Thoracic Esophageal Carcinoma Research Articles

A case of metachronous triple primary carcinoma complicated with pulmonary tuberculosis: Case report and review.

Multiple primary malignant neoplasms with tuberculosis are rare. The interaction between tuberculosis and tumor remains unclear. Moreover, the treatment of multiple primary tumors combined with tuberculosis is relatively complicated. Herein, we report a case of metachronous triple primary carcinoma complicated with pulmonary tuberculosis. This report aims to analyze the clinical characteristics of 3 primary tumors combined with tuberculosis. We report the long-term survival of this patient after personalized treatment and this patient have a good quality of life. A 55-year-old male patient was diagnosed with squamous cell carcinoma of the lower thoracic esophagus (cT4bN1M0 IVA) and received concurrent chemoradiotherapy, followed by 2 cycles consolidate chemotherapy. During the follow-up, he was diagnosed with secondary tuberculosis (TB) and accepted anti-TB treatment. During anti-TB treatment, he was diagnosed with squamous cell carcinoma of the oropharynx (cT1N0M0 I P16(-)), then he received radical radiation therapy. However, within a year, the patient was diagnosed with oral squamous cell carcinoma (cT3N0M0 IIIA). He accepted an individualized chemotherapy with paclitaxel combined with capecitabine. Moreover, immunohistochemistry of the patient's 3 biopsies indicated positive P53 expression. Since the patient suffered from esophageal cancer, oropharyngeal cancer, and oral floor cancer, no tumor recurrence or metastasis was observed. And he has a good quality of life. Tuberculosis, TP53 mutation, radiotherapy, smoking, and drinking history may be risk factors for multiple primary tumors. The treatment of multiple primary tumors combined with pulmonary tuberculosis is complicated. Individualized treatment allows patients to achieve long-term survival while also having a good quality of life. Limitations in this case: surgery may be an alternative strategy for the patient, but the patient refused surgery.

Robot-assisted cervical esophagectomy with simultaneous transhiatal abdominal procedure for thoracic esophageal carcinoma

BackgroundMinimally invasive robot-assisted cervical esophagectomy has been sporadically reported as a novel thoracic esophagectomy technique for patients with thoracic esophageal carcinoma. Most reports indicate that the abdominal component of robot-assisted cervical esophagectomy is performed sequentially after the cervical phase. However, if the cervical and abdominal phases are performed simultaneously using a nerve integrity monitoring system with no administration of muscle relaxants, there are two major advantages: a reduced risk of recurrent nerve palsy and a shorter operative time. We herein report our experience performing novel robot-assisted transcervical esophagectomy with a simultaneous transhiatal abdominal approach using a nerve integrity monitoring system.MethodsThirty cases of robot-assisted cervical esophagectomy performed from 2023 to April 2024 were reviewed. The operative and short-term surgical outcomes of this procedure were compared with those of robot-assisted cervical esophagectomy using a sequential abdominal approach, and the feasibility and efficacy of the simultaneous procedure were analyzed.ResultsAll patients successfully underwent robot-assisted cervical esophagectomy with no intraoperative adverse events. There were no differences in the patients’ demographic or operative data between the two groups. There was no difference in the mean operation time for the cervical procedure (p = 0.23). However, there was a significant difference in the total time for the whole procedure (sequential group: 453.8 ± 26.8 min, simultaneous group: 291.2 ± 36.1 min; p < 0.01). There were no differences in postoperative surgical complications between the groups. There was also no difference in the total number of surgically harvested mediastinal lymph nodes (p = 0.33).ConclusionsRobot-assisted transcervical esophagectomy, a new technique for thoracic esophageal cancer, was safe and feasible under intraoperative management using nerve integrity monitoring without muscle relaxants. This procedure facilitates intraoperative monitoring of recurrent laryngeal nerve activity, significantly shortening the total operative time.

321. ANASTOMOTIC LEAK WITH ENHANCED RECOVERY PROTOCOL VERSUS CONVENTIONAL CARE AFTER ESOPHAGECTOMY FOR CANCER: CLINICAL CHARACTERISTICS AND OUTCOMES

