Squamous Cell Carcinoma Of The Esophagus Research Articles

Predictive value of the modified systemic inflammation score in patients undergoing curative resection of squamous cell carcinoma of the esophagus.

447 Background: Inflammation plays a critical role in the development and progression of cancers. Here we aimed to evaluate the clinical significance of the preoperative modified systemic inflammation score (mSIS) to predict long-term outcomes of patients with esophageal squamous cell carcinoma (ESCC). Methods: We included 443 patients who underwent curative resection of ESCC. The mSIS was formulated according to the serum albumin level (ALB) and lymphocyte-to-monocyte ratio (LMR) as follows: mSIS 0 (ALB ≥4.0 g/dL and LMR ≥3.4), mSIS 1 (ALB < 4.0 g/dL or LMR < 3.4), and mSIS 2 ( ALB < 4.0 g/dL and LMR < 3.4). Results: Patients were categorized into preoperative mSIS 0 (n = 165), mSIS 1 (n = 183), and mSIS 2 (n = 95) groups. Preoperative mSIS was significantly associated with age, preoperative body mass index, and pathological disease stage. The disease-specific survival times of patients in preoperative mSIS 0, 1, and 2 sequentially shortened ( P = 0.009), and mSIS 2 was identified as an independent prognostic factor (hazard ratio 2.63, 95% confidence interval 1.33–5.27, P = 0.0053). In most patient subgroups, the mSIS was associated with greater risk of disease-specific death. A stepwise increase in the prevalence of hematogenous recurrences was directly proportion to the mSIS. When patients were subdivided by mSIS before neoadjuvant treatment, there were no significant differences in disease-specific survival. Conclusions: Our findings demonstrate that the preoperative mSIS may serve as a powerful prognosticator of ESCC that definitively stratifies clinical outcomes as well as a tool for selecting treatment strategies.

Anesthetic Management for Squamous Cell Carcinoma of the Esophagus.

While surgery plays a major role in the treatment and potential cure of esophageal cancers, esophagectomy remains a high-risk operation with significant perioperative morbidity and mortality compared to other oncosurgical procedures. Perioperative management for esophagectomy is complex, and close attention to detail in various areas of anesthetic and perioperative management is crucial to improve postoperative outcomes. Patients undergoing esophagectomy should be offered an evidence-based risk assessment for their postoperative outcomes to allow active participation and informed, shared-decision making. Novel perioperative risk scores have been developed to predict both short-term and long-term outcomes in patients with esophageal cancer, although independent validation of such scoring systems is still required. Apart from accurate preoperative risk assessment, further efforts to improve morbidity and mortality from esophagectomy is achieved through comprehensive Enhanced Recovery after Surgery (ERAS) protocols, which comprise an individualized bundle of care throughout the perioperative journey for each patient and should be implemented as a standard practice. Furthermore, anesthetic practice and perioperative anesthetic drug usage can potentially affect cancer progression and recurrence. This chapter reviews current evidence for various factors that contribute to the improvement of perioperative outcomes, including prehabilitation, preoperative optimization of anemia, thoracic epidural analgesia, intraoperative protective ventilatory strategies, goal-directed fluid therapy, as well as special attention to other perioperative issues that potentially reduce anastomotic and cardiopulmonary complications. In summary, it is difficult to show a measurable benefit from any one single intervention, and a multidisciplinary approach that encompasses multiple aspects of perioperative care is necessary to improve outcomes after esophagectomy.

