Resectable Esophageal Cancer Research Articles

ASO Author Reflections: Early Recurrence After Esophageal Cancer Resection Cannot be Predicted Preoperatively: A Call for More Reliable Biomarkers

ASO Author Reflections: Early Recurrence After Esophageal Cancer Resection Cannot be Predicted Preoperatively: A Call for More Reliable Biomarkers

OGC SO37 - Pyloric drainage interventions for delayed gastric conduit emptying after oesophagectomy: A single centre analysis

Abstract Background Oesophagectomy in combination with perioperative multimodal therapy is the cornerstone of modern curative treatment for resectable oesophageal cancer. Delayed gastric emptying (DGE) is a common postoperative complication that results from the anatomical and physiological changes in the gastric conduit after an oesophageal resection. It is associated with an increased risk of pneumonia, anastomotic leak and prolonged hospital stay. Although several prophylactic pyloric drainage interventions have been postulated to mitigate the risk of DGE, the optimal modality remains debatable. This study aimed to define the incidence, evaluate prognostic factors, and characterise the management of DGE following oesophagectomy. Method Consecutive patients who underwent an oesophagectomy for oesophageal cancer between January 2022 and March 2024 were retrospectively identified from a hospital database. Pyloric drainage procedures consisted of expectant management, endoscopic/open pyloric Botox and pyloroplasty. Univariable and multivariable analyses were performed to define the incidence of DGE after each pyloric drainage modality, evaluate prognostic factors for DGE, and characterise the need for subsequent intervention in the management of DGE. Results The study cohort comprised 137 patients – mean age 66 years, male 78%. The incidence of DGE was 31%. Pyloroplasty had the lowest incidence of DGE (16%) followed by endoscopic botox (21%). Intra-operative pyloric drainage reduced the risk of DGE (p=0.03). The modality of prophylactic pyloric drainage used significantly influenced the risk of developing DGE (p=0.028). No significant differences were identified between patient demographics, operative approach, and oncological variables in the development of DGE. On multivariable analysis, pyloroplasty was associated with a reduced risk of DGE (OR 0.27, 95% CI 0.09 – 0.71). DGE did not influence overall survival. Conclusion DGE is a common postoperative complication which affects up to 39% of patients undergoing oesophagectomy. Patients who did not undergo a prophylactic pyloric drainage procedure during the index oesophagectomy were at an increased risk of developing DGE. Most patients with DGE (71%) require further intervention via endoscopy and botox injection. Pyloroplasty as a prophylactic drainage modality significantly reduced the risk of developing DGE compared to endoscopic botox. Further prospective randomised controlled trials are required to validate these findings.

More May Not Be Better: Comparison of Oncologic Outcomes Following Induction Chemotherapy Plus Chemoradiation and Chemoradiation Alone for Esophageal Adenocarcinoma.

The oncologic benefit of induction chemotherapy (IC) before chemoradiation (CRT) compared to CRT alone for locally advanced esophageal and gastroesophageal junction (GEJ) adenocarcinoma is not well defined. We hypothesized that IC with CRT would improve survival and pathologic complete response rate compared to CRT alone. A retrospective review of patients with biopsy proven esophageal or GEJ adenocarcinoma treated with preoperative CRT and IC + CRT and surgical resection from 2007 to 2023 at a single institution was performed. First order outcomes were overall survival and pathologic complete response rate; secondary outcomes included disease-free survival and distant metastasis failure. Subgroup analyses were conducted based on baseline characteristics and tumor-specific features. Survival analysis was performed with Kaplan-Meier curves with log-rank tests and Cox regression analysis. Of 205 patients that met inclusion criteria, 76 (38%) patients underwent IC + CRT. There were no significant differences in demographic or tumor-specific characteristics between the two cohorts. There were no differences in the median overall survival between CRT and IC + CRT groups (47 months vs. not reached, p = 0.194). The rate of pathologic complete response in the overall cohort was 22%; IC + CRT was not associated with higher complete tumor response than CRT alone (20% vs. 23%, p = 0.557). There were no significant differences in any of the secondary outcomes between the two treatment paradigms. We could not detect added oncologic benefit in survival or pathologic complete response with IC over CRT alone for resectable esophageal and GEJ cancer. Biomarker driven prospective studies exploring the optimal perioperative treatment regimens are warranted.