Abstract Objective The anastomotic leak (AL) is greatly concerned in the clinical pathway of enhanced recovery after surgery (ERAS) with esophagectomy. This retrospective study was to compare the clinical characteristics and outcomes of AL between the ERAS protocol and conventional care in patients undergoing esophagectomy for cancer. The strategy for improving the safety of ERAS was explored. Methods The clinical data and outcomes were retrospectively analyzed in patients with thoracic esophageal carcinoma who received esophagectomy with esophagogastric anastomosis and experienced a postoperative AL from January 2018 to August 2023. The “Non Tube Non Fasting” edition was implemented in the ERAS group. Results 33 ERAS and 141 conventional patients experienced an AL in 489 ERAS and 1424 conventional patients with esophagectomy. The incidence of AL was significantly lower in the ERAS group (6.7%, 33/489) than in the conventional group (9.9%, 141/1424) (P&amp;lt;0.05). AL rate had no significant differences in the anastomotic sites between the two groups: cervical region (7.0%, 31/443 vs. 10.1%, 126/1250) and intrathoracic region (4.3%, 2/46 vs. 8.6%, 15/174) (P&amp;gt;0.05). There were no significant differences in the time-related AL between the two groups: delayed AL (39.4%, 13/33 vs. 54.6%, 77/141) and AL after planned discharge (24.2%, 8/33 vs. 23.4%, 33/141) (P&amp;gt;0.05). 164 patients received endoscopy and presented no significant differences in the average length of leakage between the two groups (5.7±3.8mm vs. 6.1±4.6mm, P&amp;gt;0.05). The comparison of the incidence of the most common early clinical manifestations showed no significant differences between the two groups: cervical wound infection (24.2%, 8/33 vs. 23.4%, 33/141), tachyarrhythmia (93.9%, 31/33 vs. 87.2%, 123/141), fever beyond 38°C (87.9%, 29/33 vs. 91.7%, 135/141), leukocytosis (81.8%, 27/33 vs. 89.4%, 126/141), cervical subcutaneous emphysema (42.4%, 14/33 vs. 41.1%, 58/141), purulent drainage (6.1%, 2/33 vs. 19.1%, 27/141), dyspnea (21.2%, 7/33 vs. 31.9%, 45/141), and right pneumothorax (54.5%, 18/33 vs. 50.4%, 71/141) (P&amp;gt;0.05). The incidences of the time-related early alarm signals were not significantly different between the two groups: within 3 days after surgery (100%, 33/33 vs. 95.7%, 135/141), during postoperative 4 days to 7 days (0%, 0/33 vs. 3.5%, 5/141), and after postoperative 7 days (0%, 0/33 vs. 0.7%, 1/141) (P&amp;gt;0.05). The 30-day mortality was significantly higher in the ERAS group than in the conventional group, and there were no differences in the other outcomes between the two groups (Table). Conclusion The ERAS protocol does not deteriorate the clinical characteristics and outcomes of AL compared with conventional care in patients undergoing esophagectomy for cancer. Improving the identification of delayed AL and the AL-associated mortality can enhance the safety of ERAS.

817. ARTERIA LUSORIA: IMPLICATIONS FOR ESOPHAGEAL SURGERY

Abstract Background The aberrant right subclavian artery, also known as arteria lusoria, is an embryologic abnormality affecting 0.5-1.8% of individuals. Instead of arising from the brachiocephalic artery, the right subclavian artery emerges as the fourth branch of the aortic arch. In most cases (80%), the artery has a retro-esophageal trajectory, while in 20% it runs anteriorly, which may pose difficulties in performing a safe intra-thoracic or cervical anastomosis. This condition is associated with a non-recurrent right inferior laryngeal nerve. Methods Following Kurokawa’s publication in 2019, our unit has adopted routine recurrent bilateral laryngeal nerve lymphadenectomy in esophageal and cardia carcinomas with over than 4 cm of esophageal involvement. We present a video that features a 68-year-old male diagnosed with a squamous cell carcinoma of lower thoracic esophagus, staged as cT3N+M0. He presents with a retro-esophageal arteria lusoria and non-recurrent right inferior laryngeal nerve. Following the CROSS protocol with neoadjuvant chemoradiotherapy, the patient underwent a Mckeown esophagectomy with total thoracic lymphadenectomy. Results In this presentation, we explore the anatomical details and surgical considerations associated with the arteria lusoria in esophageal surgery. This video details the essential procedural steps for the identification of the vagus nerve and the identification of the arteria lusoria during upper mediastinal dissection. This case emphases the need for customized surgical strategies and the role of interdisciplinary collaboration, particularly integration of radiological insights. Such cooperation ensures that the surgical team is ready to address the unique challenges presented by these anatomical deviations and minimize the risks. Conclusion In conclusion, this presentation aims to highlight the procedural intricacies and the collaborative effort required to manage effectively the arteria lusoria in esophageal surgery. https://drive.google.com/file/d/1agjPmA6lxPoVVPxvgJCHaDCqs1dJP-xk/view

