Thoracic Esophageal Carcinoma Research Articles

Relationship between perioperative change of total psoas muscle area and cancer prognosis in esophageal carcinoma.

314 Background: As surgery for esophageal carcinoma in the elderly people has been increasing, sarcopenia is a severe problem not only in complications, but also in long-term prognosis. However, the relationship between perioperative skeletal muscle loss especially in the early postoperative period and long-term prognosis has not been clarified. Methods: This study retrospectively analyzed 152 patients with thoracic esophageal carcinoma who had underwent radical esophagectomy in our institution from April 2008 to March 2015 (Patients with postoperative hospital stay longer than 6 weeks were excluded). As an index of perioperative sarcopenia, total psoas muscle area (TPA) was measured before surgery (as baseline), at postoperative day (POD) 7 and postoperative month (POM) 6 from CT images. We investigated the correlation between the change of TPA and the postoperative survival. Results: Of 152 patients, 52 (34.2%) showed a TPA decrease from baseline to POD 7, and 98 (64.5%) showed a TPA decrease from baseline to POM 6. At the time of POD 7, overall survival (OS) decreased significantly in a TPA decrease group (P = 0.008, 5-year survival rate: non-decrease group 82.3% / decrease group 56.8%). Recurrence free survival (RFS) was also significantly decreased in a TPA decrease group (P < 0.001, 5-year recurrence free survival rate: non-decrease group 73.7% / decrease group 44.9%). On the other hand, at the time of POM 6, OS and also RFS had no significant difference between decrease and non-decrease groups. In univariate analysis for OS, pStage ≥3 and TPA decrease at POD 7 had poor prognosis. In multivariate analysis for OS, pStage ≥3 (HR:5.516, P < 0.001, 95%CI:2.634-11.551) and TPA decrease at POD 7 (HR:2.036, P = 0.047, 95%CI:1.010-4.103) were also independent poor prognostic factors. In the univariate analysis for RFS, pStage ≥3, TPA decrease at POD 7 and age ≥60 years had poor prognosis. In multivariate analysis, pStaeg ≥3 (HR:3.831, P < 0.001, 95%CI:2.182-6.728) and TPA decrease at POD 7 (HR:1.942, P = 0.021, 95%CI:1.104-3.416) were independent poor prognostic factors. Conclusions: Our findings suggest that the TPA decrease early in a postoperative period has poor prognosis on OS and also RFS.

Long-Term Survival after Surgical Resection for Left Solitary Adrenal Metastasis from Thoracic Esophageal Carcinoma

Long-Term Survival after Surgical Resection for Left Solitary Adrenal Metastasis from Thoracic Esophageal Carcinoma

706例胸段食管癌患者术后无进展生存状况分析

706例胸段食管癌患者术后无进展生存状况分析

P37 LIMITED MEDIASTINAL LYMPHADENECTOMY FOR ELDERLY PATIENTS OVER 75 YEARS OLD WITH THORACIC ESOPHAGEAL CARCINOMA IS PERMISSIBLE

Abstract Aim The aim of this study is to investigate the influence on postoperative complications and survival rate by the difference in the number of mediastinal lymph node dissection for elderly patients over 75 years old with thoracic esophageal carcinoma. Background & Methods In esophagectomy for thoracic esophageal carcinoma, mediastinal lymphadenectomy is an essential procedure for the radical cure and also an invasive procedure. In elderly patients, especially, the postoperative complications are likely to be serious, and less-invasive surgical procedure is preferred. We sometimes perform limited mediastinal lymphadenectomy for elderly patients with thoracic esophageal carcinoma depending on the case, but the influence on survival rate is controversial. 55 patients who underwent esophagectomy for thoracic esophageal carcinoma over 75 years old between 2007 and 2015 were included in this study. Patients were divided into two groups by number of mediastinal lymph node dissection: normal group (15 or more: n=28) and limited group (less than 15: n=27). The short- and long-term outcomes were retrospectively examined to those groups. Results The median age of the normal and limited group were 76.5 and 79, respectively. No significant differences were demonstrated in clinical stage, operation time and estimated blood loss between these groups. The incidences of postoperative circulatory complications were 37.0% in the normal group and 25.0% in the limited group, but there was no statistically significant difference (P = 0.43). In the normal group, the postoperative respiratory complications (46.4 vs. 14.8%, P = 0.011) and recurrent laryngeal nerve paralysis (21.4 vs. 3.7%, P = 0.049) were significantly higher than that of the limited group. The 5-year overall survival rate (OS) and the 5-year relapse free survival rate (RFS) did not show statistical differences between the normal and limited group (OS: 45.0 vs. 46.0%, P = 0.44; RFS: 39.7 vs. 37.7%, P = 0.57). Conclusion In the limited mediastinal lymphadenectomy group, the postoperative respiratory complications and recurrent laryngeal nerve paralysis have a low occurrence rate. There was no difference in the survival rate between these groups. It was considered that limited mediastinal lymphadenectomy for elderly patients with thoracic esophageal carcinoma is permissible to prevent postoperative complications.