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

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

P77 SIGNIFICANCE OF NEOADJUVANT DOWNSTAGING IN CARCINOMA OF THE ESOPHAGUS AND GASTRO-ESOPHAGEAL JUNCTION

Abstract Aim The aim of this study was to determine the importance of cTNM and ypTNM, and impact of downstaging of disease in patients with esophageal or gastro-eesophageal junction (GOJ) carcinoma who received neoadjuvant treatment followed by surgery. Background Most locally advanced esophageal cancers are treated with neoadjuvant therapy (chemotherapy or chemoradiotherapy). TNM staging is used prior (cTNM) and after (ypTNM) neoadjuvant treatment and surgery. Methods Data from consecutive patients with esophageal cancer from a single center were evaluated. Patients with either adenocarcinoma or squamous cell carcinoma of the esophagus who were treated with neoadjuvant chemo(radio) therapy followed by transthoracic esophagectomy and two-field lymphadenectomy were included. Comparison of outcomes with those primarily treated with surgery was made. The cTNM and ypTNM were applied and compared according to the American Joint Commission on Cancer (AJCC) 8th edition staging system. Results This study included 1115 patients of which 486 patients received surgery alone and 629 patients received neoadjuvant therapy and resection. Of patients receiving neoadjuvant therapy, 9 (1%) had cTNM stage 2 and 451 (72%) had a cTNM stage 3. Rates of downstaging were similar in esophageal adenocarcinoma and SCC (54% vs 62%, p=0.4). Downstaging was associated with significantly longer survival than patients with no change for both adenocarcinoma (median: 48 vs 15 months, p<0.001) and SCC (median: NR vs 17 months, p<0.001). On adjusted Cox regression, downstaging was associated with significantly longer survival in patients for esophageal adenocarcinoma but not SCC. Conclusion This study demonstrates ypTNM stage is provides a better estimate of prognosis compared to clinical stage. Downstaged patients may have an improved outcome over those with comparable pathological stage that did not receive neoadjuvant treatment.

Coincident of Gastrointestinal Stromal Tumor and Two Other Primary Malignancies: A Case Report

Introduction: Gastrointestinal Stromal Tumor (GIST) is an uncommon mesenchymal tumor of the gastrointestinal tract. It is rarely presented as Multiple Primary Malignancy Syndrome (MPMS) without an association with the familial syndromes. Case Presentation: A 63-year-old Iranian Azeri man admitted to a government hospital, affiliated to the Tabriz University of Medical Sciences, Tabriz, Iran, in 2012. The illness presented with complicated gastrointestinal problems with the diagnosis of GIST of the stomach, treated with imatinib. They family history and the screening tests of malignancies were negative, but the patient diagnosed with Squamous Cell Carcinoma (SCC) of the lower lip, leading to 28 courses of radiotherapy, followed by the recurrence of gastrointestinal symptoms, the GIST and SCC of the esophagus, that was also detected accidentally. Conclusions: Management of the multiple primary malignancy syndrome needs multidisciplinary teamwork. The study of MPMs, its etiology, and epidemiology can provide us proper ways of management.

New Esophageal Cancer Indication for Pembrolizumab.

Pembrolizumab (Keytruda) is now approved for patients with recurrent, locally advanced or metastatic squamous cell carcinoma of the esophagus whose tumors express programmed death ligand 1. A special diagnostic test to determine patient eligibility has also been approved.The drug carries the same ad

Optimized Cutoff Value of Serum Squamous Cell Carcinoma Antigen Concentration Accurately Predicts Recurrence After Curative Resection of Squamous Cell Carcinoma of the Esophagus.

Squamous cell carcinoma antigen (SCC-Ag) and carcinoembryonic antigen (CEA) are widely used in clinical practice to predict the prognosis of patients with esophageal squamous cell carcinoma (ESCC). However, their predictive values for prognosis are controversial. This study determined optimal cutoff values of serum SCC-Ag and CEA concentrations for predicting postoperative recurrence of ESCC, which enabled selection of high-risk patients. The study retrospectively analyzed 427 patients who underwent curative resection for ESCC. The optimal cutoff values of preoperative SCC-Ag and CEA concentrations for predicting postoperative recurrence were determined using combined analysis of hazard ratios and sensitivities for recurrence. Using the optimal cutoff value, the study evaluated survival, recurrence patterns, and temporal changes in marker concentrations. The preoperative SCC-Ag concentration of 1.1ng/ml was the optimal cutoff value for predicting postoperative recurrence, whereas precise cutoff values could not be determined for preoperative CEA concentrations. High preoperative SCC-Ag concentrations (> 1.1ng/ml), which were significantly associated with more aggressive tumor phenotypes and shorter disease-free survival, were identified as an independent prognostic factor in the multivariable analysis. High preoperative SCC-Ag concentrations were significantly associated with greater prevalence of lung/pleura and local recurrences. Normalization of serum SCC-Ag concentrations after neoadjuvant treatment or esophagectomy was not associated with a decreased risk of postoperative recurrence. The optimal cutoff value of preoperative SCC-Ag concentrations that predicted recurrence of ESCC was 1.1ng/ml, illuminating the utility of serum SCC-Ag concentrations as an easily measurable tool for selecting a perioperative management strategy.

Modified Systemic Inflammation Score is Useful for Risk Stratification After Radical Resection of Squamous Cell Carcinoma of the Esophagus.