398. DYSPHAGIA OR REGURGITATION AND ITS CORRELATES AMONG UP TO 10-YEAR ESOPHAGEAL SQUAMOUS CELL CARCINOMA SURVIVORS

Abstract Background Dysphagia and regurgitation significantly impair the quality of life among survivors of esophageal squamous cell carcinoma (ESCC). Notably, the prevalence and associated factors of these symptoms in long-term survivors, particularly within Asian populations, remain underexplored. This study endeavors to bridge these critical knowledge gaps. Methods We evaluated the severity of dysphagia and regurgitation (mild, moderate, and severe), and their associations with clinical features and lifestyle factors among 512 10-year ESCC survivors who underwent ESCC radical surgery. Demographic, clinical, and lifestyle information was collected at study enrollment, which occurred 6 months post-surgery, and dysphagia and regurgitation was assessed at the 10-year post-surgery follow-up survey. Results In this study, 13.3% and 27.0% of participants reported dysphagia and regurgitation, respectively. Multivariable polytomous regression analysis revealed a significant association of dysphagia with upper thoracic esophageal carcinoma (mild dysphagia OR: 2.371, 95% CI: 1.051, 5.347) and postoperative radiotherapy and chemotherapy (mild dysphagia OR: 4.352, 95% CI: 2.168, 8.732; moderate/severe dysphagia OR: 3.651, 95% CI: 1.046, 12.745). An inverse relationship was observed between dysphagia and dietary quality as measured by the CHFP-2007 score (mild dysphagia OR: 0.458, 95% CI: 0.341, 0.615; moderate/severe dysphagia OR: 0.168, 95% CI: 0.089, 0.316). For regurgitation, positive associations were found with higher income level (mild regurgitation OR: 2.074, 95% CI: 1.020, 4.216), insomnia (moderate/severe regurgitation OR: 3.523, 95% CI: 1.127, 11.010), and use of Chinese patent medicine (mild regurgitation OR: 2.264, 95% CI: 1.279, 4.007). Conversely, age at surgery (moderate/severe dysphagia OR: 0.907, 95% CI: 0.848, 0.970) and higher dietary quality (mild dysphagia OR: 0.744, 95% CI: 0.606, 0.914; moderate/severe dysphagia OR: 0.406, 95% CI: 0.259, 0.634) showed protective effects against regurgitation. Conclusions The prevalence of dysphagia and regurgitation among long-term survivors of ESCC in China is high, underscoring a significant health concern. This study identifies critical correlates such as the tumor's anatomical site, the nature of postoperative interventions, dietary quality, socioeconomic standing, and concurrent health issues. These findings advocate for the integration of postoperative management approaches, including tailored dietary and lifestyle adjustments, aimed at mitigating these symptoms in long-term ESCC survivors.

Metastatic patterns of subcarinal, right and left recurrent laryngeal nerve lymph nodes in thoracic esophageal squamous cell carcinoma without neoadjuvant therapy

PurposeThis research aimed to clarify the metastatic patterns of subcarinal, right and left recurrent laryngeal nerve lymph nodes in thoracic esophageal squamous cell carcinoma and to investigate appropriate strategies for lymph node dissection.MethodsPatients with thoracic esophageal squamous cell carcinoma receiving esophagectomy from December 2020 to April 2024 were retrospectively analyzed. Risk factors for subcarinal, right and left recurrent laryngeal nerve lymph nodes metastasis were determined by chi-square test and multivariate logistic regression analysis. We visualized the metastasis rates of these specific lymph nodes based on the different clinicopathological characteristics. Correlation between subcarinal, right and left recurrent laryngeal lymph nodes metastasis and postoperative complications were also analyzed.ResultsA total of 503 thoracic esophageal squamous carcinoma patients who underwent esophagectomy were enrolled. The metastasis rates of subcarinal, right and left recurrent laryngeal nerve lymph nodes were 10.3%, 10.3%, and 10.9%, respectively. The lymphovascular invasion status and tumor location were the significant predictors for subcarinal and right recurrent laryngeal nerve lymph nodes metastasis, respectively (P < 0.001 and P = 0.013). For left recurrent laryngeal nerve lymph node metastasis, younger age (P = 0.020) and presence of lymphovascular invasion (P = 0.009) were significant risk factors. Additionally, pulmonary infection is the most frequent postoperative complication in patients with dissection of subcarinal, right and left recurrent laryngeal lymph nodes. There was no significant difference in the incidence of anastomotic leakage (P = 0.872), pulmonary infection (P = 0.139), chylothorax (P = 0.702), and hoarseness (P = 0.179) between the subcarinal lymph node dissection cohort and the reservation cohort. The incidence of hoarseness significantly increased in both right (P = 0.042) and left (P = 0.010) recurrent laryngeal nerve lymph nodes dissection cohorts compared by the reservation cohorts, with incidence rates of 5.9% and 6.7%, respectively.ConclusionsThe metastasis rates of subcarinal, right and left recurrent laryngeal nerve lymph nodes in thoracic esophageal squamous cell carcinoma were all over 10%. The dissection of subcarinal lymph nodes does not increase postoperative complications risk, while recurrent laryngeal nerve lymph nodes dissection significantly increases the incidence of hoarseness. Thus, lymph node dissection of subcarinal lymph nodes should be conducted routinely, while recurrent laryngeal nerve lymph nodes dissection may be selectively performed in specific patients.

