Thoracic Esophageal Cancer Research Articles

124. LONGITUDINAL STUDY OF POSTOPERATIVE SYMPTOMS AND QUALITY OF LIFE IN PATIENTS WITH ESOPHAGEAL SQUAMOUS CELL CARCINOMA

Abstract Patients with esophageal squamous cell carcinoma have a variety of symptoms after surgery, which will affect the normal performance of various functions of patients for a long time, affect the quality of life of patients, and even affect the survival time of patients. In the past, we paid more attention to patients’ symptoms and quality of life at a single time point after surgery, which lacked continuity and long-term nature. In this study, 244 patients with esophageal squamous cell carcinoma who received thoracoscopic radical resection of esophageal carcinoma in Sichuan Tumor Hospital from April to December 2019 were selected by convenience sampling method. Adopt Chinese VERSION MD Anderson Symptom Inventory, European Organization for Research and teatment of cancer quality of life Questionnaire, EORTC QLQ-C30 and QLQ-OES18 were used to investigate the patients at 10 time points one year after surgery, and Pearson correlation analysis was used to analyze the correlation between postoperative symptoms and quality of life. Postoperative role and emotional function of the patients recovered to the baseline level 1 month after surgery, cognitive and social function recovered to the baseline level 3 months after surgery, and physical function and overall health status did not recover to the baseline level 1 year after surgery. Sleep restlessness, distress, drowsiness, and dry mouth recovered to baseline 3 months after surgery, while pain and fatigue did not recover to baseline 1 year after surgery. One year after surgery, the main symptoms were negatively correlated with body, role, emotion, cognition, social function and overall health status (P < 0.05). laparoscopic thoracic esophageal cancer radical surgery in patients with esophageal squamous cell carcinomas there were different degree of symptoms within one year after surgery, and multiple symptoms one year after surgery still exists, the serious influence the patient’s quality of life, health care workers should pay attention to the symptoms of patients with postoperative longitudinal change characteristic, value assessment and management of patients with symptoms, improve patient quality of life after surgery.

313. RISK FACTORS FOR RECURRENCE IN ADVANCED ESOPHAGEAL CANCER PATIENTS WHO RECEIVED NEOADJUVANT CHEMOTHERAPY FOLLOWED BY ESOPHAGECTOMY

Abstract Recently, nivolumab adjuvant therapy has become a new treatment option in Japan. However, who is the good candidate of this adjuvant therapy has not been fully investigated. The aim of this study was to clarify the risk factors for recurrence in advanced esophageal cancer patients who received neoadjuvant chemotherapy (NAC) followed by esophagectomy. We retrospectively reviewed the records of 83 patients with advanced thoracic esophageal cancer who received NAC followed by esophagectomy between 2000 and 2018 (69 men and 14 women with a median age of 65 years). We evaluated relapse-free survival (RFS) and investigated the risk factors for recurrence by multivariate analysis. The regimen of NAC was Cisplatin +5-FU (CF) in 74 patients, Docetaxel + Cisplatin +5-FU in six, and CF with radiotherapy in three. The median follow-up period after esophagectomy was 53 months. The 3-year RFS rate was 58.8%. Multivariate analyses revealed ypT3–4 (Hazard ratio, 3.71; 95% confidence interval, 1.67–8.29), lymphatic invasion (3.45; 1.62–7.39), and postoperative infectious complications (2.99; 1.47–6.07) were significant risk factors for recurrence. Moreover, the prognosis of the patient group with 2 or more risk factors was significantly worse than that of the patient group with 0–1 factor (The 3-year RFS rates, 75.2% vs. 23.1%; p < 0.001). ypT3–4, lymphatic invasion, and postoperative infectious complications were significant risk factors for recurrence after esophagectomy after neoadjuvant chemotherapy. The prognosis of the patient group with 2 or more these risk factors was significantly worse, therefore, it is considered to be a candidate for nivolumab adjuvant therapy.