Inflammation plays a critical role in the development and progression of cancers. We evaluated the clinical significance of the preoperative modified systemic inflammation score (mSIS) to predict long-term outcomes of patients with esophageal squamous cell carcinoma (ESCC). We included 443 patients who underwent curative resection of ESCC. The mSIS was formulated according to the serum albumin level (ALB) and lymphocyte-to-monocyte ratio (LMR) as follows: mSIS 0 (ALB ≥ 4.0g/dL and LMR ≥ 3.4), mSIS 1 (ALB < 4.0g/dL or LMR < 3.4), and mSIS 2 (ALB < 4.0g/dL and LMR < 3.4). Patients were categorized into preoperative mSIS 0 (n = 165), mSIS 1 (n = 183), and mSIS 2 (n = 95) groups. Preoperative mSIS was significantly associated with age, preoperative body mass index, and pathological disease stage. The disease-specific survival times of patients in preoperative mSIS 0, 1, and 2 sequentially shortened (P = 0.009), and mSIS 2 was identified as an independent prognostic factor (hazard ratio 2.63, 95% confidence interval 1.33-5.27, P = 0.0053). In most patient subgroups, the mSIS was associated with greater risk of disease-specific death. A stepwise increase in the prevalence of hematogenous recurrences was directly proportion to the mSIS. When patients were subdivided by mSIS before neoadjuvant treatment, there were no significant differences in disease-specific survival. Our findings demonstrate that the preoperative mSIS may serve as a powerful prognosticator of ESCC that definitively stratifies clinical outcomes as well as a tool for selecting treatment strategies.

760P - Pembrolizumab vs chemotherapy in patients with advanced/metastatic adenocarcinoma (AC) or squamous cell carcinoma (SCC) of the esophagus as second-line therapy: Analysis of the Chinese subgroup in KEYNOTE-181

BackgroundKEYNOTE-181 (NCT02564263) is an open-label, randomized, phase 3 trial of pembrolizumab (P) vs investigator’s choice of single-agent paclitaxel, docetaxel, or irinotecan (standard of care [SOC]) in advanced/metastatic AC or SCC of the esophagus. In the global cohort, P was superior to SOC for OS in pts with PD-L1 combined positive score (CPS) ≥10, with a more favorable safety profile. We present results of the China cohort. MethodsEligible pts were randomly assigned 1:1 to receive P 200mg Q3W for up to 2 y or investigator’s choice of SOC. Randomization was stratified by histology (SCC vs AC) and region (Asia vs rest of world). Primary end points were OS in the intention-to-treat (ITT), SCC, and PD-L1 CPS ≥10 populations. ResultsOf the 123 Chinese pts enrolled, 119 had SCC and 54 had CPS ≥10. Pts were randomly assigned to receive P (62 pts; 60 had SCC; 25 had CPS ≥10) or SOC (61 pts; 59 had SCC; 29 had CPS ≥10). As of Feb 13, 2019, the median follow-up (from randomization, regardless of death) was 15.1mo (P) vs 14.7mo (SOC). Median OS was longer with P vs SOC overall (8.4 vs 5.6mo; HR 0.55; 95% CI 0.36-0.82) and in the SCC (8.4 vs 5.6mo; HR 0.55; 95% CI 0.37-0.83), and CPS ≥10 groups (12.0 vs 5.3mo; HR 0.34; 95% CI 0.17-0.69). Median OS for P vs SOC in the CPS <10 group was 6.4 vs 6.1mo (HR 0.72; 95% 0.43-1.21). OS rates at 12mo for the P vs SOC groups were 36.3% vs 16.7% overall, 35.7% vs 15.3% in the SCC, and 53.1% vs 16.1% in the CPS ≥10 groups. PFS rates at 6mo were similar for P vs SOC (26.4% vs 24.1% in the ITT group), but ORR was substantially higher (16.1% vs 3.3% in the ITT group). Median DOR was not reached for P (4.4+ to 14.6+ mo) and was 3.2mo (2.6-3.9) for the SOC group. Fewer pts receiving P vs SOC had any-grade (76% vs 83%) or grade 3-5 (21% vs 42%) drug-related AEs or drug-related AEs that resulted in discontinuation (6.4% vs 11.9%). ConclusionsP showed favorable OS, compared with SOC, as second-line therapy for AC/SCC in Chinese pts, with a more favorable safety profile. In China, more patients had SCC than AC and P showed clinically meaningful OS improvement regardless of PD-L1 status. This finding was consistent with that of the Asia group from the full global cohort. Clinical trial identificationNCT02564263, September 30, 2015. Editorial acknowledgementAmy McQuay, PhD, of the ApotheCom pembrolizumab team (Yardley, PA, USA), funded by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA. Legal entity responsible for the studyMerck Sharp & Dohme Corp, a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA. FundingMerck Sharp & Dohme Corp, a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA. DisclosureJ. Zhang: Advisory / Consultancy: Bayer; Advisory / Consultancy: BMS; Speaker Bureau / Expert testimony: Roche; Speaker Bureau / Expert testimony: Sanofi; Speaker Bureau / Expert testimony: Merck-Serono; Speaker Bureau / Expert testimony: Pfizer; Speaker Bureau / Expert testimony: Taiho; Speaker Bureau / Expert testimony: HengRui; Speaker Bureau / Expert testimony: Novartis. Y. Cui: Full / Part-time employment: MSD, China. P. Bhagia: Full / Part-time employment: Merck & Co., Inc. S.P. Kang: Full / Part-time employment: Merck & Co., Inc.; Shareholder / Stockholder / Stock options: Celgene; Shareholder / Stockholder / Stock options: Macrogenics; Shareholder / Stockholder / Stock options: Celldex; Shareholder / Stockholder / Stock options: Agenus; Shareholder / Stockholder / Stock options: Pharmacyclics; Shareholder / Stockholder / Stock options: Endocyte. W. Lu: Full / Part-time employment: MSD, China. Y. Zhou: Full / Part-time employment: MSD China. All other authors have declared no conflicts of interest.

