcomes in esophageal cancer.

Treatment outcomes of esophageal cancer in Eastern Africa: protocol of a multi-center, prospective, observational, open cohort study

BackgroundEsophageal squamous cell carcinoma (ESCC) is a major cause of cancer morbidity and mortality in Eastern Africa. The majority of patients with ESCC in Eastern Africa present with advanced disease at the time of diagnosis. Several palliative interventions for ESCC are currently in use within the region, including chemotherapy, radiation therapy with and without chemotherapy, and esophageal stenting with self-expandable metallic stents; however, the comparative effectiveness of these interventions in a low resource setting has yet to be examined.MethodsThis prospective, observational, multi-center, open cohort study aims to describe the therapeutic landscape of ESCC in Eastern Africa and investigate the outcomes of different treatment strategies within the region. The 4.5-year study will recruit at a total of six sites in Kenya, Malawi and Tanzania (Ocean Road Cancer Institute and Muhimbili National Hospital in Dar es Salaam, Tanzania; Kilimanjaro Christian Medical Center in Moshi, Tanzania; Tenwek Hospital in Bomet, Kenya; Moi Teaching and Referral Hospital in Eldoret, Kenya; and Kamuzu Central Hospital in Lilongwe, Malawi). Treatment outcomes that will be evaluated include overall survival, quality of life (QOL) and safety. All patients (≥18 years old) who present to participating sites with a histopathologically-confirmed or presumptive clinical diagnosis of ESCC based on endoscopy or barium swallow will be recruited to participate. Key clinical and treatment-related data including standardized QOL metrics will be collected at study enrollment, 1 month following treatment, 3 months following treatment, and thereafter at 3-month intervals until death. Vital status and QOL data will be collected through mobile phone outreach.DiscussionThis study will be the first study to prospectively compare ESCC treatment strategies in Eastern Africa, and the first to investigate QOL benefits associated with different treatments in sub-Saharan Africa. Findings from this study will help define optimal management strategies for ESCC in Eastern Africa and other resource-limited settings and will serve as a benchmark for future research.Trial registrationThis study was retrospectively registered with the ClinicalTrials.gov database on December 15, 2021, NCT05177393.

Does VO2peak Provide a Prognostic Value in Esophagectomy and Gastrectomy for Post-operative Outcomes?

Esophagectomy and gastrectomy are procedures with considerable physical burden and intense post-operative care of which the patient's physical condition seems to be a relevant predictor. The gold standard of the cardiorespiratory fitness is the peak oxygen consumption (VO2peak). This pilot study examined the prognostic value of VO2peak on post-surgery outcomes in esophageal and gastric cancer patients. In this prospective cross-sectional study, patients scheduled for esophagectomy or gastrectomy were examined 24 h before the surgery regarding their VO2peak. The post-operative complications according to Clavien-Dindo grade IIIb/IV/V, Intensive-Care-Unit days, and overall hospital stay were documented following surgery. In a subset, body weight changes from surgery until hospital discharge and first aftercare visit were recorded. The functional capacity was significantly reduced in 34/35 of the included patients compared to matched norm-values (p<0.01). The only significant correlation was found between VO2peak values and body weight change from surgery to the first aftercare visit. A subgroup comparison of patients with a VO2peak <17 ml/min/kg and ≥17 ml/min/kg suggested small, non-significant differences in post-surgery outcomes and significant differences in the body weight change from surgery to hospital discharge, favoring the higher-VO2peak subgroup. The impaired functional capacity following esophagectomy or gastrectomy may strengthen the rational for exercise programs during neoadjuvant and pre-surgery phases. The prognostic value of VO2peak on post-operative outcomes remains uncertain due to noticeable descriptive differences, but no significant correlations, potentially limited by the smallsized population. Nonetheless, a correlation between VO2peak and body weight change post-surgery was observed and indicates a potential prognostic value of VO2peak.

Higher Pre-Treatment Skin Sympathetic Nerve Activity and Elevated Resting Heart Rate after Chemoradiotherapy Predict Worse Esophageal Cancer Outcomes

Higher Pre-Treatment Skin Sympathetic Nerve Activity and Elevated Resting Heart Rate after Chemoradiotherapy Predict Worse Esophageal Cancer Outcomes

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.

