Neoadjuvant chemotherapy is established in the management of most resectable esophageal and esophagogastric junction adenocarcinomas. However, assessing the downstaging effects of chemotherapy and ...predicting response to treatment remain challenging, and the relative importance of tumor stage before and after chemotherapy is debatable.
We analyzed consecutive resections for esophageal or esophagogastric junction adenocarcinomas performed at two high-volume cancer centers in London between 2000 and 2010. After standard investigations and multidisciplinary team consensus, all patients were allocated a clinical tumor stage before treatment, which was compared with pathologic stage after surgical resection. Survival analysis was conducted using Kaplan-Meier analysis and Cox regression analysis.
Among 584 included patients, 400 patients (68%) received neoadjuvant chemotherapy. Patients with downstaged tumors after neoadjuvant chemotherapy experienced improved survival compared with patients without response (P < .001), and such downstaging (hazard ratio, 0.43; 95% CI, 0.31 to 0.59) was the strongest independent predictor of survival after adjusting for patient age, tumor grade, clinical tumor stage, lymphovascular invasion, resection margin status, and surgical resection type. Patients downstaged by chemotherapy, compared with patients with no response, experienced lower rates of local recurrence (6% v. 13%, respectively; P = .030) and systemic recurrence (19% v. 29%, respectively; P = .027) and improved Mandard tumor regression scores (P = .001). Survival was strongly dictated by stage after neoadjuvant chemotherapy, rather than clinical stage at presentation.
The stage of esophageal or esophagogastric junction adenocarcinoma after neoadjuvant chemotherapy determines prognosis rather than the clinical stage before neoadjuvant chemotherapy, indicating the importance of focusing on postchemotherapy staging to more accurately predict outcome and eligibility for surgery. Patients who are downstaged by neoadjuvant chemotherapy benefit from reduced rates of local and systemic recurrence.
Background
The optimal surgical approach to tumours of the oesophagus and oesophagogastric junction remains controversial. The principal randomized trial comparing transhiatal (THO) and transthoracic ...(TTO) oesophagectomy showed no survival difference, but suggested that some subgroups of patients may benefit from the more extended lymphadenectomy typically conducted with TTO.
Methods
This was a cohort study based on two prospectively created databases. Short‐ and long‐term outcomes for patients undergoing THO and TTO were compared. The primary outcome measure was overall survival, with secondary outcomes including time to recurrence and patterns of disease relapse. A Cox proportional hazards model provided hazard ratios (HRs) and 95 per cent confidence intervals (c.i.), with adjustments for age, tumour stage, tumour grade, response to chemotherapy and lymphovascular invasion.
Results
Of 664 included patients (263 THO, 401 TTO), the distributions of age, sex and histological subtype were similar between the groups. In‐hospital mortality (1·1 versus 3·2 per cent for THO and TTO respectively; P = 0·110) and in‐hospital stay (14 versus 17 days respectively; P < 0·001) favoured THO. In the adjusted model, there was no difference in overall survival (HR 1·07, 95 per cent c.i. 0·84 to 1·36) or time to tumour recurrence (HR 0·99, 0·76 to 1·29) between the two operations. Local tumour recurrence patterns were similar (22·8 versus 24·4 per cent for THO and TTO respectively). No subgroup could be identified of patients who had benefited from more radical surgery on the basis of tumour location or stage.
Conclusion
There was no difference in survival or tumour recurrence for TTO and THO.
Surgical approach makes little difference to long‐term outcomes
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
Esophageal cancer has a poor prognosis, and many patients undergoing surgery have a low chance of cure. Imaging studies suggest that tumor volume is prognostic. The study aimed to evaluate ...pathological tumor volume (PTV) as a prognostic variable in esophageal cancer.
Methods
This single-center cohort study included 283 patients who underwent esophageal cancer resections between 2000 and 2012. PTVs were obtained from pathological measurements using a validated volume formula. The prognostic value of PTV was analyzed using multivariable regression models, adjusting for age, tumor grade, tumor (T) stage, nodal stage, lymphovascular invasion, resection margin, resection type, and chemotherapy response, which provided hazard ratios (HRs) with 95 % confidence intervals (CIs). Primary outcomes were time to death and time to recurrence. Secondary outcomes were margin involvement and lymph node positivity. Correlation analysis was performed between imaging and PTVs.
Results
On unadjusted analysis, increasing PTV was associated with worse overall mortality (HR 2.30, 95 % CI 1.41–3.73) and disease recurrence (HR 1.87, 95 % CI 1.14–3.07). Adjusted analysis demonstrated worse overall mortality with increasing PTV but reached significance in only one subgroup (HR 1.70, 95 % CI 1.09–2.38). PTV was an independent predictor of margin involvement (OR 2.28, 95 % CI 1.02–5.13) and lymph node–positive status (OR 2.77, 95 % CI 1.23–6.28). Correlation analyses demonstrated significant positive correlation between computed tomography (CT) software and formula tumor volumes (
r
= 0.927,
p
< 0.0001), CT and positron emission tomography tumor volumes (
r
= 0.547,
p
< 0.0001), and CT and PTVs (
r
= 0.310,
p
< 0.001).