Prognostic Significance of the Upper-Mediastinal Elective Nodal Irradiation in Locally Advanced Esophageal Cancer Treated with Preoperative Chemoradiation Followed By Surgery

Appropriate RT field in preoperative CRT for locally advanced thoracic esophageal carcinoma is still controversial. We investigated retrospectively a cohort of patients with clinically staged T3 to T4 with intention to treat (ITT) preoperative CRT followed by surgery in order to clarify the significance of ENI related to tumor location. We started a cohort study from 2011 for clinically staged T3 to T4 thoracic ESCC with preoperative CRT (50.4Gy/28F and concurrent 2 courses of FP) followed by planned surgery with a fixed 3-field lymph node dissection. When the 3-field ENI was used, lung constrains were V5<55%, V10<37%, and V20<25% to keep risk of Grade 3-5 radiation pneumonitis (RP) less than 4%. After 2015 we adopted the concepts of involved field (IF) or ENI related to tumor location without any necessary 3-field ENI. This change in fields setting has made it possible to analyze retrospectively whether ENI affects prognosis. The prognostic factors were derived from 161 patients, and 131 of them in fact were treated with surgery 1.5 months after CRT. In 30 patients without surgery, 14 experienced CR after CRT, and other 13 and 3 were inoperable because of tumor progression and toxicities, respectively. After ENI setting became to be optional, a few regulations were as follows: when tumor location was Ut, the upper end of ENI was No104 level, when tumor location was Mt or Lt, the upper end was No101 level. Five-year overall survival (OS) in 161 patients (average 65 years old) was 50.9%. There was no significance in 5-Y OS between each 2 groups in cT3 vs. cT3/4 (T3 undeniable T4 and T4) and in cN0 vs cN1-3 (T3: 59 vs. T3/4:102; p=0.11, cN0:15 vs cN1-3:146; p=0.09). In the single variate analyses, gender (male: 127 vs. female: 34; p=0.012), surgery (CRT-S: 131 vs. CRT alone: 30; p=0.009), and upper mediastinal ENI (UM-ENI)(UM-ENI+: 123 vs. ENI-: 38; p=0.009 were significant. These 3 prognostic factors were also significant in the multivariate analysis and each hazard ratio (Exp.β) and p-value were as follows; female: (3.29) p＝0.002, surgery: (2.31) p=0.003, and UM- ENI: (1.44) p=0.012. On the other hand, abdominal ENI (A-ENI)(A- ENI＋: 133 vs. ENI-: 28)was not significant (p＝0.076) and neither in 79 patients whose tumor location was Lt (A-ENI+: 67 vs. ENI-:12, p＝0.067). To find out serious toxicities which affected OS, causes of 70 deaths were analyzed excluding 3 unrelated deaths. Six (3.7%) died of the adverse events, and 3 out of them died of RP. As all of them were treated with UM-ENI, 3 out of 123 (2.4%) treated with UM-ENI died of RP. Clinical relevance of the UM-ENI in preoperative CRT was suggested in this study, because of the object limited in locally advanced stages and with a constant surgical method. Furthermore, clinical evaluation of the UM-ENI combined and RP risk should be done with a randomized controlled trial.

Clinical results of intensity-modulated radiotherapy for 250 patients with cervical and upper thoracic esophageal carcinoma.