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

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

172. THE MEDIASTINOSCOPIC RADICAL ESOPHAGECTOMY WITH A TRANS-BICERVICAL APPROACH USING INTRAOPERATIVE NERVE MONITORING (IOMN)

Abstract We developed ‘mediastinoscopic esophagectomy with lymph node dissection’ (MELD), performed under pneumomediastinum via a trans-bicervical and transhiatal approach using cadavers. A clinical trial on the feasibility and safety of MELD showed it to be useful for complete mediastinal lymph node dissection. We report the indications and novel aspects of MELD. MELD was indicated for patients of thoracic esophageal cancer without bulky primary lesions or lymph node metastases. MELD was performed in 16 patients. First, 101R and part of the 106recR lymph nodes were dissected in open surgery. After attaching an APS electrode for intraoperative nerve monitoring (IOMN) to the right vagus nerve, open surgery was changed to the pneumomediastinal method. The dorsal side of the esophagus was dissected along the visceral sheath. The 106tbL lymph nodes and the106recR lymph nodes were dissected using a right trans-cervical pneumomediastinal approach. The 106recL lymph nodes were dissected using a left trans-cervical pneumomediastinal approach. The median pneumomediastinal operation time was 320 minutes. The median amount of bleeding was 230 mL, and the median postoperative hospital stay was 16 days. Regarding complications, eight patients developed recurrent laryngeal nerve palsy (right, n = 3; left, n = 2; bilateral, n = 3), but no patients required conversion to thoracotomy, and no leakage, pneumonia, or operative deaths occurred. After incorporating the use of IOMN, the incidence of recurrent laryngeal nerve palsy was drastically reduced recurrent laryngeal nerve palsy was drastically decrease. Previous clinical trials shown that MELD can retrieve the mediastinal lymph nodes at the same level as thoracoscopic esophagectomy. The incidence of recurrent laryngeal nerve palsy was reduced by IONM; thus, MELD is considered a feasible procedure for radical esophagectomy.

447. IMPACT OF PERIOPERATIVE MANAGEMENT BASED ON ERAS IN THORACIC ESOPHAGEAL CANCER SURGERY

Abstract Esophagectomy for esophageal cancer is one of the most invasive surgeries, thus it has high morbidity and mortality rates. A multidisciplinary perioperative management is required for improvement in surgical outcomes. Early recovery after surgery (ERAS) is now standard in the care of patients and has been associated with reduced complication rates and hospital stays. The aim of this study was to evaluate the impact of perioperative management based on ERAS for thoracic esophageal cancer patients. A total 357 patients performed esophagectomy between January 2009 and August 2020 were enrolled. Patients were classified into non-ERAS (NE) group (n = 174) and ERAS (E) group (n = 183). Operative outcomes were compared between two groups. Postoperative complications were graded according to Clavien-Dindo classification. The complication defined as above Grade 3. Nutritional Status was evaluated with Controlling nutritional status (CONUT). Changes in body weight (BW) and area of psoas muscle mass at 3 months after surgery were evaluated. Operative factors such as operative time and blood loss were not significant different between the NE and E groups. In E group, Postoperative any complications (p = 0.023), respiratory complications (p = 0.043) were significantly less than in NE group. CONUT score was lower on postoperative 1 month (p = 0.025) and 3 months (p = 0.044) in E group. Reduction rate of BW and psoas muscle mass index (PMI) on postoperative 3 months in E group was lower than in NE group (BW: 5.6 ± 6.4% vs 7.8 ± 5.2% (p = 0.045), PMI: 6.7 ± 14.9% vs 12.3 ± 13.3% (p = 0.021)). ERAS could be effective for maintenance of a better nutritional status and prevention of the postoperative respiratory complication and loss of the BW and PMI.

Prognostic risk factors for T1 thoracic esophageal cancer: a retrospective cohort study.