Pembrolizumab vs chemotherapy as 2L therapy for advanced esophageal cancer: Japanese Subgroup Analysis in KEYNOTE-181

Abstract Background Safe and effective treatment of advanced esophageal cancer is an area of unmet need. KEYNOTE-181 is a global, randomized, open-label, phase 3 study of pembrolizumab (PBR) vs chemotherapy (SoC) as second-line therapy for pts with advanced or metastatic esophageal cancer. Methods Eligible pts were aged ≥18 y, had confirmed, advanced adenocarcinoma (AC) or squamous cell carcinoma of the esophagus (ESCC), or HER2-negative Siewert type 1 AC of the gastroesophageal junction, documented progression on 1 prior-line therapy, measurable disease per RECIST v1.1, ECOG PS 0 or 1, and provision of a tumor sample for biomarker analysis. Pts were randomized 1:1 to PBR 200 mg Q3W for 2 years or investigator’s choice of paclitaxel 80-100 mg/m 2 on days 1, 8, and 15 of every 28-day cycle, docetaxel 75 mg/m 2 Q3W, or irinotecan 180 mg/m 2 Q2W. Stratification was by histology and geographic region. Primary endpoints were OS in the ITT, ESCC, and PD-L1 combined positive score (CPS) ≥10 populations. Secondary endpoints were PFS and ORR, by RECIST v1.1, and safety. Results Of the 152 Japanese pts enrolled, 133 (88%) were male, 94 (62%) had ECOG PS 0, 149 (98%) had ESCC, and 79 (52%) had PD-L1 CPS ≥10. Pts were randomized to PBR (77 pts) or SoC (75 pts), and median follow-up durations were 11.5 mo (range, 1.0-29.2) and 8.2 mo (range, 0.8-32.2), respectively. Median OS was improved with PBR vs SoC in pts with PD-L1 CPS ≥10 (12.5 vs 8.4 mo; HR 0.70; 95%CI 0.43-1.13; P = 0.0682), in pts with ESCC (11.9 vs 8.2 mo; HR 0.68; 95%CI 0.48-0.97; P = 0.0156) and in the ITT population (11.5 vs 8.2 mo; HR 0.68; 95%CI 0.48-0.96; P = 0.0147). These 3 primary OS data in Japanese were consistent to entire global populations, respectively. Fewer pts had any-grade (74% vs 96%) or grade 3-5 (17% vs 50%) drug-related AEs with PBR vs SoC. Conclusion PBR improved OS compared with SoC as second-line therapy for advanced esophageal cancer in Japanese patients, with a more favorable safety profile than SoC.