PurposeTo evaluate and analyze the efficacy and prognostic factors of intensity-modulated radiotherapy in 250 patients with cervical and upper esophageal carcinoma.Patients and methodsFrom September 2009 to September 2016, we retrospectively analyzed 250 patients with cervical and upper esophageal carcinoma treated with intensity-modulated radiotherapy (IMRT). In our study, all patients received IMRT, 54 patients with cervical esophageal carcinoma and 196 patients with upper esophageal carcinoma. Treatment response, survival status and failure modes of treatment were observed, and prognostic factors were analyzed.ResultsThe median survival time was 22.60 months and 3-year survival rate was 42%. The median progress-free survival time was 14.52 months and 3-year progress-free survival rate was 29.3%. The median survival time and the median progress-free survival time for cervical esophageal carcinoma were 20.40 and 15.15 months, respectively. The median survival time and the median progress-free survival time for upper esophageal carcinoma were 25.80 and 14.52 months, respectively (P>0.05). The significant clinical factors associated with survival were patient age, radiotherapy dose and T stages (P<0.05). Radiotherapy dose and concurrent chemoradiotherapy were the significant clinical factors related to progression-free survival (P<0.05). Recurrence appeared in 55.2% patients, including local recurrence in 22.40%, region relapse in 10.40% and distant metastasis in 12.40%. Local recurrence was the main mode of treatment failure. During treatment, the main treatment-related acute toxicity was leukocytopenia and anemia.ConclusionIn this study, IMRT demonstrated clinical benefit and well-tolerated toxicity in patients with cervical and upper esophageal carcinoma.

The clinical significance of the intraoperative pathological examination of bilateral recurrent laryngeal nerve lymph nodes using frozen sections in cervical field lymph node dissection of thoracic esophageal squamous cell carcinoma.

The aim of this study was to evaluate intraoperative pathological examination of the left and right recurrent laryngeal nerve lymph nodes (LNs) using frozen section as a predictor of cervical LN metastasis. Retrospectively collected data from 69 patients with esophageal squamous cell carcinoma who had undergone intraoperative pathological examination of the left and right recurrent laryngeal nerve LNs using frozen sections and three-field LN dissection in the Fujian Medical University Union Hospital from December 2015 to April 2018, was used to explore the relationship between recurrent laryngeal nerve LN metastasis and cervical LN metastasis and to determine whether cervical-field LN dissection should be performed in patients with thoracic esophageal cancer. In the entire cohort, 15.9% (11/69) of patients had metastasis in the cervical LNs. We detected 1,195 cervical LN, with an average of 17.3 LN dissections per patient; 28 (2.3%) cases had LN metastasis. Patients with recurrent laryngeal nerve LN metastasis tended to have a high incidence of cervical LN metastasis (P=0.017). Multivariate analysis showed that left recurrent laryngeal nerve LN metastasis was the only independent risk factor for cervical LN metastasis (P=0.02). The incidence of postoperative pulmonary infection was 18.8% (13/69), chylothorax was 2.9% (2/69), anastomotic leakage was 2.9% (2/69), and hoarseness was 8.7% (6/69) for the entire cohort. There was no significant increase in complications compared with patients with 2-field LN dissection in our hospital during the same period. Additional studies are necessary to establish postoperative locoregional recurrence rates and long-term survival. Intraoperative pathological examination of left recurrent laryngeal nerve LN using frozen sections has some prognostic value in predicting cervical LN metastasis and it can be an indicator for the selection of cervical-field dissection in thoracic esophageal carcinoma.

Analysis on CT in diagnosis of lymph node metastasis of thoracic esophageal cancer with minimum diameter greater than 1 cm