BackgroundEsophageal cancer has a poor overall prognosis and a high incidence of post-treatment complications. This study aimed to analyze the common surgical methods for treating T1 thoracic esophageal cancer and explore its prognostic risk factors to provide a basis for appropriate treatment selection.MethodsIn this population-based retrospective cohort study, data of patients diagnosed with T1 thoracic esophageal cancer from 2010 to 2016 were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Patients were divided according to those who had surgery and those who had radiotherapy. Survival curves were generated using the Kaplan-Meier method and validated by the log-rank test. Cox’s regression model was used to analyze the independent prognostic risk factors.ResultsOverall, 2,027 eligible patients, including 824 and 1,203 patients in the surgical and non-surgical groups, respectively, were analyzed. There was no significant difference in survival between the surgical and non-surgical groups (P=0.79). In subgroup analysis, the Cox regression analysis showed that radiotherapy was a significant prognostic factor (P=0.00059).ConclusionsThe impact of surgery on patients with T1 thoracic esophageal cancer was insignificant; however, radiotherapy was an independent prognostic risk factor. These results provide a reliable basis for clinical treatment of patients with T1 thoracic esophageal cancer.

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

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

The value and related complications of lymph node dissection along bilateral recurrent laryngeal nerves in esophageal cancer patients

Esophageal cancer is one of the most common malignant tumors of digestive tract, lymph node metastasis is a frequently encountered metastasis in the esophageal cancer patients. The number of lymph node metastasis is reported as an important prognostic factor, and it also affects the choice of postoperative treatments in the esophageal cancer. It was reported that the recurrent laryngeal nerve lymph nodes are the most common sites of nodal metastasis and need to be completely dissected during the esophagectomy for thoracic esophageal cancers. Dissection of the lymph nodes along bilateral recurrent laryngeal nerves not only improves the accuracy of staging, but also improves postoperative survival of esophageal cancer patients due to reducing the local recurrence. However, it also brings problems such as injury of laryngeal recurrent nerves, and increases postoperative complications such as pulmonary complications and malnutrition due to aspiration and coughing. Therefore, it is necessary to preserve the structure and function of bilateral recurrent laryngeal nerves during esophagectomy through careful manipulations, and minimize the impact of complications in prognosis and quality of life from injury to the recurrent laryngeal nerve.

A prospective study of radical external beam radiotherapy versus external beam radiotherapy combined with intraluminal brachytherapy for primary esophageal cancer

PURPOSEThis study compared the efficacy and side effects of external beam radiotherapy (EBRT) + intraluminal brachytherapy (IBT) with EBRT alone in patients with primary thoracic esophageal cancer. MATERIALS AND METHODSBetween 2013 and 2020, 64 patients with primary thoracic esophageal cancer without surgery received radiotherapy. Thirty-two patients received EBRT + IBT. EBRT dose was 50 Gy, 2 Gy/f, 5 times a week, and IBT dose was 10 Gy, 5 Gy/f, once a week. Thirty-two patients received EBRT alone, and the total dose was 60 Gy. The median followup was 19 months. RESULTSThe local control rates (LCR) of EBRT + IBT and EBRT alone group at 1, 2, and 3 years after treatment were 88% and 72%, 53% and 22%, 25%, and 9%, respectively. The overall survival (OS) of the EBRT + IBT and EBRT alone group at 3 years after treatment were 38% and 9%. The 3-year local recurrence-free survival (LRFS) rates of EBRT + IBT and EBRT alone group were 25% and 9%. Univariate analysis showed that EBRT + IBT could be the prognostic factor improving OS (p = 0.04), and tumor located in the mid-thoracic region exhibited a poorer prognosis on LRFS (p = 0.03). Grade 3 or higher acute side effects included two cases of dysphagia and three cases of bone marrow suppression. Severe late side effects included three cases of fistula, three cases of radiation pneumonia, and five cases of stenosis requiring treatment. CONCLUSIONSCompared with EBRT alone, EBRT + IBT is an effective treatment modality for T1∼3NanyM0 primary thoracic esophageal cancer with good local control. It can prolong the survival time of patients and has acceptable toxicity.