1716 Esophageal Squamous Cell Carcinoma-Associated Dancing Eye Syndrome in an Adult: Negative Paraneoplastic Antibodies Screen and Rapid Response to Intravenous Immunoglobulin and Methylprednisolone

INTRODUCTION: Dancing eye or opsoclonus-myoclonus syndrome is a rare paraneoplastic syndrome that has been mostly associated with small cell lung cancer. It was reported in association with esophageal cancer in one case. Here we report a second case. CASE DESCRIPTION/METHODS: A 59-year-old man presented with 5 weeks of rapidly worsening vertigo and gait difficulty that lead to frequent falls and inability to perform daily activities. About 5 weeks prior to presentation, he completed three rounds of cisplatin and 5-FU for recently diagnosed squamous cell carcinoma of the esophagus. He had long standing hypertension treated with hydrochlorothiazide, lisinopril, and carvedilol, and diabetes mellitus treated with glipizide, glyxambi, and sitagliptin. He denied alcohol, tobacco, or illicit drug use and recent viral infection. He was fully alert and oriented and afebrile. He had spontaneous, involuntary, arrhythmic, conjugate, multidirectional saccades occurring in all directions of gaze without a saccadic interval and pronounced ataxia on standing associated with unsteadiness. Complete blood count and routine chemistry were unremarkable. Brain MRI with and without contrast revealed no evidence of intracranial hemorrhage, mass lesion, acute infarct or pathologic enhancement. HIV screen was negative. Hepatits C virus antibody was non-reactive. Paraneoplastic autoantibodies screening was negative. He received 5 day course of 0.4g/kg/day intravenous immunoglobulin (IVIG) and 250 mg BID methylprednisolone with marked improvement of rhythmic eye beating at rest, coordination of multidirectional eye movements, ataxia, and vertigo by day 3. He was discharged to acute rehabilitation facility on day 8. DISCUSSION: Our patient has dancing eye or opsoclonus-myoclonus syndrome that followed the diagnosis of esophageal cancer and rapidly responded to IVIG and methylprednisolone, strongly suggesting a paraneoplastic association. Interestingly and consistent with the single case previously reported of this association, paraneoplastic autoantibodies screen was negative.

765P - Drinking alcohol, smoking, multiple dysplastic lesions and the risk of field cancerization of squamous cell carcinoma in the esophagus and head and neck region

BackgroundMultiple development of squamous cell carcinoma (SCC) in the upper aero-digestive tract is known as the field cancerization phenomenon. We examined the association of this phenomenon with dysplastic squamous epithelium in the background mucosa, drinking alcohol, and smoking. Methods331 patients with early esophageal SCC were enrolled. Using Lugol chromoendoscopy, we evaluated the dysplastic squamous epithelium in the esophagus. Lugol voiding lesions (LVL) were graded into 3 categories (A = no lesion; B=1 to 9 lesions; C≥10 lesions). The endpoint of this cohort study was the cumulative incidence of metachronous multiple SCC in the esophagus or head and neck after endoscopic resection of esophageal SCC according to the grade of LVL. At study entry, all patients were instructed to abstain from drinking alcohol and smoking. Data collected from a different cross-sectional cohort (n=1042) were used as an historical control. ALDH2 status was determined by questionnaire facial flushing after drinking alcohol (present and past flushing=inactive ALDH2, never flushing=active ALDH2). ResultsIn the median follow-up period of 69.6 months, LVL grade (A to B to C) was associated with progressive increases in the 5-year cumulative incidence of metachronous multiple SCC (esophagus = 6.0%, 17.8% and 47.1%, respectively, p=0.022 for A vs. B and p<0.0001 for A vs. C; head and neck = 0.0%, 4.3% and 13.3%, respectively, p=0.12 for A vs. B and p=0.0007 for A vs. C; esophagus or head and neck = 6.0%, 19.8% and 52.6%, respectively, p=0.012 for A vs. B and p<0.0001 for A vs. C). Alcohol and smoking abstinence decreased the risk of multiple SCC of the esophagus (adjusted hazard ratio=0.47 and 0.49, respectively) (p=0.013 for alcohol and p=0.024 for smoking). Adjusted odds ratio (OR) of LVL grade B and C associated with heavy drinking was significantly stronger in inactive ALDH2 (OR=47.5 and 358, respectively) than active ALDH2 (OR=12.8 and 138, respectively) (p<0.05 for B and p<0.05 for C). ConclusionsMultiple dysplastic lesions in the esophagus are a useful predictor of the risk of multiple SCC associated with field cancerization. Alcohol and smoking abstinence is required to prevent a second primary SCC. Clinical trial identificationUMIN000001676. Legal entity responsible for the studyJEC study group. FundingNational Cancer Center Research and Development Fund 36 by the Ministry of Health, Labour and Welfare of Japan. DisclosureAll authors have declared no conflicts of interest.