Objectives: To evaluate the diagnostic value of CT for lymph node metastasis of thoracic esophageal carcinoma with a diameter of more than 1 cm, and to find the optimal diagnostic index by comparing relevant CT indexes. Methods: Totally 80 patients with pathologically proved thoracic esophageal cancer with preoperative CT examination revealed lymph node diameter greater than 1 cm admitted at Department of Thoracic Surgery, the First Affiliated Hospital of University of Science and Technology of China from January 2016 to January 2018 were enrolled in this study. There were 70 males and 10 females, aging of (60±14) years (range: 40-85 years). According to the pathological result of lymph nodes, all the patients and lymph nodes were divided into two groups (N+group: 47 patients, 62 lymph nodes; N-group: 33 patients, 39 lymph nodes). The average number of dissected lymph nodes were 21±4 and 101 lymph nodes' diameter were greater than 1 cm. The clinicopathologic factors, postoperative complications, lymph node dissection and relevant CT indexes like the minimum diameter of lymph nodes (Min D), the maximum diameter of lymph node (Max D), lymph node axial ratio(LAR), the enhancement of lymph node (ELN) and the boundary of lymph node (BLN) were compared. The clinicopathological data, lymph node dessection and CT parameters of the two groups were compared by t test, χ(2) test or Wilcoxon rank sum test. Receiver operating characteristic (ROC) curve analysis was used to compare the ability to predict lymph node metastasis between Min D, Max D, LAR, ELN and BLN. Multiple Logistic regression analysis were performed to determine the independent variables for prediction of lymph node metastasis. Results: The difference of tumor segmentation, pN stage, pTNM stage, total number of metastatic lymph nodes, total number of abdominal lymph node metastases, Min D, Max D, ELN and BLN between the two groups were statistically significant. The results of univariate and multivariate analyses showed that gender (OR=0.128, 95%CI: 0.019 to 0.858, P=0.034), pTNM stage (OR=1.514, 95%CI: 1.020 to 2.247, P=0.039), Min D (OR=0.102, 95%CI: 0.010 to 0.995, P=0.050) and LAR (OR=0.195, 95%CI: 0.052 to 0.731, P=0.015) were the independent relative factors. The area under the curve of ROC curve analysis of Min D, Max D, LAR, ELN and BLN were 0.679, 0.666, 0.561, 0.650 and 0.820, respectively. BLN was the best CT index to diagnosis lymph node metastasis, while the accuracy of dignosis of lymph node metastasis of BLN was 97.0%. The Youden index of Min D, Max D and LAR were 1.25 cm, 1.64 cm and 0.77, respectively. Combining the BLN and ELN had a higher diagnostic rate (97.0%) of lymph node metastasis. Conclusions: CT has high diagnostic value for lymph node metastasis in thoracic esophagel cancer when the lymph node diameter is greater than 1 cm. BLN is the best diagnostic index for lymph node metastasis.

Clinical observation of modified gastric tube in middle and lower thoracic esophageal carcinoma surgery

BackgroundA clinical case-control study was conducted to analyze the short-term efficacy of modified gastric tube in surgery for middle (mid)- and lower- thoracic esophageal carcinoma compared with the conventional gastric tube and its effect on postoperative pulmonary function.MethodsA total of 70 patients with mid- and lower-thoracic esophageal cancer who underwent esophagectomy between October 2012 and September 2018 in our hospital were recruited in the study. They were randomly divided into a modified gastric tube group (n = 35) and a conventional gastric tube group (n = 35). The operation time, intraoperative blood loss, number of intraoperative lymph node dissection, gastrointestinal decompression time and postoperative hospital stay were recorded. The operation results and complications were recorded, and the pulmonary function was recorded at 3 days before surgery and 6 weeks after surgery.ResultsThe operation time in the modified gastric tube group was significantly lower than that in the gastric tube group (P < 0.05). There were no anastomotic leakage or death occurred in the modified gastric tube group. There was 1 case of anastomotic leakage in the conventional gastric tube group. The pulmonary function in both groups was improved at 6 weeks after surgery, but there was no significant difference between both groups (P > 0.05).ConclusionModified gastric tube has a good clinical application value compared with gastric tube for patients with mid- and lower-thoracic esophageal cancer. It is easy and safe, and can shorten the operation time without aggravation of pulmonary function after surgery.

A propensity-score matching analysis comparing long-term survival of surgery alone and postoperative treatment for patients in node positive or stage III esophageal squamous cell carcinoma after R0 esophagectomy