Effect of Postoperative Oral Intake Status on Sarcopenia Six Months After Esophageal Cancer Surgery

PurposeIn patients with esophageal cancer, skeletal muscle mass has been reported to decrease progressively after surgery and be independently associated with a poor prognosis. The purpose of this study was to investigate perioperative changes in dysphagia, oral intake status, and nutritional status and identify factors related to sarcopenia 6 months after esophagectomy.MethodsA total of 134 patients who underwent radical resection for thoracic esophageal cancer between March 2016 and July 2019 were analyzed retrospectively. The diagnosis of sarcopenia was made by CT taken 6 months postoperatively using the cut-off criteria of skeletal muscle index (SMI) < 52.4 cm2/m2 for male and SMI < 38.5 cm2/m2 for female patients. As factors related to postoperative sarcopenia, dysphagia, oral intake status, nutritional status, and physical function were extracted from the medical records. Multivariate logistic regression analysis was performed to identify perioperative risk factors related to sarcopenia 6 months after surgery.ResultsOf the 134 patients, 34.3% were judged to be unable to start oral intake on swallowing assessment. At discharge, 30.6% received tube feeding with or without oral intake. In the non-oral intake group on swallowing assessment, a significantly higher proportion of patients received tube feeding at discharge (p = 0.014). Preoperative BMI, postoperative handgrip strength, and tube feeding at discharge were independent risk factors for sarcopenia 6 months after esophagectomy in male patients.ConclusionTube feeding at discharge is significantly related to postoperative sarcopenia in patients with esophageal cancer. Identifying high-risk groups might allow early detection of malnutrition and provision of appropriate care.

Clinical Features of Recurrence Pattern with Lung Metastasis After Radical Esophagectomy for Thoracic Esophageal Cancer.

One of the difficulties in the treatment of esophageal cancer surgery is the high rate of postoperative recurrence. After esophagectomy, distant metastatic recurrence frequently occurs in the lung. This study aimed to determine the clinical features of a recurrence pattern with lung metastasis. The current study analyzed data from 138 patients who had postoperative recurrence of esophageal cancer after a radical esophagectomy. According to the recurrence pattern at the time of initial diagnosis, the patients were classified into two groups as follows: those with lung metastasis and those without. Twenty-three of the 138 investigated patients had a recurrence pattern with lung metastasis. Salvage surgery and postoperative pneumonia (p = 0.041 and 0.030, respectively) were identified as risk factors for recurrence pattern with lung metastasis in multivariate analysis. When we compared the sites of primary esophageal tumors, we found that the frequencies of distant metastases, such as lung and liver metastases, as well as pleural/peritoneal dissemination, were higher in the mid and distal esophageal tumors. Patients with a recurrence pattern showing lung metastasis alone had a better overall and post-recurrence survival than those with other recurrence patterns (p < 0.001 and p < 0.001). In patients who had postoperative recurrence after esophagectomy for thoracic esophageal cancer, salvage surgery, and postoperative pneumonia were significantly related to recurrence pattern with lung metastasis. Postoperative recurrence with lung metastasis alone had a better prognosis than other recurrence patterns; therefore, when pulmonary recurrence is suspected, performing intensive examinations for early diagnosis is critical.

The impact of the American Society of Anesthesiology-Physical Status classification system on the treatment and prognosis of patients with esophageal cancer undergoing esophagectomy.

The American Society of Anesthesiologists-Physical Status (ASA-PS) classification system has been shown to predict morbidity and mortality after surgery. However, the impact of the ASA-PS on esophageal cancer treatment remains unclear. This study examined both the impact of the ASA-PS on treatment, including surgery and perioperative chemotherapy, and the prognostic effects of ASA-PS class in patients who had undergone esophagectomy for thoracic esophageal cancer or esophagogastric junction cancer. ASA-PS status was collected for 301 patients who had undergone esophagectomy between January 2007 and June 2016 for thoracic esophageal cancer or esophagogastric junction cancer at a single institution. As the ASA-PS was updated in 2014, the previous classifications of all patients were reevaluated using the updated standard by a surgeon with the previous classifications masked. The dose intensity of preoperative chemotherapy was also compared across classes. Multivariate Cox regression analysis was used to analyze the association between ASA-PS class and overall survival. Patients whose reevaluations had placed them in a more severe ASA-PS class showed significantly poorer overall and cancer-specific survival rates. The dose intensities of cisplatin and 5-fluorouracil for preoperative chemotherapy were significantly lower in patients in the more severe ASA-PS classes. Multivariate analysis showed that ASA-PS class was an independent prognostic factor for overall survival. Preoperative ASA-PS classification may influence the intensity of perioperative treatment and may be a valuable long-term prognostic factor for patients with esophageal cancer undergoing esophagectomy.