Neoadjuvant immunotherapy (PD-1) combined with chemotherapy for locally advanced thoracic esophageal carcinoma (EC): A single-arm, open-label, phase II study.

4075 Background: This study aimed to evaluate the efficacy and safety of PD-1 combined with chemotherapy as neoadjuvant therapy in patients with locally advanced EC and sought to explore biomarkers related to treatment prognosis and efficacy prediction for screening patients who would benefit most from this therapy. Methods: In this phase 2 study, patients (pts) with histopathologically confirmed ESCC, diagnosed as clinical stage cT1-3N1-3M0 and ECOG PS 0-1 were enrolled to receive two cycles of neoadjuvant chemoimmunotherapy with PD-1 blockade (Pembrolizumab/Tislelizumab on d1) plus nab-paclitaxel (260mg/m2 in total on d1 and d8) and cisplatin (60mg/m2 in total on d1-3) of each 21-day cycle, followed by esophagectomy. Biopsied pretreatment tumor tissues along with surgical tumor specimens were collected for RNA sequencing. The primary endpoint was complete pathologic response (pCR) rate. The secondary endpoints were overall response rate (ORR), event-free survival (EFS), overall survival (OS) and safety. Biomarkers associated with clinical prognosis were assessed as exploratory objectives. Results: From Jan 11, 2021 to, Apr 25 2022, 56 pts were enrolled and 42 pts received neoadjuvant therapy and operation. Among them, 66.7% (28/42) had clinical complete response, 50% (21/42) had partial response, and ORR was 78.6% (33/42). 42 pts underwent surgical resection, achieving a 100% (42/42) R0 resection rate and a pCR rate of 33.3% (14/42), tumor regression grade (TRG, Mandard system) 1, 2 and 3 were 14.3% (6/42), 14.3% (6/42) and 71.4% (30/42) respectively. With a median follow-up of 24.4 months (range 14.3-33.4), 12(28.6%) patients had disease recurrence. Within 24 months, 14.3% (2/14) pts who achieved pCR experienced recurrence. 2-year EFS rate was 54.8% (95%CI,43.4, 66.3% ), 2-year OS rate was 81.5% (95%CI,69.4, 90.2% ). Overall, grade ≥3 AEs included leukopenia (11.9% [5/42]), thrombocytopenia (4.8% [2/42]), and no deaths were due to TRAEs. With 34 patients of RNA sequenced, we divided the patients into two groups based on whether they had recurred within 24 months as favorable prognosis and poor prognosis respectively, to analyze gene expression in different treatment effect. The poor outcome patients had significant molecular differences were seen in PI3K−Akt pathway gene expression, markers of immune activation, and genes involved in ECM−receptor interaction and focal adhesion in baseline samples, and the pathway enriched by differential genes expression in samples after treatment validated this result. Conclusions: Combining PD-1 blockade with nab-paclitaxel and cisplatin is feasible and effective in patients with locally advanced resectable ESCC, and might be a promising approach for neoadjuvant treatment. Clinical trial information: NCT05028231 .

Value of Serum C-Reactive Protein (CRP) Level in Early Detection of Anastomotic Leakage following Salvage Esophagectomy after Definitive Chemoradiation for Esophageal Squamous Cell Carcinoma

Background Definitive chemoradiation therapy is an alternative curative treatment for esophageal squamous cell carcinoma (ESCC). The prevalence of anastomotic leakage (AL) after salvage esophagectomy is significantly higher than planned esophagectomy after chemoradiation, which increases operative mortality. Minimizing AL-related mortality requires early detection. Several investigators have demonstrated the role of serum C-reactive protein (CRP) in early AL detection after esophagectomy for decades. However, its value in early AL detection after salvage esophagectomy is unknown. This study aims to evaluate the value of serial serum CRP levels for early AL detection in ESCC patients after salvage esophagectomy. Methods We retrospectively reviewed the medical record of 36 patients diagnosed with thoracic squamous cell esophageal carcinoma who underwent salvage esophagectomy at our hospital between December 2016 and May 2022. The CRP level was measured daily from postoperative day (POD) 1 to 5. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were calculated to determine the optimal cutoff value. Results A total of 36 patients underwent salvage esophagectomy. Of these 36 patients, 3 patients (8.3%) were diagnosed with AL. The CRP level on POD 2 to 5 had been significantly associated with the presence of AL. The ROC curve showed the excellent diagnostic accuracy of CRP level on POD 2 to 5, with an area under the curve of 0.98, 0.98, 0.93, and 0.87, respectively. The optimal cutoff value of CRP on POD2 to 5 was 270, 250, 200, and 150 mg/L, respectively, with high sensitivity, specificity, and negative predictive value. Conclusion Postoperative serial CRP level after salvage esophagectomy is a reliable useful tool for early AL detection, similar to other settings of esophagectomy.