Disparities in esophageal cancer care based on race: a National Cancer Database analysis

Esophageal cancer is one of the most common cancer killers in our country. The effects of racial disparities on care for esophageal cancer patients are incompletely understood. Using the National Cancer Database, we investigated racial disparities in treatment and outcome of esophageal cancer patients. The National Cancer Database was queried from 2004 to 2017. Logistic regression and survival analysis were used to determine racial differences in access, treatment and outcome. A total of 127,098 patients were included. All minority groups were more likely to be diagnosed at advanced stages versus Caucasians after adjusting for covariates (African American OR-1.64 [95% confidence interval 1.53-1.76], Hispanic OR-1.19 [1.08-1.32], Asian OR-1.78 [1.55-2.06]). After adjustment, all minorities were less likely at every stage to receive surgery. Despite these disparities, Hispanics and Asians had improved survival compared with Caucasians. African Americans had worse survival. Racial disparities for receiving surgery were present in both academic and community institutions, and at high-volume and low-volume institutions. Surgery partially mediated the survival difference between African Americans and Caucasians (HR-1.13 [1.10-1.16] and HR-1.04 [1.02-1.07], without and with adjustment of surgery).There are racial disparities in the treatment of esophageal cancer. Despite these disparities, Hispanics and Asians have improved overall survival versus Caucasians. African Americans have the worst overall survival. Racial disparities likely affect outcome in esophageal cancer. But other factors, such as epigenetics and tumor biology, may correlate more strongly with outcome for patients with esophageal cancer.

2021 Canadian Surgery Forum: Virtual, online Sept. 21-24, 2021.

# 01. Design and validation of a unique endoscopy simulator using a commercial video game {#article-title-2} Procedural simulation has been shown to enhance early endoscopy training. In this proof of concept study, we aimed to show that a first-person shooter (FPS) video game with a novel in-house

Exercise capacity in the stair-climbing test predicts outcomes of operable esophageal cancer in minimally invasive era

IntroductionThe risk of complications after esophagectomy highlights the need for careful preoperative assessment. Aim was to assess whether stair-climbing test (SCT) could predict outcomes of patients with operable esophageal cancer in minimally invasive era. Materials and methodsPatients with esophageal cancer were evaluated for surgical treatment in Central Finland Central Hospital from 2012 to March 2021. Of evaluated 162 patients, 138 were scheduled to eventually undergo surgery. The exercise capacity was evaluated with symptom limited SCT. Patients were divided into four study groups on intent-to-treat basis: surgery and the SCT >14 m (Group 1), surgery and the SCT <11 m (Group 2), non-surgical therapy and the SCT <11 m (Group 3) and non-surgical therapy and the SCT >14 m (Group 4). Results were adjusted for confounders. ResultsMajor complication rate was 10.1% vs 40.0% between Group 1 and 2 (p = 0.006), and 90-day mortality 0% vs 20.0% (p < 0.001). Overall survival rates in Groups 1–4 at 1-year were 92.3% vs 72.2% vs 46.8% vs 81.8%, at 3-year 68.5% vs 52.7% vs 15.6% vs 27.3% and at 5-year 58.7% vs 39.5% vs 0% vs 0%, respectively (p < 0.001). In adjusted analysis when compared to Group 1, other groups had increased 5-year mortality hazard (Group 2 HR 2.88 (95% CI 1.25–6.63), Group 3 HR 15.6 (95% CI 5.57–43.5) and Group 4 HR 5.35 (95% CI 2.08–13.7)). ConclusionExercise capacity measured with SCT in esophageal cancer patients is a strong predictor of complications and survival, and is a potential parameter to be included in any risk or prognostic models.

Prognostic significance of T-cell-inflamed gene expression profile and PD-L1 expression in patients with esophageal cancer.

PurposeThe ability of the T‐cell–inflamed gene expression profile (GEP) to predict clinical outcome in esophageal cancer (EC) is unknown. This retrospective observational study assessed the prognostic value of GEP and programmed death ligand 1 (PD‐L1) expression in patients with EC treated in routine clinical practice.MethodsTumor samples of 294 patients from three centers in Denmark, South Korea, and the United States, collected between 2005 and 2017, were included. T‐cell–inflamed GEP score was defined as non‐low or low using a cutoff of −1.54. A combined positive score (CPS) ≥10 was defined as PD‐L1 expression positivity. Associations between overall survival (OS) and GEP status and PD‐L1 expression were explored by Cox proportional hazards models adjusting for age, sex, histology, stage, and performance status.ResultsMedian age was 65 years; 63% of patients had adenocarcinoma (AC) and 37% had squamous cell carcinoma (SCC). Thirty‐six percent of tumors were GEP non‐low, with higher prevalence in AC (46%) than SCC (18%). Twenty‐one percent were PD‐L1–positive: 32% in South Korean samples versus 16% in non‐Asian samples and 26% in SCC versus 18% in AC. GEP scores and PD‐L1 CPS were weakly correlated (Spearman’s R = 0.363). OS was not significantly associated with GEP status (non‐low vs low; adjusted hazard ratio, 0.91 [95% CI, 0.69–1.19]) or PD‐L1 expression status.ConclusionNeither GEP nor PD‐L1 expression was a prognostic marker in Asian and non‐Asian patients with EC.