Esophagectomy for the patients with squamous cell carcinoma of the esophagus after allogeneic hematopoietic stem cell transplantation.

The number of long-term survivors after allogeneic hematopoietic stem cell transplantation (HSCT) has increased recently. Esophageal squamous cell carcinoma occurs at a particularly high incidence as a secondary cancer after HSCT. However, standard treatment for these patients has not been established yet. The objectives of this study were to investigate outcomes of esophagectomy for esophageal carcinoma developed in HSCT patients, and to provide the appropriate perioperative management. Ten HSCT patients underwent esophagectomy for esophageal squamous cell carcinoma between December 2007 and September 2017 at the National Cancer Center Hospital. The surgical outcomes and long-term prognosis of these patients were reviewed retrospectively. In the former group, 5 of the 7 patients (71.4%) developed pneumonia after esophagectomy, with two of them requiring intubation because of respiratory failure. None of the three patients of the latter group, who received broad-spectrum antibiotics for more than 7days after the surgery, developed any postoperative complications. The estimated survival probability of these patients at 5years after the surgery was 53.3%. HSCT patients have an extremely high risk of developing pneumonia after esophagectomy, and the condition can easily become serious. Therefore, broad-spectrum antibiotics should be administered prophylactically to prevent severe pneumonia during the perioperative period in these patients.

Esophageal Leukoplakia.

CASE REPORT A 64-year-old white man with a history of tobacco use and stable weight presented to the gastroenterology clinic due to an 11-month history of solid-food esophageal dysphagia. On physical examination, patient was alert and in no acute distress. His vital signs were within normal limits. His head and neck examination revealed normal oropharyngeal mucosa. No thyromegaly, lymphadenopathy, or masses in his neck were noted on palpation. Abdominal examination presented normal bowel sounds, without distension or tenderness. Upper endoscopy demonstrated white plaques at the gastroesophageal junction (Figure 1).Figure 1.: Upper endoscopy showing white plaques at the gastroesophageal junction.Biopsies obtained from this abnormality showed esophageal epidermoid metaplasia consistent with leukoplakia and mild patchy active chronic inflammation. Gomori methenamine–silver nitrate stain for fungal organisms was negative. Given the potential for malignant transformation of leukoplakia, endoscopic resection was suggested for the patient. An endoscopic submucosal dissection was planned, due to the lesion size to ensure compete removal. Chromoscopy with methylene blue was used to mark the borders of the lesion, and endoscopic submucosal dissection was accomplished without adverse events (Figure 2). Histologic examination confirmed hyperplastic squamous esophageal mucosa with marked hyperkeratosis without dysplasia and negative margins. During the 2-year follow-up, the patient reported complete resolution of his dysphagia. An upper endoscopy was ordered for surveillance.Figure 2.: Chromoscopy with methylene blue was used to mark the borders of the lesion.Epidermal metaplasia is a histological correlate to a white patch on the surface of a mucous membrane that cannot be rubbed off, known as leukoplakia.1 It is a common finding in oral mucosa, but rare in esophageal mucosa.1,2 The etiology of this condition in the esophagus is unclear and thought to be associated with esophageal tobacco and alcohol exposure or possibly an unusual response to chronic acid reflux.1,3,4 Although generally asymptomatic, symptom presentation can include dysphagia.3 Endoscopic features include slightly elevated whitish surface, which can be translucent or cobblestone-like in appearance.2,4 The natural history is unknown. As adjacent dysplasia and possible squamous cell carcinoma of the esophagus has been reported, and it is suggested that there is a potential for malignant transformation and therefore strict surveillance or endoscopic resection or ablation is warranted.1,5 DISCLOSURES Author contributions: PV Hernandez drafted the manuscript. D. Snyder, A. Kahn, KK Wang, DA Katzka, JL Horsley-Silva revised the manuscript. JL Horsley-Silva is the article guarantor. Financial disclosure: None. Previous presentation: This case report was presented as a poster at the 2019 ACG Annual Meeting; October 25-30, 2019; San Antonio, TX. Informed consent was obtained for this case report.