Risk of Financial Toxicity Among Adults Undergoing Lung and Esophageal Resections for Cancer

Although financial toxicity, defined as the harmful financial burden experienced by patients undergoing cancer treatment, has been of growing interest, data in thoracic oncology are lacking. We aimed to examine the risk of financial toxicity among patients undergoing surgical resection of thoracic malignancies. Adults undergoing lobectomy, pneumonectomy, or esophagectomy for cancer were identified in the 2012-2021 National Inpatient Sample (NIS). Risk of financial toxicity was defined as health expenditure (total hospitalization costs for the uninsured and maximum out-of-pocket costs for the insured) exceeding 40% of post-subsistence income. Multivariable logistic regressions were used to identify factors associated with financial toxicity risk. Of 384,340 patients, 69.5% had government-funded insurance, 27.2% private insurance, and 1.0% were uninsured. Compared to those with insurance, uninsured patients were more commonly Black and Hispanic and less commonly electively admitted. Mortality, complications, LOS, and costs were comparable regardless of insurance status. Approximately 68.9% of uninsured and 17.3% of insured patients were at risk of financial toxicity, and incidence of financial toxicity remained stable over time. After risk adjustment, complications were associated with over 2-fold increased risk of financial toxicity among uninsured (AOR 2.21, 95% CI 1.38-3.55). Among the insured, Black, Hispanic, and publicly insured patients demonstrated greater risk of financial toxicity, while minimally invasive operations and metropolitan hospitals exhibited lower risk of financial toxicity. Concordant with prior work examining financial toxicity in abdominal oncologic surgery, thoracic surgery demonstrates a comparable burden of financial toxicity. Referral policies and care subsidization may be considered in patients undergoing thoracic malignancy resections at risk for financial toxicity.

The role of computed tomography and esophageal ultrasonography in the preoperative evaluation of esophageal cancer resection

The role of computed tomography and esophageal ultrasonography in the preoperative evaluation of esophageal cancer resection

Recent Noteworthy Studies in Thoracic Oncology.

In this paper, we review recent prospective surgical studies on resectable esophageal and lung cancer. A narrative literature review was performed using the terms 'resectable esophageal cancer' and 'multimodal therapy' and 'resectable non-small cell lung cancer'. Prospective surgical trials performed from 2010 to 2023 were identified and analyzed. gov was queried for ongoing studies. The studies on esophageal cancer demonstrate the benefits of neoadjuvant chemoradiation, compared with surgery alone, and the emerging role of immunotherapy as part of induction and adjuvant treatment protocols. The selected studies on lung cancer demonstrate the evolving role of sublobar resection for patients with peripheral node-negative clinical stage IA1 disease and the developing role of neoadjuvant and adjuvant immunotherapy for patients with stage II-IIIA disease. The methods of treating patients with resectable esophageal or lung cancer are changing. Efforts to limit patient morbidity and optimize tumor treatment before surgery are increasingly being pursued and these approaches will likely continue to evolve as tumor biology and long-term pharmacologic mechanisms of action become clearer. Personalized medicine strategies that are based on tumor characteristics and the host genetic profile remain on the horizon, not yet ready for adoption in routine clinical practice.

Effect of sprayable, highly adhesive hydrophobized gelatin microparticles on esophageal stenosis after endoscopic submucosal dissection: an experimental study in a swine model.

Esophageal mucosal resection for superficial esophageal cancer can lead to postoperative esophageal stricture, with current preventive measures being insufficient. Sprayable wound dressings containing hydrophobized microparticles exhibit strong adhesion. This study aimed to investigate the preventive effects of hydrophobized microparticles on esophageal stenosis following endoscopic submucosal dissection. Circumferential esophageal endoscopic submucosal dissection was performed on miniature swine (n = 6). Swine were categorized into two groups: those sprayed with hydrophobized microparticles (sprayed group) and those not sprayed (non-sprayed group). Hydrophobized microparticles were sprayed onto the sprayed group on Days 0, 3, and 7 of endoscopic submucosal dissection. The non-sprayed group underwent endoscopy on the same days. Esophageal stricture rate, submucosal inflammatory cell infiltration, submucosal fibrosis, and thickening of the muscular layer were compared between the groups on Day 14 of endoscopic submucosal dissection. Spraying of hydrophobized microparticles was easily performed using an existing endoscopic spraying device. The esophageal stricture rate was significantly lower in the sprayed group than in the non-sprayed group (76.1% versus 90.6%, p < 0.05). The sprayed group showed suppression of inflammatory cell infiltration in the submucosal layer (p < 0.01) and thickening of the muscular layer (p < 0.01). Sprayable tissue-adhesive hydrophobized microparticles reduce the stricture rate after esophageal ESD by inhibiting inflammatory cell infiltration, submucosal fibrosis, and thickening of the muscular layer. The use of hydrophobized microparticles for preventing post-endoscopic submucosal dissection esophageal stenosis offers a promising avenue for clinical applications in endoscopic procedures, potentially improving patient outcomes.