BackgroundSurveillance was recommended for patients after R0 esophagectomy by National Comprehensive Cancer Network (NCCN) guidelines. However, local failure was high in locally advanced patients (48–78%). The present study aimed to determine whether adjuvant treatment improved survival for stage IIb-III thoracic esophageal squamous cell carcinoma (TESCC). MethodsA retrospective review of patients diagnosed as esophageal carcinoma at the Chinese Academy of Medical Sciences Cancer hospital, between January 2004 and December 2011, was performed. A database compiling 975 patents with node positive or stage III thoracic esophageal carcinoma after R0 surgery with or without postoperative radiation/chemoradiation was created. A 1:1 matched study group was generated by the Greedy method after propensity score matching (PSM) analysis. Survival curves were calculated by the Kaplan–Meier method and compared with the log-rank test. Univariate and multivariate analyses were using the Cox proportional hazards regression model. Results975 patients were enrolled in the study, 510 patients (52.3%) did not receive any postoperative treatment after R0 surgery and 465 patients had either postoperative chemoradiation or radiotherapy. Median follow-up was 69.2 months. After PSM, 222 well-balanced patients in each group demonstrated the same results. The 3-year, 5-year survival rates and median survival in surgery group (33.0%, 26.4%, 24.3 months) were inferior to those in postoperative treatment group (48.3%, 37.1% and 34.3 months), (P = 0.002). Compared with radiotherapy, postoperative chemoradiation did not improve DFS and OS (P = 0.692; P = 0.368). N stage and adjuvant treatment are independent prognostic factors. ConclusionsAdjuvant treatment could improve survival for patients with stage IIb-III TESCC.

Total mesoesophagus excision by thoracoscopy and laparoscopy in the radical resection of esophageal carcinoma.

Esophageal carcinoma is a malignant tumor with a high incidence in China. Surgical treatment is the main treatment method. Endoscopic-assisted radical resections of esophageal carcinoma have shown promising results with shorter operation times, less intraoperative blood loss, and thorough lymph node dissection (1). Our team is skilled in the total mesoesophageal excision (TME) based on thoracoscopy and laparoscopy in the radical resection of thoracic esophageal carcinoma (2).

Palliative interventions for patients with incurable locally advanced or metastatic thoracic esophageal carcinoma

The aim of this study was to assess the clinical outcomes of palliative interventions for patients with incurable locally advanced or metastatic esophageal carcinoma. A total of 131 patients with thoracic esophageal carcinoma who underwent palliative interventions were enrolled. Insertion of a self-expandable metallic stent (SEMS), tube enterostomy for enteral nutrition (EN), and palliative esophagectomy (PE) were performed in 38, 65, and 28 patients, respectively. The clinicopathological characteristics and clinical outcomes of each group were retrospectively reviewed. Patients in the EN group frequently received chemoradiotherapy (P < 0.01). SEMS insertion, but not PE or EN, improved the mean dysphagia score after the intervention (P < 0.01). For the SEMS, EN, and PE groups, the occurrence of intervention-related complications was 31.6, 10.8, and 96.4%, respectively, the median survival time was 88, 208, and 226days (P < 0.01), and the mean ratio of duration of home care to survival time was 28.9, 38.5, and 39.6% (P = 0.95). SEMS insertion effectively relieved obstructive symptoms, but had no survival benefit. Tube enterostomy showed a low complication rate and has the potential to improve survival in combination with additional treatment, with no palliation of obstructive symptoms.

Society for Translational Medicine Expert consensus on the selection of surgical approaches in the management of thoracic esophageal carcinoma.

Esophageal cancer (EC) is a highly prevalent malignancy in China. According to the data released by National Cancer Registry Center of China in 2015, the prevalence of EC was 21.17/100,000 in China in 2012, ranking fifth among all malignancies; the mortality rate was 15.58/100,000, ranking fourth. It is expected that there will be 477,900 new EC cases nationwide in 2015, whereas 375,000 people will die from EC (1,2). Worldwide, EC is the 8 th most common malignancy, with 416,000 new cases in 2012 (3). At present, EC treatment is based on multidisciplinary treatment, but surgery remains the most effective therapy in optimizing long-term prognosis in patients without metastatic disease. The ideal surgical approach is a matter of debate.

Supraclavicular and celiac metastases in squamous cell carcinoma of the middle thoracic esophagus.

Squamous cell carcinoma of the middle thoracic esophagus (SCC-ME) often metastasizes to the neck, mediastinum, and abdomen. This study aims to assess the prognostic impact of supraclavicular (SC) and celiac (CE) lymph node (LN) metastases in patients with SCC-ME. We examined 210 patients who underwent curative esophagectomy with three-field LN dissection for SCC-ME. The clinicopathological features and survival outcomes of patients with and without SC and/or CE metastases were compared to assess the prognostic significance of SC and/or CE metastases. We observed metastases to SC and CE in 25 (11.9%) and 20 (9.5%) patients, respectively. Seven patients (3.3%) had both SC and CE metastases. Although the survival of patients with SC and/or CE metastases was worse compared with those without, that of patients with SC metastases but without CE metastases was comparable with that of patients with CE metastases but without SC metastases; the 5year overall survival rates were 35.6% and 46.2%, respectively. However, survival of patients with both SC and CE metastases was the worst among all groups, and all patients with both SC and CE metastases experienced disease recurrence. The prognosis of patients with both SC and CE metastases was extremely poor. In contrast, patients with metastasis to either one of these sites could be candidates for surgery as the main modality in a multidisciplinary strategy.