The Volume of Low-Dose Thoracic Irradiation Influences Systemic Inflammation-Immunity Status After Chemoradiation in Esophageal Cancer

Definitive chemoradiation is essential in non-operative thoracic esophageal cancer. Concerns have posed onto the possible radiation-induced lymphopenia and correlation with different survival outcomes. Neutrophil to lymphocyte ratio (NLR) is a simple way to surrogate the inflammation-immunity status and predict survival. We aim to evaluate the clinical variables and radiation dosimetric parameters associated with hematologic variables changes.Between 2010 and 2015, we identified 93 newly diagnosed thoracic esophageal squamous-cell cancer patients who had completed definitive concurrent chemoradiotherapy (CCRT). Patients' clinical, dosimetric, and hematological data, including absolute neutrophil count, absolute lymphocyte count, and NLR were analyzed at baseline and during CCRT. Cox regression model and Kaplan-Meier analyses were used to validate different survival outcomes. The possible relationships between clinical, hematologic, and dosimetric variables were tested using Spearman's rank or Pearson correlation coefficients, and a further multivariable logistic regression model was created to verify these significant variables.The participant group (mean age = 58.6 y) predominantly comprised males (94%) with 27% stage II (n = 25) and 73% stage III (n = 68). Median overall survival (OS) was 13 months (95% confidence interval: 10.304-15.696). We confirmed that baseline NLR (NLR-b) and highest NLR during CCRT (NLR-h) significantly predicted OS, progression-free survival, disease-specific survival, and freedom from distant metastasis. Dichotomized NLR-b with > 3.68 or ≤3.68 also predicted the survival outcomes. Primary esophageal tumor length (Spearman's correlation coefficient r = 0.324, P = 0.011) and baseline body weight (Spearman's r = -0.251, P = 0.019) were significantly correlated with baseline NLR > 3.68. In multivariable logistic regression, primary esophageal tumor length (OR = 1.345, P = 0.021) remained associated with a higher NLR-b. For NLR-h, lung V5 (Pearson r = 0.254, P = 0.014) and V10 (Pearson r = 0.317, P = 0.002) were significantly correlated. In the percentage of ALC nadir decreased during CCRT, lung V5 (Pearson r = 0.299, P = 0.005) and heart V10 (Pearson r = 0.273, P = 0.011) were significantly correlated.Inflammation predicts survival outcomes and is correlated with tumor size. Low-dose thoracic irradiation affects inflammation-immunity dynamics because lung V5 and V10 are related to NLR-h; lung V5 and heart V10 with extent of lymphocyte decrease. A novel approach to decrease these unnecessary exposures may further improve survival outcomes in esophageal cancer treated with CCRT.

Epidemiology, Risk Factors and Management of Esophageal Cancer in East of Sudan (Single center experience from 2016-2018)

Esophageal Cancer is 6th common cause of cancer death worldwide, internationally the outcome of esophageal cancer is very poor. In Sudan esophageal cancer is also one of the most common malignancies and devastating disease with high mortality [1,3]. This study investigated esophageal cancer in the red sea state, east of Sudan over period October 2016 to October 2018, in port Sudan oncology center. The study included 40 patients, data was collected using a constructed structure pretest questionnaire, evaluated and compared with standard published literature. Objectives: The study was aimed to look at the epidemiology, risk Factors, clinical presentations and different management modalities of esophageal cancer in the red sea state, east of Sudan. Methods and Patients: This study was across sectional retro prospective study, centre based, and was conducted in Port Sudan Oncology Center in port Sudan, East of Sudan over period of two years from October 2016 to October 2018. Results: 40 patients involved in the study, This study was showed that the female were more affected with disease(65%), all patients in this study (100%) were taking coffee with ginger and pepper regularly in the early morning, and this is considered as the most important risk factor was known through this study, while the other risk factor their percentage as following; Hot tea (95%), GERD(42.5%), Smoking(10%) ,Alcohol consumption (2.5%).Dysphagia was the shared symptom between all the cases(100%), while the other symptoms came in different percentage. Conclusion: Esophageal Cancer was higher in female, more common in the age group 50_70 years old and is common in Beja tribe (50%). The most common risk factor is regular taking of coffee with ginger (100%). Unfortunately the mortality rate (52.5%) within 5-years after the diagnosis