Predictive factors for intrathoracic anastomotic leakage and postoperative mortality after esophageal cancer resection

BackgroundEsophageal cancer is currently one of the high-risk malignant tumors worldwide, posing a serious threat to human health. This study aimed to analyse the causes of postoperative mortality and intrathoracic anastomotic leakage(IAL) after esophagectomy.MethodsA retrospective analysis was conducted on 172 patients with esophageal cancer resection and focused on the preoperative and postoperative indicators. Cox regression analysis was performed to identify factors affected IAL and evaluated the potential factors on postoperative mortality. The Kaplan-Meier curve was applied to evaluate the effect of leakage on postoperative mortality after propensity score matching.ResultsUnivariable and multivariable Cox regression analysis showed that infection and high BMI were significant risk factors for IAL, patients with BMI over 24 kg/m2 in IAL group was two times higher than that of the group without IAL (95% CI = 1.01–6.38; P = 0.048). When patients were infected, the hazard ratios(HRs) of anastomotic leakage was twice that of patients without infection (95% CI = 1.22–4.70; P = 0.011). On the other hand, IAL was a significant cause of postoperative mortality, the 40-day postoperative mortality rate in the leakage group was significantly higher than the non leakage group (28.95% in leakage group vs. 7.46% in non leakage group, P<0.01). After propensity score matching, IAL still significantly affected postoperative mortality. The total length of hospital stay of the leakage group was inevitably longer than that of the non leakage group (22.19 ± 10.79 vs. 15.27 ± 8.59).ConclusionIAL was a significant cause of death in patients underwent esophageal cancer resection. Patients with high BMI over 24 kg/m2 and infection may be more prone to developing IAL after esophagectomy. IAL inevitably prolonged the length of hospital stay and increased postoperative mortality.

Perioperative blood transfusions associated with reduced survival in gastroesophageal cancers – A Swedish population-based study

BackgroundBlood transfusion has been associated with decreased long-term survival in cancer patients, possibly due to various immunological factors. We aimed to evaluate if perioperative transfusions decrease survival in patients who undergo resection for esophageal or gastric cancer and to identify factors associated with such events. MethodsA population-based cohort study was conducted based on the Swedish National Registry for Esophageal and Gastric Cancer, which prospectively collects clinical data of patients with these tumors. Almost all patients (96 %) resected for esophageal or gastric cancer in Sweden between 2017 and 2022 were included. Survival data were acquired from the Swedish Cause of Death Registry. Multivariable Cox regression was used to calculate hazard ratios (HR) with 95 % confidence intervals (CI), adjusted for age, fitness, neoadjuvant therapy, surgical access, and pathological TNM stage. ResultsOf all 1365 patients, 227 (17 %) received perioperative transfusions. Transfusion was associated with an increased risk of all-cause mortality within 3 years of surgery (adjusted HR 1.50, 95 % CI 1.17–1.91). To exclude the influence of surgery-related postoperative complications, a sensitivity analysis was performed excluding patients who died within 30 days of resection and the negative impact of transfusions on 3-year mortality remained (adjusted HR 1.30, 95 % CI 1.01–1.68). Increasing age, open surgery, esophagectomy, perioperative bleeding, and nodal tumor involvement were all associated with an increased likelihood of receiving transfusions. ConclusionPerioperative blood transfusions might have a negative impact on 3-year survival in patients who undergo surgery for esophageal or gastric cancer.