Failure Patterns after Radical Surgery of Thoracic Esophageal Squamous Carcinoma

Radiation therapy is an important cancer treatment modality in both adjuvant and definitive setting, however, the use of radiation therapy for elective treatment of regional lymph nodes is controversial for esophageal squamous cell carcinoma after radical surgery. This analysis aims to study the metastasis pattern through a pooled analysis of published results after radical tumor and lymph nodal resection with histological study in thoracic esophageal squamous cell carcinoma. Literature search using electronic databases of MEDLINE from May 1977 to April 2017 was performed, supplemented by review of references. Thirteen researches and 2531 thoracic esophageal squamous cell carcinoma patients underwent radical surgical resection were included. The probability of recurrence and metastasis in local (anastomotic and tumor bed included), lymph node and distal area was calculated. A chi-square test was used to investigate the difference by statistical software. The recurrent rate is 24.45% for locoregional, 13.23% for distal, 22.24% for lymph node, 2.44% for local. Lymph nodes is divided into cervical and supraclavicular with the recurrent rate of 12.27%, mediastinal with rate of 18.69%(upper 28.23%, middle 17.90% and lower 5.27%, respectively) and abdominal with rate of 6.10% (paraaortic 5.95% and upper abdominal 4.01% respectively). In upper thoracic esophageal squamous cell carcinoma, the order is as follows, cervical and supraclavicular with of 24.32%, mediastinal with rate of 14.86% (upper mediastinal 9.38%, middle mediastinal 3.131%, lower mediastinal 3.13%), abdominal with rate of 1.56%. In middle thoracic esophageal squamous cell carcinoma, the order is as follows, mediastinal with rate of 11.19%(upper mediastinal 7.36%, middle mediastinal 1.74%, lower mediastinal 1.74%), cervical and supraclavicular with rate of 7.12%, and abdominal with rate of 4.75%. In lower thoracic esophageal squamous cell carcinoma, the order is as follows, abdominal LN with rate of 14.85% (paraaortic 11.39% and upper abdominal 3.47%), mediastinal LN with rate of 6.93% (upper mediastinal LN 2.79%, middle mediastinal 1.68%, lower mediastinal LN 1.68%), and cervical and supraclavicular with rate of 3.47% The distal metastatic pattern is as follows, lung (7.04%), liver (6.79%), bone (4.99%), skin (2.28%), and brain (0.74%). Thoracic esophageal squamous cell carcinoma has a high propensity of lymphatic metastases but poor propensity of anastomotic and tumor bed recurrence. Cervical and supraclavicular, upper mediastinal should be delineated as the postoperative prophylactic irradiation target volume for upper, cervical and supraclavicular, upper mediastinal and abdominal lymph nodes especially paraaortic for middle, abdominal lymph nodes especially paraaortic and mediastinal lymph nodes should be delineated for lower as the postoperative prophylactic irradiation target volume.

Clinical complete response after chemoradiotherapy for carcinoma of thoracic esophagus: Is esophagectomy always necessary? A systematic review and meta-analysis.

BackgroundAlthough a clinical complete response (cCR) after chemoradiotherapy (CRT) could lead to a better prognosis, the choice of a following strategy, such as surgical or non‐surgical approach, remains controversial.MethodsAll articles relevant to a comparison of surgical and non‐surgical treatment (including further definitive chemoradiotherapy or active surveillance) for esophageal carcinoma patients with a cCR after CRT were retrieved for meta‐analysis. The final date for data retrieval was 30 June 2018.ResultsFour retrospective studies including 648 patients met the inclusion criteria: 620 with squamous cell carcinoma and 28 with adenocarcinoma. The CRT + surgery group had an advantage over the non‐surgery group in regard to two‐year disease‐free survival (DFS); however, the two groups showed similar results in five‐year DFS. The CRT + surgery group had an advantage over the non‐surgery group in two‐year overall survival (OS); nevertheless, the two groups showed similar results in five‐year OS.ConclusionsBased on the available evidence, the addition of surgery to thoracic locally advanced esophageal carcinoma patients with a cCR after neoadjuvant CRT provided no advantage to long‐term survival. As an exception, the two‐year DFS and OS could be improved. This research conclusion might be more suitable to patients with squamous cell carcinoma.