Variation in Diagnosis, Treatment, and Outcome of Esophageal Cancer in a Regionalized Care System in Ontario, Canada

Esophageal cancer remains one of the most deadly cancers, ranking sixth highest among cancers leading to the greatest years of life lost. To determine how patients with esophageal cancer are diagnosed and treated in Ontario's regionalized thoracic surgery centers. This cohort study included patients diagnosed with esophageal cancer between January 1, 2010, and December 31, 2018, identified from the Ontario Cancer Registry, in a single-payer health care system with regionalization of thoracic surgery in the province of Ontario, Canada. Exposures included incidence of esophageal cancer and stage at diagnosis; time from the first health care visit until treatment; and the use of specialist consultations, endoscopic ultrasonography, positron emission tomography and computed tomography, endomucosal resection, esophagectomy, neoadjuvant therapy, adjuvant therapy, radiation alone, and chemotherapy alone or in combination with other treatment. Outcome measures included wait times, health care use, treatment, and overall survival. Data were analyzed from March 2020 to February 2021. There were 10 364 patients (mean [SD] age, 68.3 [11.9] years; 7876 men [76%]) identified during the study period. The incidence of esophageal cancer increased over the study period from 1041 in 2010 to 1309 in 2018, which was driven by a 30% increase in the number of adenocarcinomas. The time from first health care encounter to start of treatment was a median 93 days (interquartile range, 56-159 days). Endoscopic ultrasonography was observed for 12% of patients, and positron emission tomography and computed tomography (CT) in 45%. Use of endoscopic mucosal resection was observed for 8% of patients with stage 0 to I disease. A total of 114 of 547 patients (21%) receiving endoscopic resection had a subsequent esophagectomy. Only 2778 patients (27%) had consultations with a thoracic surgeon, a medical oncologist, and a radiation oncologist, whereas 1514 patients (15%) did not see any of these specialists. Of 3047 patients who had an esophagectomy, those receiving neoadjuvant therapy had better overall survival (median survival, 36 months; 95% CI, 32-39 months) than patients who received esophagectomy alone (median survival, 27 months; 95% CI, 24-30 months) or those who received esophagectomy with adjuvant therapy (median survival, 36 months; 95% CI, 32-44 months) despite significant early mortality (log-rank P < .001). There was significant variation in treatment modality across hospitals: esophagectomy ranged from 5% to 39%; esophagectomy after neoadjuvant therapy ranged from 33% to 93%; and esophagectomy followed by adjuvant therapy ranged from 0 to 34% (P < .001). Perioperative mortality was higher at 30 days for patients receiving esophagectomy at low-volume centers (odds ratio [OR], 3.66; 95% CI, 2.01-6.66) and medium-volume centers (OR, 2.07; 95% CI, 1.33-3.23) compared with high-volume centers (P < .001). A longer wait time until treatment was associated with better overall survival (median overall survival was 15 to 17 days vs 5 to 8 days for patients who received treatment earlier than 30 days vs 30 days or longer after diagnosis; P < .001). The results of this cohort study suggest that despite regionalization, there was significant regional variability in volumes at designated centers and in the evaluation and treatment course for patients with esophageal cancer across Ontario.