Thoracoscopic three-port single versus multiple intercostal for radical resection of esophageal cancer: a retrospective analysis

BackgroundThe purpose of this retrospective study was to compare the safety and feasibility of single-intercostal totally minimally invasive Ivor Lewis esophagectomy (MIIE) with those of multiple-intercostal MIIE.MethodsBetween January 2016 and December 2022, clinical data were collected for 528 patients who successfully underwent totally minimally invasive esophagectomy. Among these patients, 294 underwent MIIE, with 200 undergoing the single-intercostal approach and 94 undergoing the multiple-intercostal approach. Propensity score matching (PSM) was applied to the cohort of 294 patients. Subsequently, perioperative outcomes and other pertinent clinical data were analyzed retrospectively.ResultsA total of 294 patients were subjected to PSM, and 89 groups of patient data (178 persons in total) were well balanced and included in the follow-up statistics. Compared to the multiple intercostal group, the single intercostal group had a shorter operative time (280 min vs. 310 min; p < 0.05). Moreover, there was no significant difference in the incidence of major perioperative complications (p > 0.05). The total number of lymph nodes sampled (25.30 vs. 27.55, p > 0.05) and recurrent laryngeal nerve lymph nodes sampled on the both sides (p > 0.05) did not significantly differ. The single intercostal group had lower postoperative long-term usage of morphine (0,0–60 vs. 20,20–130; p < 0.01), total temporary addition (10,0–30 vs. 20,20–40; p < 0.01) and temporary usage in the first 3 days after surgery (0,0–15 vs. 10,10–20; p < 0.01) than did the multicostal group.There were no significant differences in age, sex, tumor location or extent of lymphadenectomy or in the clinical factors between the single-intercostal group (p > 0.05).ConclusionsBoth techniques can be used for the treatment of esophageal cancer. Compared to multiple intercostal MIIE, the feasibility of which has been proven internationally, the single intercostal technique can also be applied to patients of different age groups and sexes and with different tumor locations. It can provide surgeons with an additional surgical option.Trial registrationThis study was retrospectively registered by the Ethics Committee of the Second Affiliated Hospital of Zhejiang University School of Medicine, and written informed consent was exempted from ethical review. The registration number was 20,230,326. The date of registration was 2023.03.26.

Treatment strategies for elderly patients with locally advanced esophageal cancer: a systematic review and meta-analysis

BackgroundNeoadjuvant chemoradiotherapy (nCRT) followed by surgery remains a standard of care for resectable esophageal cancer (EC), and definitive chemoradiotherapy (dCRT) is an alternative for unresectable diseases. However, it is controversial for the use of the two aggressive regimens in elderly patients.MethodsWe systematically searched multiple databases for studies comparing overall survival (OS) and/or progression-free survival (PFS) between dCRT and surgery (nCRT + surgery or surgery alone) or between dCRT and radiotherapy (RT) alone in elderly patients (age ≥ 65 years) until March 28, 2024. Statistical analysis was performed using random-effects model.ResultsFourty-five studies with 33,729 patients were included. dCRT significantly prolonged OS (hazard ratio [HR] = 0.64, 95% confidence interval [CI]: 0.58–0.70) and PFS (HR = 0.67, 95% CI: 0.60–0.76) compared to RT alone for unresectable EC, and resulted in a worse OS compared to surgery for resectable cases (HR = 1.34, 95% CI: 1.23–1.45). Similar results of OS were also observed when the multivariate-adjusted HRs were used as the measure of effect (dCRT vs. RT alone: HR = 0.65, 95% CI: 0.58–0.73; dCRT vs. surgery: HR = 1.49, 95% CI: 1.28–1.74). Subgroup analyses according to age group (≥ 70, ≥ 75, or ≥ 80 years), study design, study region, histological type, radiation field, chemotherapy regimen revealed comparable results.ConclusionsnCRT + surgery is likely a preferred strategy for elderly patients with good physiological conditions; and dCRT is a better alternative for unresectable cases. Advanced age alone does not appear to be a key predictor for the tolerability of the two aggressive treatments.

Perioperative toripalimab plus neoadjuvant chemotherapy might improve outcomes in resectable esophageal cancer: an interim analysis of a phase III randomized clinical trial.