The Impact of Perioperative Fluid Balance on Postoperative Complications after Esophagectomy for Esophageal Cancer

Background: Perioperative fluid balance is an important indicator in the management of esophageal cancer patients who undergo esophagectomy. However, the association between perioperative fluid balance and postoperative complications after minimally invasive esophagectomy (MIE) remains unclear. Methods: This study included 115 patients with thoracic esophageal squamous cell cancer who underwent MIE between January 2018 and January 2020. We retrospectively evaluated the association between perioperative fluid balance from during surgery to postoperative day (POD) 2, and postoperative complications. Results: The patients were divided into lower group and higher group based on the median fluid balance during surgery and at POD 1 and POD 2. We found that the higher group at POD 1 (≥3000 mL) was the most important indicator of postoperative complications, such as acute pneumonia within 7 days after surgery, and anastomotic leakage (p = 0.029, p = 0.024, respectively). Moreover, the higher group at POD 1 was a significant independent factor for acute postoperative pneumonia by multivariate analysis (OR: 3.270, 95% CI: 1.077–9.929, p = 0.037). Conclusion: This study showed that fluid overload at POD 1 had a negative influence on postoperative complications in patients with esophageal cancer. The fluid balance must be strictly controlled during the early postoperative management of patients undergoing esophageal cancer surgery.

Association of volumetric-modulated arc therapy with radiation pneumonitis in thoracic esophageal cancer.

The lung volume receiving low-dose irradiation has been reported to increase in volumetric-modulated arc radiotherapy (VMAT) compared with three-dimensional conformal radiotherapy (3DCRT) for thoracic esophageal cancer, which raises concerns regarding radiation pneumonitis (RP) risk. This single institutional retrospective cohort study aimed to explore whether VMAT for thoracic esophageal cancer was associated with RP. Our study included 161 patients with thoracic esophageal cancer, of whom 142 were definitively treated with 3DCRT and 39 were treated with VMAT between 2008 and 2018. Radiotherapy details, dose–volume metrics, reported RP risk factors and RP incidence were collected. The RP risk factors were assessed via multivariate analysis. Dose–volume analysis showed that VMAT delivered more conformal dose distributions to the target volume (P < 0.001) and reduced V30 Gy of heart (57% vs 41%, P < 0.001) but increased V5 Gy (54% vs 41%, P < 0.001) and V20 Gy (20% vs 17%, P = 0.01) of lungs compared with 3DCRT. However, the 1-year incidence rates of RP did not differ between the two techniques (11.3% in 3DCRT vs 7.7% in VMAT, P = 0.53). The multivariate analysis suggested that the presence of interstitial lung disease (ILD) (P = 0.01) and V20 Gy of lungs ≥20% (P = 0.008) were associated with RP. Conclusively, VMAT increased the lung volume receiving low to middle doses irradiation, although this might not be associated with RP. Further studies are needed to investigate the effect of using VMAT for delivering conformal dose distributions on RP.

Mapping of Lymph Node Metastasis From Thoracic Esophageal Cancer: A Retrospective Study.