259. ROBOTIC ESOPHAGECTOMY AND THREE FIELD LYMPHADENECTOMY WITH INTRA-OPERATIVE RECURRENT LARYNGEAL NERVE MONITORING

Abstract https://www.dropbox.com/s/uu8gju382tkch29/3FTTE_ISDE_SJ_0423.mp4?dl&amp;#x003D;0. Background Surgery for esophageal malignancy is associated with significant morbidity and mortality, especially in cases requiring extensive lymphadenectomy. Recurrent laryngeal nerve (RLN) injury can result in hoarseness, aspiration, pneumonia, tracheostomy, and could even be life-threatening. A 33 year old lady with a lower thoracic esophageal squamous carcinoma with left trachea-esophageal groove nodes in the superior mediastinum underwent a Xi robotic esophagectomy and three field lymphadenectomy with intra-operative recurrent laryngeal nerve monitoring after neoadjuvant chemotherapy. Methods We used a bronchial blocker (COOPDECH bronchial blocker, Daiken-Iki Corporation, Japan) with a single-lumen electromyographic (EMG) endotracheal tube) (NIM EMG endotracheal tube, Medtronic Xomed, Jacksonville, FL, USA) for lung isolation along with capnothorax. Semiprone position with 3 robotic ports and an assistant port was utilised. Nerve monitoring provided an audiovisual waveform when either the vagus or the RLN was stimulated and transformed the laryngeal muscle activity into EMG signals. Grounding electrodes were placed on the patient’s shoulder or near the sternum. A prerequisite for adequate and effective nerve monitoring is the avoidance of neuromuscular blockers during anesthesia. Results Esophageal mobilisation was done in the standard fashion. The lymphadenectomy along the recurrent laryngeal nerves in the mediastinum and neck was guided by the nerve identification and stimulation utilising the long intra-thoracic nerve monitoring probes. In the mediastinum, the right recurrent laryngeal nerve was identified taking off from the right vagus along the lateral border of the trachea and looping around the right subclavian artery. The thoracic left recurrent nerve was identified in the aorto-pulmonary window as well along the left lateral border of the trachea in the trachea-esophageal groove where the metastatic lymph nodes were identified on radiology. Conclusion Minimally invasive esophagectomy is now the preferred modality for surgical extirpation of esophageal malignancies, with extensive lymphadenectomy used in appropriate cases. Interventions to reduce postoperative morbidity resulting from the dissection of nodes around the RLN need to be used. The use of IONM is associated with lower RLN palsy rates and superior lymph nodal yield and needs to be investigated with large-scale randomized studies for beneficial clinical outcomes.

Long-term survival of esophageal squamous cell carcinoma after surgical treatment in a large-scale retrospective study from a single cancer center

PurposeTo analyze the long-term overall survival (OS) and influencing factors of patients with esophageal squamous cell cancer (ESCC) under surgical treatment.MethodWe collected patients with ESCC who received surgical treatment in Sichuan Cancer Hospital & institute from January 2010 to December 2017, and selected 2,766 patients with thoracic esophageal carcinoma with relatively complete follow-up results as the objects of this study. We analyzed the characteristics, postoperative complications and long-term OS results of those patients.ResultsOf the 2766 patients, 81.6% were male, midthoracic esophageal cancer accounted for 53.5%. McKeown was used in 72.0% of patients and Ivor-Lewis was used in 26.4% of patients. About 47.8% of patients received minimally invasive esophagectomy (MIE). The overall complication rate was 25.8%. The 1-year, 3-year and 5-year OS rates were 86.2%, 57.5% and 46.8%, respectively. McKeown had a better long-term OS rate than Ivor-Lewis (49.5% vs 41.2%, P < 0.001), and MIE is superior to open surgery (51.8% vs 42.5%, P < 0.001).ConclusionMcKeown has advantages over Ivor-Lewis. MIE results in better long-term survival outcomes for patients. But more prospective randomized controlled trials with large samples are needed.