In the era of immunotherapy, neoadjuvant immunochemotherapy (NAIC) for the treatment of locally advanced esophageal squamous cell carcinoma (ESCC) is used clinically but lacks of high-level clinical evidence. This study aimed to compare the safety and long-term efficacy of NAIC followed by minimally invasive esophagectomy (MIE) with those of neoadjuvant chemotherapy (NAC) followed by MIE. A prospective, single-center, open-label, randomized phase III clinical trial was conducted at Henan Cancer Hospital, Zhengzhou, China. Patients were randomly assigned to receive either neoadjuvant toripalimab (240 mg) plus paclitaxel (175 mg/m2) + cisplatin (75 mg/m2) (toripalimab group) or paclitaxel + cisplatin alone (chemotherapy group) every 3 weeks for 2 cycles. After surgery, the toripalimab group received toripalimab (240 mg every 3 weeks for up to 6 months). The primary endpoint was event-free survival (EFS). The pathological complete response (pCR) and overall survival (OS) were key secondary endpoints. Adverse events (AEs) and quality of life were also assessed. Between May 15, 2020 and August 13, 2021, 252 ESCC patients ranging from T1N1-3M0 to T2-3N0-3M0 were enrolled for interim analysis, with 127 in the toripalimab group and 125 in the chemotherapy group. The 1-year EFS rate was 77.9% in the toripalimab group compared to 64.3% in the chemotherapy group (hazard ratio [HR] = 0.62; 95% confidence interval [CI] = 0.39 to 1.00; P = 0.05). The 1-year OS rates were 94.1% and 83.0% in the toripalimab and chemotherapy groups, respectively (HR = 0.48; 95% CI = 0.24 to 0.97; P = 0.037). The patients in the toripalimab group had a higher pCR rate (18.6% vs. 4.6%; P = 0.001). The rates of postoperative Clavien-Dindo grade IIIb or higher morbidity were 9.8% in the toripalimab group and 6.8% in the chemotherapy group, with no significant difference observed (P = 0.460). The rates of grade 3 or 4 treatment-related AEs did not differ between the two groups (12.5% versus 12.4%). The interim results of this ongoing trial showed that in resectable ESCC, the addition of perioperative toripalimab to NAC is safe, may improve OS and might change the standard treatment in the future.

382. NUMBER OF LYMPH NODES RESECTED IS ASSOCIATED WITH OVERALL SURVIVAL IN PATHOLOGICALLY NODE-NEGATIVE ESOPHAGEAL CANCER

Abstract Background Lymphadenectomy is a key part of curative resection of esophageal cancer, with multiple quality assurance systems suggesting a minimum of 15 lymph nodes should be resected and subjected to pathological examination. Nevertheless, whether the absolute number of nodes resected is a surrogate marker for quality in surgery and staging, or has therapeutic benefit is debated. The aim of this study was to determine the impact of lymphadenectomy on survival in patients with resected pathologically node-negative disease (both treated and untreated with neoadjuvant therapy). Methods A review of our institutional prospectively maintained database was conducted from 2010-2020 inclusive. Inclusion criteria were patients undergoing esophagectomy for esophageal cancer aged 18+ who consented to data inclusion. Exclusion criteria were patients undergoing resection for benign disease, patients with Siewert III tumours undergoing gastrectomy or extended total gastrectomy, patients undergoing re-operative surgery, or patients where final pathology was not available. Univariable and multivariable analyses were performed as appropriate. Results 195 patients (49%) had pathologically node negative disease, with median lymph node count of 25. 47% of patients were clinically node positive, but pathologically node negative following neoadjuvant therapy. On univariable survival analysis, number of nodes resected was a significant predictor of overall survival (HR 0.96, 0.93-0.98, p=0.001). On multivariable analysis, R status (HR 4.9, 1.2-21.1, p=0.03), number of nodes resected (HR 0.97, 0.94-0.99, p=0.02) and prior cN+ status (HR 2.28, 1.16-4.49, p=0.02) were predictors of overall survival. Patients with cN0, (y)pN0 disease had improved overall survival compared with cN+, (y)pN0 (median not reached vs 43.4 months, p=0.04). Conclusion Lymphadenectomy is a key part of resection of esophageal cancer. In pathologically node negative patients, the extent of lymphadenectomy remains a key predictor of overall survival. Conversion from clinically node positive to pathologically node negative disease is associated with worse outcomes compared to clinically and pathologically node negative disease. Even in early stage cancer, a thorough, multi-field lymphadenectomy should be encouraged.