BRF2 as a promising indicator for radical lymph-node dissection surgery in patients with cN0 squamous cell carcinoma of the middle thoracic esophagus.

Radical lymph-node dissection surgery in patients with cN0 middle thoracic esophageal squamous cell carcinoma (ESCC) remains controversial. We sought a novel biomarker that could be used for decision-making in relation to radical lymph-node dissection. One hundred and nineteen patients with cN0 middle thoracic ESCC undergoing three-field lymph-node dissection (3FLND) or two-field lymph-node dissection (Ivor Lewis) esophagectomy were reviewed. A survival analysis, and Chi-square and parametric tests were performed. A Cox regression analysis revealed that the expression of BRF2 was an independent prognostic factor for overall survival (P = 0.014) and progression-free survival (P = 0.014). The survival of patients who underwent 3FLND was better than that of patients who underwent Ivor Lewis esophagectomy in the BRF2 overexpression group (P = 0.002), but not in the BRF2 nonoverexpression group (P = 0.386). The risk of lymph-node recurrence and the number of recurrent lymph nodes in patients with the overexpression of BRF2 were increased in the Ivor Lewis group in comparison to the 3FLND group (P = 0.01 and P < 0.001). The risk of cervical and superior mediastinal lymph-node recurrence was positively correlated with the overexpression of BRF2 (P = 0.027). Furthermore, in the Ivor Lewis group, a significant correlation was found between the risk of lymph-node recurrence or the number of recurrent lymph nodes and the expression of BRF2 (P = 0.002 and P = 0.004), but not in the 3FLND group (P = 0.193 and P = 0.694). 3FLND generated better survival outcomes and reduced the rate of lymph-node recurrence in comparison to Ivor Lewis in patients with the overexpression of BRF2. BRF2 can be used as an indicator for radical lymph-node dissection surgery in cN0 ESCC patients.

PS01.185: STATUS OF SUBCARINAL LYMPH NODE METASTASIS AND DISSECTION STRATEGY FOR THORACIC ESOPHAGEAL CARCINOMA

Abstract Background The subcarinal lymph node metastasis, although with the debate whether it is a characteristic of lung cancer or esophageal cancer, is prevalent in esophageal carcinoma, and with the incidence of 4.1%-17.5% according to some estimates. The aim of this study is to assess the pattern of subcarinal lymph node metastasis and the dissection strategy for thoracic esophageal carcinoma. Methods A large cohort, retrospective study was conducted on 596 patients with thoracic esophageal carcinoma treated from July 2008 to December 2010. The metastasis rate of subcarinal lymph node was investigated. Survival of patients treated by different dissection strategies was compared. The effectiveness index was used to assess the outcome of subcarinal lymph node dissection. Results Of 596 patients, 447 had documented subcarinal lymph node dissection (75.0%). According to whether the subcarinal lymph node was harvested or not, they were divided into two groups: dissection group (n = 447) and non-dissection group (n = 149). Their 5-year survival rates were 48.3 ± 1.7 months for dissection group vs. 38.1 ± 2.8 months for non-dissection group (P &lt; 0.001). The overall subcarinal node metastasis rate in the dissection group was 12.5% (56/447). Based on the status of subcarinal nodes, there was a significant difference in survival, 52.3 ± 1.8 months with negative nodes (n = 391) compared to 19.9 ± 2.2 months for those with positive nodes (n = 56) (P &lt; 0.001). Subgroup analysis was further conducted for the positive subcarinal nodes patients. The metastasis rates in patients with upper, middle and lower esophageal cancer were 5.4%, 15.1% and 10.1%, respectively (P &lt; 0.05 for comparison between patients with upper and other segments). The effectiveness indices for these three groups of patients were as 0%, 4.8% and 27.2%, respectively. The metastasis rates for T0, T1, T2, T3 and T4 esophageal carcinoma were 0%, 0%, 3.5%, 10.7% and 19.0%, respectively (P &lt; 0.05 for comparison between T0/T1/T2 and T3/T4 tumors. Conclusion Thoracic esophageal carcinoma has a high incidence of subcarinal lymph node metastasis, especially among those with middle and lower esophageal cancer, and for deeper invaded tumors. Therefore, for middle and lower esophageal tumors, subcarinal lymph node dissection is necessary, whereas for T1/2 upper esophageal tumors, subcarinal lymph node dissection can be spared from subcarinal lymph node dissection. Disclosure All authors have declared no conflicts of interest.