This retrospective study was designed to investigate the optimal extent of dissection for thoracic esophageal cancer (EC) based on the incidence of lymph node metastasis (LNM). We retrospectively identified 1014 patients with thoracic esophageal carcinoma who underwent esophagectomy at our institution between May 2018 and November 2020. Also, the location and rate of LNM in relation to the postoperative pathological results were retrieved. We separately counted the metastasis rates of routinely excised lymph node stations according to the Japan Esophageal Society (JES) staging system. A total of 1666 consecutive patients were screened, and 1014 were enrolled. Generally, the rates of LNM in thoracic EC may be arranged in the descending order of station 7 > station 106recR > station 2 > station 106recL. Esophageal cancer in the middle and lower thoracic segment also had a high rate of LNM along bilateral recurrent laryngeal nerve. Stations 106tbL and 111 were the lowest frequent sites of metastasis with rate less than 5%; only the patients with clinically positive LNs need to dissect. The cT3-4, cN+, or G3 were independent risk factors for LNM and neoadjuvant therapy did not change the distribution of LNM for thoracic EC cases. This study accurately identified the distribution of LNM for thoracic EC patients. Neoadjuvant therapy could not change the overall distribution of LNM in thoracic EC patients. However, whether LNs dissection at stations 106tbL and 111 is related to the survival of thoracic EC or not, needs a long follow-up time to verify.

The Impact of Weight Loss during Chemoradiotherapy for Unresectable Esophageal Cancer: Real-World Results.

Weight loss is a common phenomenon presented in unresectable esophageal cancer (EC) patients during their definitive chemoradiotherapy (dCRT) treatment course. This study explored the prognostic value of weight changes during dCRT in unresectable EC patients. From 2009 to 2017, 69 cT4b thoracic EC patients undergoing complete curative dCRT without baseline malnutrition were included. Clinical factors were analyzed via the Cox proportional hazards model and survival was analyzed by the Kaplan–Meier method. During dCRT, the median weight loss percentage was 5.51% (IQR = 2.77–8.85%), and the lowest body weight was reached at 35 days (IQR = 23–43 days). Median OS of these patients was 13.5 months. Both univariate and multivariate analysis demonstrated that weight loss ≤ 4% during dCRT was significantly associated with superior OS with a hazard ratio of 2.61 (95% CI: 1.40–4.85, p = 0.002). The median OS for patients with weight loss ≤ 4% and >4% during dCRT was 59.6 months and 9.7 months, respectively (p = 0.001). Our study demonstrated that weight loss ≤ 4% during dCRT course is a favorable prognostic factor for cT4b EC patients. This index could serve as a nutrition support reference for unresectable EC patients receiving dCRT in the future.

Propensity-Matched Analysis of the Short-Term Outcome of Robot-Assisted Minimally Invasive Esophagectomy Versus Conventional Thoracoscopic Esophagectomy in Thoracic Esophageal Cancer.

In this matched-cohort study, we investigated the short-term outcome of robot-assisted minimally invasive esophagectomy (RAMIE) compared with conventional minimally invasive thoracoscopic esophagectomy (MIE) in esophageal cancer patients. One hundred eighty-nine patients with thoracic esophageal cancer scheduled to undergo thoracic esophagectomy between 2020 and 2021 were assigned to either RAMIE or MIE. Then, we retrospectively evaluated the postoperative surgical complications between two groups in a propensity-matched analyzation. Based on the propensity-matched score, 50 patients who underwent RAMIE or MIE were selected. Thoracic surgery time in RAMIE/MIE group were 233.1/173.3min (p < 0.01), respectively. No significant intergroup differences were observed regarding incisional anastomotic leakage (RAMIE group 4.0% vs. MIE group 6.0%) and pneumonia (RAMIE group 8.0% vs. MIE group 12.0%; p = 0.68). The respective incidences of recurrent laryngeal nerve paralysis were 34.0 and 8.0% in the MIE and RAMIE groups, respectively (p < 0.01). In the matched cohort, no differences were observed between the groups in the success accomplishment of the clinical management pathway (RAMIE group 94.0% vs. MIE group 88.0%). Although patients who underwent RAMIE had longer operation times, the incidence of recurrent laryngeal nerve paralysis was lower than with MIE. Further study in a prospective multi-institutional setting are required to confirm the superiority of RAMIE compared with MIE.