785. MANAGEMENT OF ESOPHAGEAL CANCER WITH CONCURRENT CERVICAL NODE METASTASIS: A NATIONWIDE POPULATION-BASED COHORT STUDY

Abstract Background In the Netherlands, the standard treatment of locally advanced, resectable esophageal cancer without metastasis is neoadjuvant chemoradiotherapy followed by esophagectomy. There is a small subset of patients that present with concurrent cervical lymph node metastasis (LNM). Historically this was seen as distant metastasis and surgical intervention has usually not been an option for these patients. The contemporary TNM classification now categorizes these lymph node stations as locoregional disease. Our current study aims to describe current treatment paradigms in the Netherlands for patients presenting with esophageal cancer and concurrent cervical LNM. Methods This population-based cohort study utilized data from the Netherlands Cancer Registry (NCR), encompassing patients with locally advanced thoracic esophageal or gastroesophageal junction cancer and concurrent cervical lymph node metastasis. Treatment modalities were categorized into five options: neoadjuvant therapy followed by surgery (Neo + S), definitive chemoradiotherapy (dCRT), chemotherapy with or without radiotherapy &amp;lt; 30 Gray (CT), radiotherapy (RT), and best supportive care (BSC). Overall survival (OS) was assessed using the Kaplan-Meier method and compared via the log-rank test. Hazard rates were computed using Cox proportional hazards regression, with adjustment for confounding achieved through inverse probability of treatment weighting (IPTW). Results Between 2015 and 2021, a cohort of 412 patients was identified from the NCR database. Median survival durations were observed as follows: 24.2 months for Neo + S, 18.0 months for dCRT, 14.5 months for CT, 7.0 months for RT, and 3.2 months for BSC (Figure). A comparison between the Neo + S group and dCRT demonstrated a significant improvement in survival (p=0.02). Further subdivision of the surgical group into neoadjuvant CRT or chemotherapy did not reveal a significant difference in survival (p=0.6). Utilizing IPTW to adjust for confounding factors, Neo + S maintained its survival advantage. Conclusion The retrospective cohort findings suggest that neoadjuvant therapy followed by surgery may represent the optimal approach for managing esophageal cancer patients with cervical LNMs Yet, it's vital to recognize the influence of confounding by indication, which statistical adjustments may not entirely rectify. Furthermore, immortal time bias notably skews results favorably toward surgery. Nevertheless, the results emphasize the importance of considering surgery as a viable option for these patients. These limitations underscore the critical need for a prospective study, prompting the launch of the NODE-II trial.

622. COMPARISON OF ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY WITH CONVENTIONAL MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: A MULTI-INSTITUTIONAL COHORT STUDY

Abstract Background The Japanese public insurance system approved robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer in 2018. Since then, an increasing number of RAMIE has been performed every year. However, it is unclear whether RAMIE is more beneficial than conventional minimally invasive esophagectomy (MIE) in terms of short-term and long-term outcomes. Methods A total of 396 patients (RAMIE, 145; MIE, 251) with resectable esophageal cancer who underwent esophagectomy between 2016 and 2019 at 6 institutions were included. A propensity score matching analysis was performed to compare the short-term outcome. Two-stage esophagectomy, salvage surgery, and palliative resection were excluded. Individual propensity scores were calculated based on the following 15 variables: age, sex, body mass index, American Society of Anesthesiologists Physical Status (ASA-PS), hemodialysis, oral steroid use, obstructive pulmonary disease, histology, tumor location, clinical T, N, M classification, preoperative therapy, field of lymphadenectomy, and organ used for reconstruction. Results After matching 272 patients were analyzed. RAMIE took the significantly longer operating time (629min; 570min, p=0.0005), but the amount of blood loss (90g; 84g), number of harvested mediastinal nodes (24; 25), and in-hospital mortality (1.5%; 0.7%) were comparable. RAMIE group showed a trend of less severe post-operative morbidity (Clavien–Dindo grade III or higher) (18%; 27%) and significant reduction of recurrent laryngeal nerve palsy (23%; 35%, p=0.046). The 5-year overall and relapse-free survival in the RAMIE and MIE groups were 65%; 61% [hazard ratio (HR), 0.77; 95% CI: 0.51, 1.17], and 61%; 51% (HR, 0.73; 95% CI: 0.51, 1.06), respectively. Conclusion RAMIE was safely performed even during the early period of its application. Despite the longer operating time, RAMIE would be a promising alternative to MIE, with a better trend of short- and long-term outcomes, including a significantly lower incidence of postoperative recurrent laryngeal nerve palsy.