Intrathoracic anastomosis using handsewn purse-string suturing by the double-ligation method in laparo-thoracoscopic esophagectomy

In minimally invasive esophagectomy (MIE), it is important to reduce the rate of anastomotic leakage to ensure its safety. At our institute, the double-ligation method (DLM) has been introduced to insert and fix the anvil of the circular stapler for intracorporeal circular esophagojejunostomy in gastric surgery. We adopted this method for intrathoracic anastomosis (IA) in MIE. The aim of this study was to investigate the safety of IA with DLM in MIE.In this study, 48 patients diagnosed with primary middle or lower third segment thoracic esophageal carcinoma with clinical stage I, II, III or IV disease were retrospectively evaluated. Postoperative outcomes were assessed.Among the 48 patients, 42 patients underwent laparo-thoracoscopic esophagectomy and IA using a circular stapler with the DLM. The average total operation time and thoracoscopic operation time were 433 and 229 minutes, respectively. The average purse-string suturing time was 4.7 minutes. The rates of anastomotic leakage and stenosis were 2.4% and 14.3%, respectively. The overall incidence of postoperative complications (Clavien-Dindo grade of ≥III) was 16.7%. The average postoperative stay was 16 days.The procedure of IA using a circular stapler with the DLM in MIE was safe and provided a low rate of anastomotic leakage.

McKeown esophagectomy for a thoracic esophageal carcinoma patient who has a history of definitive chemoradiotherapy for esophageal carcinoma and total pharyngolaryngectomy for hypopharyngeal cancer

A 64-year-old man, who had previously undergone definitive chemoradiotherapy (dCRT) and endoscopic resections for metachronous multiple esophageal squamous cell carcinoma (ESCC) and had also received total pharyngolaryngectomy (TPL) for hypopharyngeal cancer, was diagnosed with ESCC in the middle thoracic esophagus (cT3N0M0). Thoracoscopic McKeown esophagectomy was performed for the patient. Although the tumor was tightly adherent to the thoracic duct and both main bronchi, they were successfully mobilized. In order to maintain the blood supply to the trachea, we preserved the bilateral bronchial arteries and avoided prophylactic upper mediastinal lymph node dissection. Cervical end-to-side anastomosis between the jejunum and a gastric conduit was performed. Minor pneumothorax was managed conservatively, and the patient was discharged 44 days after the surgery. Overall, thoracoscopic McKeown esophagectomy was safely performed in a patient with a history of TPL and dCRT. Surgeons should be very careful to prevent tracheobronchial ischemia by optimizing the extent of lymph node dissection.

Clinical advantage of transmediastinal esophagectomy in terms of postoperative respiratory complications.

Although the transmediastinal approach as a radical esophagectomy for esophageal carcinoma patients has attracted attention, its advantages over the transthoracic approach remain unclear. This study aimed to evaluate the efficacy of transmediastinal esophagectomy (TME) in terms of postoperative respiratory complications compared to that of open transthoracic esophagectomy (TTE). We reviewed patients with thoracic and abdominal esophageal carcinoma who underwent TME or TTE between February 2014 and November 2021. We compared postoperative respiratory complications as the primary outcome. The secondary outcomes included perioperative operation time, blood loss, postoperative complications, and the number of harvested mediastinal lymph nodes. Overall, 60 and 54 patients underwent TME and TTE, respectively. The baseline characteristics were similar between the two groups, except for age and histological type. There were no intraoperative lethal complications in either group. The incidence of respiratory complications was significantly lower in the TME group than in the TTE group (6.7 vs. 22.2%, p = 0.03). The TME group had a shorter operation time (403 vs. 451min, p < 0.01), less blood loss (107 vs. 253mL, p < 0.01), and slightly higher anastomotic leakage (11.7 vs. 5.6%, p = 0.33). The number of harvested lymph nodes was similar in both groups (24 vs. 26, p = 0.10). Multivariate analysis revealed that TME is an independent factor in reducing respiratory complications (odds ratio = 0.27, p = 0.04). TME for esophageal carcinoma was performed safely. TME was superior to TTE in terms of postoperative respiratory complications; however, the relatively higher frequency of anastomotic leakage should be considered and requires further evaluation.

Pattern of relapse following three-field lymphadenectomy of esophageal carcinoma and related factors predictive of recurrence

PurposeFor treatment of esophageal carcinoma, the optimal postoperative radiotherapy target volume after three-field lymph node dissection (3-FLD) had not been determined. We analyzed local recurrence pattern of thoracic esophageal carcinoma and risk factors of lymph node recurrence after 3-FLD without prophylactic radiotherapy. Material and methodsWe reviewed 1282 patients with thoracic esophageal squamous cell carcinoma (ESCC) who were treated with 3-FLD without radiotherapy from 2010 to 2018 and analysed local recurrence patterns and risk factors of lymph node recurrence, in order to provide a reference for determination of the radiotherapy target volume for thoracic ESCC. ResultsThe lymph node recurrence accounted for 91.0% of treatment failures. The mediastinal, cervical and abdominal lymph node recurrence accounted for 84.92%, 36.07% and 22.30%, respectively (χ2=264.776, P=0.000). The superior, middle and inferior mediastinal lymph node recurrence rates were 67.54%, 27.87% and 0.98%, respectively (χ2=313.600, P=0.000). Cervical metastases were significantly associated with N stage and Preoperative cervical lymph node status. Abdominal metastases were significantly associated with the number of preoperative abdominal lymph node metastases (LNM), tumor location and N stage. ConclusionsThe main pattern of local-regional recurrence might be lymph node metastasis after radical 3-FLD without radiotherapy in esophageal carcinoma. The dangerous lymph node recurrence regions included neck, superior and middle mediastinum. The abdominal areas might be irradiated for lower TEC patients with preoperative abdominal LNM.