546 INTENSIVE SURVEILLANCE AFTER CURATIVE INTENT SURGERY FOR ESOPHAGEAL CANCER: INITIAL RESULTS OF THE ENSURE STUDY

Abstract Emerging data demonstrate long-term survival after salvage interventions for local or oligometastatic recurrence after planned curative resection for esophageal cancer, providing rationale for postoperative surveillance. However, the impact of intensive surveillance on oncologic outcome is unknown. This multicenter collaborative study aimed to characterize oncologic surveillance protocols across esophageal cancer centers internationally and determine the independent effect of intensive surveillance on oncologic outcome. Methods The ENSURE international multicenter study included consecutive patients who underwent surgery with curative intent for cTxNxM0 esophageal cancer from June 2009 to June 2015. Intensive surveillance was defined as use of cross-sectional imaging, at least annually, during the first three postoperative years. The estimated sample size of 4425 provided 90% power to detect a 5% increase in 5-year overall survival (OS, primary outcome measure). Secondary outcome measures included disease-free (DFS) and disease-specific survival (DSS), surveillance strategies, incidence of oligometastatic recurrence, treatment strategies, and HRQOL. The study was registered on ClinicalTrials.gov (NCT03461341). Results 4597 patients were included. The participating 27 centres undertook mean(SD) 52.3(17.1) esophageal cancer resections annually between 3.5 ± 1.3 attending surgeons. 37%, 11% and 19% centers utilized postoperative surveillance CT, PET-CT and endoscopy, respectively. Among all patients, intensive surveillance was associated with improved OS (HR0.92 [0.85–0.99]) but not DSS (HR0.93 [0.85–1.01]) or DFS (HR0.97 [0.90–1.04]), and on multivariable analysis, intensive surveillance did not provide oncologic benefit (OS HR1.10 [0.99–1.22], DSS HR1.12 [1.00–1.25]), but reduced observed DFS (HR1.19 [1.08–1.31]). Evaluating surveillance modalities, neither surveillance endoscopy nor laboratory tests improved oncologic outcome, however flexible nasolaryngoscopy was associated with improved OS (HR0.84 [0.69–1.0]). Conclusion ENSURE, the first study powered to assess the impact of postoperative surveillance protocols on oncologic outcome in esophageal cancer, demonstrated no overall survival benefit following intensive imaging surveillance, with reduced observed disease-free survival time. However, routine assessment for secondary aerodigestive malignancies may be of oncologic benefit. The present data do not support the use of intensive imaging surveillance among all patients following esophageal cancer surgery. Further reports detailing subgroup analyses and HRQOL impact are anticipated.

111 CLINICAL IMPORTANCE OF MEAN CORPUSCULAR VOLUME AS A PROGNOSTIC MARKER AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Abstract High MCV is suggested to be relevant to the incidence and prognosis of several malignancies. However, few studies investigating the correlation between MCV and survival outcome of esophageal cancer have been conducted. Methods This study included 570 patients with esophageal cancer who underwent radical esophagectomy between April 2005 and December 2017. Patients were divided into two groups according to the standard value of pretreatment MCV: normal (83–99 fL) and high (&amp;gt;99 fL) groups. Clinical backgrounds, short-term outcomes, and prognostic outcomes post-esophagectomy were retrospectively compared between the groups. Results Of all patients, 410 (71.9%) had normal MCV, and 160 (28.1%) had high MCV. High MCV was significantly associated with lower body mass index, higher frequency of habitual alcohol and tobacco use, and higher incidence of multiple primary malignancies other than esophageal cancer. High MCV also correlated with higher incidence of postoperative morbidity of the Clavien–Dindo classification ≥II and pulmonary morbidity. Overall survival was significantly worse in patients with high MCV. Multivariate analysis suggested that high MCV was an independent risk factor for worse survival outcome (hazard ratio, 1.54; 95% confidence interval, 1.098–2.151; p = 0.012). Conclusion Patients with high MCV have various disadvantages in clinical background that can adversely affect both short-term and long-term outcomes after esophagectomy. MCV can become a predictive marker to estimate survival outcome after esophagectomy for esophageal cancer.

Sex differences in tumor characteristics, treatment, and outcomes of gastric and esophageal cancer surgery: nationwide cohort data from the Dutch Upper GI Cancer Audit

BackgroundSex differences in clinicopathological characteristics, treatment, and postoperative outcomes of gastric and esophageal cancer are largely undefined. This study aimed to compare tumor and treatment characteristics and outcomes of gastric and esophageal cancer surgery between male and female patients.MethodsPatients after elective surgery for primary esophageal (EAC) or gastric adenocarcinoma (GAC) registered in the Dutch Upper GI Cancer Audit between 2011 and 2016 were included. The primary endpoint, 5-year relative survival with relative excess risk (RER), i.e., adjusted for the normal life expectancy, was compared between male and female patients with EAC and GAC.ResultsIn total, 4937 patients were included (75% male) with a mean age of 66 years. cT and cN-stages showed a similar distribution in male and female patients. In females, antrum GAC was more frequent (47% vs. 38%, p < 0.001). Female patients with EAC less frequently received neo-adjuvant treatment (OR = 0.60, 95% CI 0.38–0.96, p = 0.033). For GAC, less postoperative morbidity (33% vs. 38% p = 0.017) and less re-interventions (12% vs. 16%, p = 0.008) were observed in females, although they had inferior 5-year relative survival (49% vs. 56%, RER = 1.31, 95% CI 1.09–1.58, p = 0.004). No differences in relative survival of EAC were observed.ConclusionsIn addition to significant sex differences in tumor location, female patients with esophageal adenocarcinoma less frequently received neo-adjuvant therapy, and female patients with gastric adenocarcinoma had inferior relative survival. Further consideration and exploration of sex differences in surgical treatment and outcomes are necessary to improve tailored treatment and outcomes.