Clinical utility of pegfilgrastim on day 3 of preoperative docetaxel, cisplatin and 5-fluorouracil chemotherapy in elderly patients with resectable esophageal cancer

Clinical utility of pegfilgrastim on day 3 of preoperative docetaxel, cisplatin and 5-fluorouracil chemotherapy in elderly patients with resectable esophageal cancer

492. OUTCOMES OF ESOPHAGECTOMY IN THE ELDERLY- IS IT WORTH THE EFFORT?

Abstract Background Esophageal cancer is the sixth most common cancer in India and most patients are diagnosed at locally or loco-regionally advanced stages. Multimodal management offers the best chance of cure, with surgery being the cornerstone. With improved life expectancy, elderly patients with esophageal cancer are being referred for surgery more frequently. Although recent studies have shown encouraging outcomes, increased post-operative complications are common. The aim of our study was to evaluate morbidity and survival in patients above 70 years undergoing curative surgery for esophageal cancer from 2011 to 2021 at our centre. Methods Of 2291 patients undergoing esophagectomy, 122 were above 70 years, ten were inoperable. Mean age was 73.3 years (70-84 years), with 78% males and 83% squamous cell carcinoma, most common location being lower-third (63.6%). Of the 110 patients, 80 (72.7%) received neoadjuvant treatment, 68(61.8%) were ASA grade II or more. McKneown’s approach was common, utilized in 55%, of which minimally invasive in 53%, with Ivor- Lewis, left thoraco-abdominal and transhiatal approaches in the rest. Mean blood loss was 350 ml, with mean operative time of 270 minutes and circumferential positivity rate of 12.7%. Results The mean ICU stay was 1 day, with the mean hospital stay being 13 days. Almost half (49%) had Clavien-Dindo grade III or higher morbidity, with pulmonary complications seen in 27%. Anastomotic leakage was seen in 20/110 (18%), with only 2 patients needing an intervention. 30-day mortality was 8.2%. Recurrences were seen in 21 patients, anastomotic and regional recurrences in 6, distant in 6, regional with distant in 9. The median recurrence free survival was 26 months with 3-year RFS of 43.7%. With a median follow-up of 25 months, median overall survival was 30 months and 3-year OS was 45.3%. Conclusion Despite higher post-operative morbidity and mortality, elderly patients have reasonable recurrence free and overall survival outcomes with curative surgery. With continuing refinements in prehabilitation, operative techniques, wider adoption of minimally invasive surgery, intra-operative management and post-operative care, early post-operative outcomes are likely to improve further. Elderly patients with resectable esophageal cancer should not be denied surgery.

389. WILL SYNCHRONOUS ESOPHAGEAL AND LUNG RESECTION INCREASE THE INCIDENCE OF ANASTOMOTIC LEAKS? A MULTICENTER RETROSPECTIVE STUDY

Abstract Background Reports on combined resection for synchronous lung lesions and esophageal cancer (CRLE) cases are rare and mostly individual cases. Furthermore, the feasibility of CRLE has always been a controversial topic. In the current study, we retrospectively analyzed the feasibility of CRLE and established an individualized prediction model for esophageal anastomotic leaks after CRLE by performing a multicenter retrospective study. Methods Patients who underwent esophagectomy between January 2009 and June 2021 were extracted from a 4-centre retrospectively maintained database, and those with CRLE at the same setting were matched in a 1:2 propensity score matched (PSM) ratio to esophagectomy alone (EA) patients. A nomogram was then established based on the variables involved in multivariate logistic regression analysis. Internal validation of the nomogram was conducted utilizing Bootstrap resampling. Decision and clinical impact curve analysis were computed to assess the practical clinical utility of the nomogram. A prognosis analysis for CRLE and EA patients by Kaplan-Meier curves was conducted. Results Of the 7152 esophagectomies, 216 cases of CRLE were eligible, and 1:2 ratio PSM EA patients were matched. The incidence of anastomotic leaks following CRLE increased significantly (P=0.035). The results of the multivariate analysis indicated the leaks varied according to the type of lung resection (anatomic &amp;gt; wedge resection, P=0.016) and site of resected lobe (upper &amp;gt; middle/low lobe; P=0.027), and a nomogram was established to predict the occurrence of leaks accurately (AUC=0.786). Although no statistically significant difference in overall survival (OS) was observed in the CRLE group (P=0.070), a trend toward lower survival rates was noted. Further analysis revealed that combined upper lobe anatomic resection was significantly associated with reduced OS (P=0.027). Conclusion Our study confirms that CRLE is feasible but comes with a significantly increased risk of anastomotic leaks and a concerning trend of reduced survival, particularly when upper lobe anatomic resections are performed. These findings highlight the need for careful patient selection and surgical planning when considering CRLE.