The Evolving Landscape of Esophageal Cancer: A Four-Decade Analysis

The incidence of esophageal cancer in the United States seems to have significantly increased since the 1970s. In undertaking this study, we sought to describe changes in the incidence, histologic type, and presenting stage of esophageal cancer over the past four decades. With Institutional Review Board approval, the Surveillance, Epidemiology, and End Results database of the National Cancer Institute was queried. Regression analysis was used to analyze data, and significance was accepted with 95 per cent probability. Forty-two thousand seven hundred thirty-nine patients had squamous cell carcinoma or adenocarcinoma located in their upper, middle, and/or lower esophagus from 1973 through 2010, reflecting a 7.5-fold annual increase from 1973 through 2010. Squamous cell carcinoma increased annually 2.5-fold (P < 0.001) and esophageal adenocarcinoma increased annually 57-fold from 1973 through 2010 (P < 0.001), whereas the overall population in the United States increased only 43 per cent (215,092,900 to 308,745,538) in the same period. From 1973 through 2010, there was a significant increase in the incidence of esophageal cancer in the United States. This increase was much greater than the increase in the population in the United States. The incidence of adenocarcinoma increased much more than that of squamous cell carcinoma of the esophagus from 1973 through 2010.

Utility of 18F-FDG PET Response Assessment for Predicting Histopathologic Response to Chemoradiation in Squamous Cell Carcinoma of the Esophagus

Utility of 18F-FDG PET Response Assessment for Predicting Histopathologic Response to Chemoradiation in Squamous Cell Carcinoma of the Esophagus

Risk Factors for the Development of Esophagorespiratory Fistula in Esophageal Cancer.

The development of esophagorespiratory fistula (ERF) in esophageal cancer (EC) is a devastating complication, leading to poor survival rates and low quality of life. Goal of this study was to identify risk factors leading to fistula formation in esophageal cancer. We identified 47 patients with malignant ERF formation in EC in a period of 10 years. Clinical characteristics were compared by univariable analysis to 47 randomly selected patients with EC, but without ERF. A case-control study was conducted for patients with squamous cell carcinoma (SCC) and ERF matching in a 1:2 fashion for primary tumor localization. Identifiable risk factors in EC patients were histology of SCC (P-value < 0.001), former or current smoking status (P = 0.002) and primary tumor localization in the proximal esophagus (P < 0.001). The "hot spot" for ERF formation was tumor growth 20-25cm distal to dental arch. An additional risk factor in SCC patients was age. Patients with ERF formation in SCC were younger than patients without ERF (median 63 vs. 67 years, P = 0.02). No difference in the rate of fistula formation was seen between esophagectomy and definitive chemoradiation, but the latter developed ERF earlier in the course of the disease (237 vs. 596.5 days, P = 0.01). Patients with proximal SCC of the esophagus and a smoking history, as well as young patients with SCC should be closely monitored for ERF formation.

Endoscopic features and associated histology of an basaloid squamous cell carcinoma of the esophagus at the very early stage

BackgroundBasaloid squamous cell carcinoma of the esophagus (BSCCE) is generally detected at advanced stage and the prognosis is poorer than advanced conventional esophageal squamous cell carcinoma. Therefore, early detection is a critical to improve patients’ survival. However, only a few cases of early BSCCE have been reported and the endoscopic features of early BSCCE are not well described. We herein report the endoscopic features and associated histology of an early BSCCE limited within the mucosal lamina propria (m2). To our knowledge, this is the earliest BSCCE reported to date.Case presentationA 62-year-old male patient was admitted to our hospital because of epigastric pain for 3 months. White light endoscopy revealed a flat lesion with mild sloping at the periphery. The lesion was covered with leukoplakia, and normal vascular network could not be seen in the lesion. Magnifying endoscopy with narrow-band imaging showed abnormal intra-papillary capillary loop categorized as type B1 according to the classification of the Japan Esophageal Society. Iodine staining revealed a less-stained lesion. The lesion was completely resected through endoscopic submucosal dissection. Histopathologically, tumor cells, which were limited within the mucosal lamina propria, formed solid nests and lobule structures, with ribbon-like arrangement of sparse cytoplasm and round to ovoid hyperchromatic nuclei. A final diagnosis of early BSCCE was established.ConclusionsThis is the earliest BSCCE reported to date. The prominent lesion with a gentle rising slope and less-staining or abnormal stain might be initial feature of early BSCCE.