PS01.238: MESENTERY-ORIENTED LYMPH NODES DISSECTION AND INTRA-OPERATIVE NEURAL MONITORING TO REDUCE THE POSTOPERATIVE RECURRENT LARYNGEAL NERVE PARALYSIS IN ESOPHAGECTOMY

Abstract Description Background: As the thoracic esophageal carcinoma has a high metastatic rate of upper mediastinal lymph nodes, especially along the recurrent laryngeal nerve (RLN), it is crucial to perform complete lymph nodes dissection along the RLN without complications. Although Intraoperative neural monitoring (IONM) during thyroid and parathyroid surgery has gained widespread acceptance as the useful tool of visual nerve identification, the utilization of IONM during esophageal surgery has not become common. Here, we describe our procedures focusing on a lymphadenectomy along the RLN utilizing the IONM. Methods and Procedures: We first dissect ventral and dorsal side of the esophagus preserving the membranous structure (mesoesophagus), which contains tracheoesophageal artery, RLN and lymph nodes. We next identify the location of the RLN which runs in the mesoesophagus using IONM before visual contact. After that, we perform lymphadenectomy around the RLN preserving the nerve. To evaluate the efficacy of this method, we compared short term surgical outcome of our 36 consecutive cases (neural monitoring group; Nm) of esophagectomy in prone positioning with 56 of our historical cases (conventional method group; Cm). Results: In all 36 cases of Nm group, we could obtain the location information of the RLN before the visual contact. Although the operation time of thoracic part was significantly longer in Nm group compared to Cm group (281 min vs. 254 min each, P = 0.005), postoperative RLN paralysis according to postoperative laryngoscopy was seen in 3 cases (8.3%) after surgical operation in Nm group, which was significantly lower than that in the Cm group (18/56, 32.1%, P = 0.005). As a result, median postoperative hospital stay was significantly shorter in Nm group than Cm group (22 days vs. 39 days each, P = 0.0003). Conclusion: Mesentery-oriented lymph nodes dissection using IONM has substantial advantages to perform accurate and safe thoracoscopic esophagectomy. It could decrease the RLN paralysis and postoperative hospital stay after esophagectomy. Disclosure All authors have declared no conflicts of interest.

PS02.170: EFFICACY OF PERIOPERATIVE IMMUNONUTRITION OF ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Abstract Background Malnutrition is frequent in esophageal cancer patients and aggravated by operation, increasing postoperative complications and mortality. Although a preoperative immunonutrition pharmaceutics diet significantly reduced the incidence of postoperative infectious complications, the effect of perioperative immunonutrition of esophagectomy for esophageal cancer still remains unclear. Methods This study design was a prospective randomized study. 40 patients with thoracic esophageal carcinoma who underwent esophagectomy were divided into two groups. Continiously 7 days before and after surgery, they enrolled and received either immunomodulating enteral nutrition (IMPACT® Group: IG) or standard enteral nutrition (Ensure® Group: EG). The nutrition statement, postoperative ICU stay, postoperative hospital stay, morbidity and mortality were investigated prospectively. Results There was no difference of patient demographics between two groups. Retinol-binding protein as rapid turnover protein was significantly higher on postoperative day (POD) -1, POD 7 and POD 14 in the IG than in the EG (P = 0.009, P = 0.004 and P = 0.024, respectively). The incidence of postoperative infectious complications and changes to therapeutic antibiotics was significantly lower in the IG than in the EG (P = 0.048 and P = 0.012, respectively). No difference was observed in postoperative ICU stay and postoperative hospital stay between two groups. The 5-year PFS in the IG and EG groups were 75% and 64% (P = 0.188), respectively, and OS were 68% and 55% (P = 0.187), respectively. Conclusion This study showed that immunonutrition would be effective to improve the early nutritional status and reduce postoperative infectious complications. Disclosure All authors have declared no conflicts of interest.