471. MANAGEMENT OF EARLY ESOPHAGEAL CANCER - A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS

Abstract Background and Objectives Optimal surgical management for early oesophageal cancer remains controversial. We aimed to perform a network meta-analysis (NMA) of studies comparing outcomes after open esophagectomy (OE), minimally invasive esophagectomy (MIE), endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) for early oesophageal cancer. Methods A systematic search of electronic databases was undertaken. A network meta-analysis was performed as per PRISMA-NMA guidelines. Statistical analysis was performed using R and Shiny. Results 21 studies including 10,002 patients with stage Tis, T1a or T1b oesophageal carcinoma were included. Overall, 3,103 patients underwent ESD (31%, 3103/10,002), 6,191 underwent OE (61.9%, 6,191/10,002), 502 underwent EMR (5.2%, 502/10,002) and 206 underwent MIE (2.1%, 206/10,002). At NMA, at approximately 3.5 years follow up, there was a significant difference in recurrence rates of Tis, T1a or T1b disease following OE (odds ratio (OR): 0.32, 95% CI 0.12 – 0.83) as compared to EMR. Compared to ESD, estimated 5 year overall survival for Tis, T1a and T1b disease were equivocal following OE and EMR respectively (OR: 0.98, 95% CI 0.66 – 1.44), (OR: 0.88, 95% CI 0.38-2.04). When compared with ESD, superior resection rate was observed in OE (OR: 4.04 95% CI 2.56, 6.37) and MIE (OR: 16.49, 95% CI 2.19, 123.86). OE had the highest rate of pulmonary complications. Compared with ESD, pulmonary complications were significantly different to those who underwent OE (OR: 4.06, 95% CI 2.28 – 7.22). OE had the highest rate of recurrent laryngeal nerve injury, post operative ileus and procedure specific mortality as compared to ESD, EMR and MIE which was not found to be significantly different at NMA. ESD and EMR exhibited advantages over OE and MIE in certain procedural aspects including procedure duration, length of hospital stay and cost. Conclusions OE was associated with superior surgical outcomes compared to ESD. Disease recurrence was also higher in EMR compared to OE with improved cost-effectiveness for ESD and EMR. ESD demonstrated reduce morbidity as compared to OE. Considering these results, OE, MIE, ESR and EMR are all feasible options for primary early oesophageal cancer, contingent on surgeon and institutional expertise.

223. OUR SURGICAL TECHNIQUE OF TRACHEAL RESECTION AND ANTERIOR MEDIASTINAL TRACHEOSTOMY (AMT) IN THE MULTIDISCIPLINARY TREATMENT OF ESOPHAGEAL CANCER INVADING TRACHEA

Abstract Combined tracheal resection and anterior mediastinal tracheostomy (AMT) for esophageal cancer with tracheal invasion is a challenging treatment and technically demanding. Herein, we introduce our surgical procedure of AMT and its tips to reduce postoperative complications. Briefly, in a supine position with cervical approach, the manubrium, the medial half of the clavicle, and the adjacent first and second ribs on both sides were removed to achieve an open cervico-thoracic view. After completion of tumor resection, AMT was performed; after encircling brachiocephalic artery and transected innominate vein if needed, the tracheal stoma was translocated from the left to right side of the brachiocephalic artery to avoid postoperative hemorrhage caused by tracheal compression. In a case of free-jejunum reconstruction, we usually harvest mesentery as much as possible to fill in the surrounding dead space in the upper mediastinum around trachea and major arteries to prevent infection (we also use the pectoral myocutaneous flap and omentum for this purpose). The tracheal stoma was finally created using interrupted stitched to attach the tracheal stump to the native chest skin. https://photos.google.com/photo/AF1QipNDuxhBpSYDIDydLYD_0Vk917Kd13bG5t6ILtb6