Health-related quality of life (HRQoL) of pembrolizumab (pembro) versus physician choice single-agent paclitaxel, docetaxel, or irinotecan in subjects with advanced/metastatic adenocarcinoma (ACC) or squamous cell carcinoma (SCC) of the esophagus that has progressed after first-line standard therapy (KEYNOTE-181).

4048 Background: KEYNOTE-181 (NCT02564263) is an open-label, randomized, phase 3 trial in ACC and SCC of the esophagus that evaluated IV pembro 200 mg Q3W for up to 2 years vs investigator choice of single-agent paclitaxel/docetaxel/irinotecan (control). Pembro was superior to control for OS in patients with PD-L1 CPS ≥10 (N = 222; median 9.3 vs 6.7 months; P= 0.0074). Here we present results of prespecified HRQoL analyses in this population. Methods: The EORTC QLQ-C30 and EORTC QLQ-OES18 were administered at baseline; weeks 2, 3, 4, 6, 9, 12, 18; every 9 weeks up to 1 year/end of treatment; and 30-day safety follow-up visit. Data from patients receiving ≥1 dose of study treatment and completing ≥1 HRQoL assessment were analyzed. Least squares mean (LSM) score change from baseline to week 9, 95% CI, and nominal P values were calculated. Time to deterioration (TTD) (≥10-point decline from baseline) was assessed by Kaplan-Meier method and Cox regression model. HRs, 95% CIs, and nominal P values are provided. Results: The HRQoL population included 218 PD-L1 CPS ≥10 patients (107 pembro, 111 control). QLQ-C30 compliance at week 9 was 88.9% for pembro and 83.9% for control. There was no significant difference in LSM between arms (3.68; 95% CI –2.28, 9.64; P= 0.2248) in global health status (GHS)/QoL score. Week 9 QLQ-OES18 compliance was 88.4% for pembro and 83.3% for control. QLQ-OES18 scores were not significantly different between arms. TTD for pain (HR 1.02; 95% CI 0.58, 1.81; P= 0.5282), reflux (HR 1.69; 95% CI 0.83, 3.47; P= 0.9254), and dysphagia (HR 1.81; 95% CI 0.97, 3.37; P= 0.9693) subscales were not significantly different between arms. Conclusions: Over 9 weeks, patients treated with pembro had stable GHS/QoL scores similar to those of patients treated with single-agent docetaxel/paclitaxel/irinotecan. Combined with the superior OS and lower rate of treatment-related AEs seen with pembro, these data support clinically meaningful benefit of pembro in esophageal cancer patients with PD-L1 CPS ≥10. Clinical trial information: NCT02564263.

Neoadjuvant chemoradiotherapy combined with surgery in the treatment of potentially operable thoracic squamous cell carcinoma of the esophagus(ChiCTR-OIC-17011648): A phase II single center clinical study.

e15543 Background: To investigate the efficacy and safety of neoadjuvant radiotherapy and chemotherapy combined with surgery in the treatment of potentially operable thoracic esophageal squamous cell carcinoma. Methods: Nineteen patients with advanced thoracic esophageal squamous cell carcinoma hospitalized in our hospital from July 2016 to June 2018 were prospectively studied. All patients received neoadjuvant concurrent radiotherapy and chemotherapy: intensity modulated conformal radiotherapy (40 ∽ 44Gy/20 ∽22f, 2 Gy/f), chemotherapy (paclitaxel 150 ∽ 175 mg/m2 d1, 22+lobaplatin 25-30 mg/m2 d2, 23, 2 cycles). After radiotherapy and chemotherapy, the efficacy and safety of the operation were observed. Results: Two case (10.5%) was completely remitted after neoadjuvant radiotherapy and chemotherapy, 17 cases (89.5%) were partially remitted, and the objective effective rate was 100%. All patients underwent radical surgery successfully, the R0 resection rate was 100% and the pCR rate was 52.6%. The main adverse reactions of neoadjuvant radiotherapy and chemotherapy were granulocytopenia and grade III-IV granulocytopenia. The rate of survival was 16.7%, and anastomotic leakage occurred in 1 patients after operation. Conclusions: Neoadjuvant chemoradiotherapy for thoracic esophageal squamous cell carcinoma can effectively reduce the volume of the tumor, significantly reduce the pathological grade, improve the resection rate, and have less adverse reactions, which is worthy of clinical application. Clinical trial information: ChiCTR-OIC-17011648.