胸部食道癌術後の嚥下障害に対するチーム医療

胸部食道癌術後の嚥下障害に対するチーム医療

Comparison of intensity modulated proton therapy beam configurations for treating thoracic esophageal cancer.

Specific proton-beam configurations are needed to spare organs at risk (OARs), including lungs, heart, and spinal cord, when treating esophageal squamous cell carcinoma (ESCC) in the thoracic region. This study aimed to propose new intensity-modulated proton therapy (IMPT) beam configurations and to demonstrate the benefit of IMPT compared with intensity-modulated x-ray therapy (IMXT) for treating ESCC. IMPT plans with three different beam angle configurations were generated on CT datasets of 25 ESCC patients that were treated with IMXT. The IMPT beam designs were two commonly-used beam configurations (anteroposterior and posterior oblique) and a recently proposed beam configuration (anterosuperior with posteroinferior). The target doses were 50-54Gy(RBE) and 60-64Gy(RBE) to the low-risk and high-risk target volumes, respectively. Robust optimization was applied for the IMPT plans. The differences in the dose-volume parameters between the IMXT and IMPT plans were compared. With target coverage comparable to standard IMXT, IMPT had significantly lower mean doses to the OARs. IMPT with an anteroposterior opposing beam generated the lowest lung dose (mean=7.1Gy(RBE), V20=14.1%) and the anterosuperior with posteroinferior beam resulted in the lowest heart dose (mean=12.8Gy(RBE), V30=15.7%) and liver dose (mean=3.9Gy(RBE), V30=5.9%). For the subgroup of patients with an inferior tumor location (PTVs overlapping a part of the contoured heart), the novel beam demonstrated the optimal OARs sparing. Compared with IMXT, the IMPT plans significantly reduced the radiation dose to the surrounding organs when treating ESCC. IMPT beam configuration selection depends on the tumor location relative to the heart.

Intraperitoneal perforation through lymph node metastases in a patient with esophageal squamous cell carcinoma during intensive chemotherapy: A case report with literature review.

IntroductionEsophageal fistula after treatment is a critical and fatal complication of esophageal cancer. A fistula forming from lower thoracic esophageal cancer to the peritoneum through lymph node metastases following chemotherapy has not been reported. We report a case of peritonitis due to lymph node perforation through the tumor ulcer after induction of biweekly docetaxel, cisplatin, and 5FU combined chemotherapy (Bi-DCF) for advanced esophageal squamous cell carcinoma (ESCC).Presentation of caseA 48-year-old woman was referred to us with a diagnosis of lower thoracic ESCC and thoracoabdominal aortic aneurysm. Esophagogastroduodenoscopy showed a circumferential type 3 tumor with stenosis in the lower thoracic esophagus. Contrast-enhanced computed tomography (CT) showed a thoracoabdominal aortic aneurysm and wall thickening of the lower thoracic esophagus that was suspicious of esophageal cancer. Lymph node metastases dumpling from around the tumor to abdominal cavity were also observed. The initial diagnosis was ESCC T3 N3 M1 (para-aortic lymph nodes and liver) Stage IVB. She was started on Bi-DCF (docetaxel 35 mg/m2 days 1/15, cisplatin 40 mg/m2 days 1/15, 5FU 400 mg/m2 days 1–5, 15–19) as the first-line regimen. The third day after starting chemotherapy, she felt strong abdominal pain, and internal necrosis of lymph nodes around the primary lesion and free air in the abdominal cavity were found. Peritonitis was diagnosed due to a fistula formed from the lower thoracic ESCC to the peritoneum through lymph node metastases. She underwent emergency laparoscopic drainage, omental filling, and jejunostomy. Postoperatively, her general condition and inflammatory findings improved within 10 days, and she could continue intensive chemotherapy as scheduled.DiscussionBecause of the risk of perforation and fistula in regimens that are expected to cause tumor shrinkage, careful observation may be required after starting chemotherapy.ConclusionWe report the first case of peritonitis caused by perforation through lymph node metastasis of thoracic esophageal cancer.