Dosimetric comparison of target volume coverage and sparing of organs at risk (OARs) between helical intensity modulated radiotherapy (H-IMRT) versus volumetric arc therapy (VMAT) for mid and lower thoracic oesophageal carcinoma.

469 Background: To evaluate the effectiveness of H-IMRT and VMAT in covering target volume while adequately sparing the OARs for patients with mid and distal oesophageal carcinoma, on the basis of dosimetric analysis. Methods: The target areas and organs at risk in 30 patients with locally advanced carcinoma oesophagus undergoing neo-adjuvant chemo-radiotherapy were specified and transmitted to Eclipse, Version 13.6, Varian Medical Systems) &amp; Accuray Treatment Planning System (Accuray Precision, Version 2.1.4, Accuray Medical System). Two plans (H-IMRT and VMAT) were generated for each patient for a total dose of 41.4 Gy delivered to the PTV in 23 fractions, and the Homogeneity Index (HI), Conformity Index (CI) and the dose distribution to the OARs (spinal cord, heart, lungs, kidneys and liver) were compared using dose volume histograms. Results: H-IMRT resulted in a more homogeneous dose distribution to the target (HI- 0.059) as compared to VMAT (HI- 0.07) [p-0.004]. The Conformity Indices showed no significant difference between the two techniques (H-IMRT – 0.989, VMAT – 0.987) [p-0.66]. VMAT resulted in a significantly less dose to the spinal cord (23.598 Gy vs .25.657 Gy) [p-0.021]. With VMAT plans, the heart mean dose (18.101 Gy vs. 20.031) [p- 0.00007], heart V40 (4.902% vs. 6.143) [p-0.002,] the averaged lung V20 [p-0.00005] and the mean dose to the left kidney (3.84 Gy vs. 4.721 Gy) [p- 0.010] were significantly less as compared to H-IMRT No statistically significant difference in both techniques with respect to heart V30, Mean Lung Dose (MLD), and mean dose to the righ and left kidney was observed Conclusions: VMAT proved to be better at sparing of OARs whilst providing almost the same Conformity as compared to a H-IMRT. H-IMRT has statistically better dose homogeneity but, it tends to deposit a slightly higher dose to the OARs. Whether the aforementioned differences in the dosimetric parameters translate into clinical benefits has to be evaluated by clinical outcome studies.

Optimal discharge planning for esophagectomy patients with enhanced recovery after surgery: Recommendations.

Studies have suggested that the postoperative length of stay (PLOS) of esophagectomy patients under the enhanced recovery after surgery (ERAS) pathway should be >10 days as against the previously recommended 7 days. We investigated the distribution and influencing factors of PLOS in the ERAS pathway in order to recommend an optimal planned discharge time. This was a single-center retrospective study of 449 patients with thoracic esophageal carcinoma who underwent esophagectomy and perioperative ERAS between January 2013 and April 2021. We established a database to prospectively document the causes of delayed discharge. The mean and median PLOS were 10.2 days and 8.0 days (range: 5-97), respectively. Patients were divided into four groups: group A (PLOS ≤ 7 days), 179 patients (39.9%); group B (8 ≤ PLOS ≤ 10 days), 152 (33.9%); group C (11 ≤ PLOS ≤ 14 days), 68 (15.1%); group D (PLOS > 14 days), 50 patients (11.1%). The main cause of prolonged PLOS in group B was minor complications (prolonged chest drainage, pulmonary infection, recurrent laryngeal nerve injury). Severely prolonged PLOS in groups C and D were due to major complications and comorbidities. On multivariable logistic regression analysis, open surgery, surgical duration >240 min, age >64 years, surgical complication grade >2, and critical comorbidities were identified as risk factors for delayed discharge. The optimal planned discharge time for patients undergoing esophagectomy with ERAS should be 7-10 days with a 4-day discharge observation window. Patients at risk of delayed discharge should be managed adopting PLOS prediction.

Hybrid Minimally Invasive Esophagectomy for Carcinoma Oesophagus: Experience at Tertiary Care Centre in North Karnataka.

Surgery remains the mainstay for curative treatment of carcinoma of midthoracic and lower thoracic oesophagus. In the twentieth century, open esophagectomy was the standard of care. In the twenty-first century, treatment for carcinoma oesophagus has revolutionized with incorporation of neoadjuvant treatment and application of various minimally invasive techniques for esophagectomy. At present, there is no consensus about the optimum position to perform minimally invasive esophagectomy (MIE). We share our experience of MIE with modification in the port position in this article.

Influence of age as a continuous variable on survival outcomes and treatment options in patients with upper thoracic esophageal carcinoma.

Background: This retrospective review of patients with upper thoracic esophageal squamous cell carcinoma (ESCC) analyzed the prognostic value of age, as a continuous variable, and offered insight into treatment options. Methods: 568 upper ESCC patients underwent radical therapy between 2004 and 2016. Age as a continuous variable was entered into the Cox regression model with penalized spline (P-spline) analysis to investigate a correlation between age and survival outcomes. Results: Before adjustment, P-spline regression revealed U-shaped survival curves. Sixty years was the optimal cut-off age for differences in overall and progression-free survival (OS, PFS). The cohort was divided into age groups ≤ 50, 51-69, and ≥ 70 years. Multivariate analyses showed no significant differences in either PFS or OS for patients aged ≤ 50 and 51-69 years. After adjusting for covariates, P-spline regression showed that the risk of mortality and disease progression increased with age, and ≥ 70 years was an unfavorable independent prognostic factor. For age ≥ 70 years, the OS and PFS associated with non-surgery was comparable to that of surgery. For patients younger, the OS and PFS of patients given surgery was significantly better than that of patients given non-surgery. Conclusion: Age was an independent prognostic factor for upper ESCC. Patients ≥ 70 years achieved no significant survival benefit from surgery, but for those younger than 70 years surgery was the preferred treatment option.

Proton Therapy With Concurrent Chemotherapy for Thoracic Esophageal Cancer: Toxicity, Disease Control, and Survival Outcomes.

When treating esophageal cancer with radiation therapy, it is critical to limit the dose to surrounding structures, such as the lung and/or heart, as much as possible. Proton radiation therapy allows a reduced radiation dose to both the heart and lungs, potentially reducing the risk of cardiopulmonary toxicity. Here, we report disease control, survival, and toxicity outcomes among patients with esophageal cancer treated with proton radiation therapy and concurrent chemotherapy (chemoradiation therapy; CRT) with or without surgery. We enrolled 17 patients with thoracic esophageal carcinoma on a prospective registry between 2010 and 2021. Patients received proton therapy to a median dose of 50.4-GyRBE (range, 50.4-64.8) in 1.8-Gy fractions.Acute and late toxicities were graded per the Common Terminology Criteria for Adverse Events, version 4.0 (US National Cancer Institute, Bethesda, Maryland). In addition, disease control, patterns of failure, and survival outcomes were collected. Nine patients received preoperative CRT, and 8 received definitive CRT. Overall, 88% of patients had adenocarcinoma, and 12% had squamous cell carcinoma. With a median follow-up of 2.1 years (range, 0.5-9.4), the 3-year local progression-free, disease-free, and overall survival rates were 85%, 66%, and 55%, respectively. Two patients (1 with adenocarcinoma and 1 with squamous cell carcinoma) recurred at the primary site after refusing surgery after a complete clinical response to CRT. The most common acute nonhematologic and hematologic toxicities, respectively, were grades 1 to 3 esophagitis and grades 1 to 4 leukopenia, both affecting 82% of patients. No acute cardiopulmonary toxicities were observed in the absence of surgical resection. Reagarding surgical complications, 3 postoperative cardiopulmonary complications occurred as follows: 1 grade 1 pleural effusion, 1 grade 3 pleural effusion, and 1 grade 2 anastomotic leak. Two severe late CRT toxicities occurred: 1 grade 5 tracheoesophageal fistula and 1 grade 3 esophageal stenosis requiring a feeding tube. Proton radiation therapy is a safe, effective treatment for esophageal cancer with increasing evidence supporting its role in reducing cardiopulmonary toxicity.

246. MAPPING OF LYMPH NODE METASTASIS FROM THORACIC ESOPHAGEAL CANCER: A RETROSPECTIVE STUDY

Abstract Objectives: This retrospective study aimed to investigate the optimal extent of dissection for thoracic esophageal cancer(EC) based on the incidence of lymph node metastasis(LNM). Methods: We retrospectively identified 1,014 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. Results: A total of 1,014 consecutive patients were enrolled. Generally, the rates of LNM in thoracic EC may be arranged in order of station 7 &amp;gt; station 106recR &amp;gt; station 2 &amp;gt; station 106recL. EC in 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 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. Conclusions: This study accurately identified the distribution of LNM for thoracic EC patients. And 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.