Conclusions
Tumor volume may predict survival, margin status, and lymph node positivity after surgery for esophageal cancer.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
SUMMARY
The purpose of this study was to assess the oncological outcomes of a large multicenter series of left thoracoabdominal esophagectomies, and compare these to the more widely utilized ...Ivor–Lewis esophagectomy. With ethics approval and an established study protocol, anonymized data from five centers were merged into a structured database. The study exposure was operative approach (ILE or LTE). The primary outcome measure was time to death. Secondary outcome measures included time to tumor recurrence, positive surgical resection margins, lymph node yield, postoperative death, and hospital length of stay. Cox proportional hazards models provided hazard ratios (HR) with 95% confidence intervals (CI) adjusting for age, pathological tumor stage, tumor grade, lymphovascular invasion, and neoadjuvant treatment. Among 1228 patients (598 ILE; 630 LTE), most (86%) had adenocarcinoma (AC) and were male (81%). Comparing ILE and LTE for AC patients, no difference was seen in terms of time to death (HR 0.904 95%CI 0.749–1.1090) or time to recurrence (HR 0.973 95%CI 0.768–1.232). The risk of a positive resection margin was also similar (OR 1.022 95%CI 0.731–1.429). Median lymph node yield did not differ between approaches (LTE 21; ILE 21; P = 0.426). In-hospital mortality was 2.4%, significantly lower in the LTE group (LTE 1.3%; ILE 3.6%; P = 0.004). Median hospital stay was 11 days in the LTE group and 14 days in the ILE group (P < 0.0001). In conclusion, this is the largest series of left thoracoabdominal esophagectomies to be submitted for publication and the only one to compare two different transthoracic esophagectomy strategies. It demonstrates oncological equivalence between operative approaches but possible short- term advantages to the left thoracoabdominal esophagectomy.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
6.
Reply to R.C. Turkington et al Davies, Andrew R; Gossage, James A; Zylstra, Janine L ...
Journal of clinical oncology,
03/2015, Volume:
33, Issue:
9
Journal Article
Background: Research regarding the health and wellness of medical students has led to ongoing concerns regarding patterns of alcohol and drug use that take place during medical education. Such ...research, however, is typically limited to single-institution studies or has been conducted over 25 years ago.
Objective: The objective of the investigation was to assess the prevalence and consequences of medical student alcohol and drug use and students' perceptions of their medical school's substance-use policies.
Design: A total of 855 medical students representing 49 medical colleges throughout the United States participated in an online survey between December 2015 and March 2016.
Results: Data showed that 91.3% and 26.2% of medical students consumed alcohol and used marijuana respectively in the past year, and 33.8% of medical students consumed five or more drinks in one sitting in the past two weeks. Differences in use emerged regarding demographic characteristics of students. Consequences of alcohol and drug use in this sample of medical students included but were not limited to interpersonal altercations, serious suicidal ideation, cognitive deficits, compromised academic performance, and driving under the influence of substances. Forty percent of medical students reported being unaware of their medical institution's substance-use policies.
Conclusions: Findings suggest that substance use among medical students in the US is ongoing and associated with consequences in various domains. There is a lack of familiarity regarding school substance-use policies. Although there has been some progress in characterizing medical student alcohol use, less is known about the factors surrounding medical students' use of other substances. Updated, comprehensive studies on the patterns of medical student substance use are needed if we are to make the necessary changes needed to effectively prevent substance-use disorders among medical students and support those who are in need of help.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Objective
Fatigue is a well-known risk factor for mood disturbances, decreased cognitive acuity, and impaired judgment. Sleep research in medical students typically focuses on sleep quantity, but ...less is known about the quality of a student’s sleep. The purpose of this investigation was to examine the subjective sleep quality and quantity of US medical students and to identify differences in sleep characteristics across demographic groups.
Methods
Medical students (
N
= 860) representing 49 medical colleges completed the Medical Outcomes Study Sleep Scale and a demographic questionnaire between December 2015 and March 2016.
Results
Although participants reported obtaining nearly 7 h of sleep per night, the majority of students reported indicators of poor sleep quality. First and third year students reported higher rates of sleep-related problems compared to second and fourth year students. First and second year students reported the highest levels of sleep somnolence. Ethnic minority students reported significantly lower levels of sleep adequacy and sleep quantity and significantly higher levels of sleep somnolence than Caucasian students.
Conclusions
Impaired sleep quality may contribute to fatigue in medical students even when sleep quantity seems adequate. Students appear to begin medical school with disrupted sleep patterns that may not improve until their final year of study. Education regarding proper sleep habits and the significant role of sleep quality in sustaining healthy sleep is especially important in the early stages of medical education. Minority, first year, and third year students may benefit the most from learning new behaviors that promote sufficient sleep quality during periods of sustained stress.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background: Ischemia occurring on mobilization and mesenteric division is thought to be a major factor in the etiology of anastomotic dehiscence after colorectal resection. This study assessed the ...ability of the new technique of scanning laser Doppler flowmetry to measure changes in human colonic perfusion during mobilization at and adjacent to the anastomotic site.
Study Design: Colonic perfusion was measured in 10 patients undergoing large-bowel resection by making laser Doppler scans of the proximal bowel before mobilization, after mobilization and mesenteric division, and after resection of the specimen. Mean perfusion was calculated within 1-cm
2 regions of interest, each of which contained 1,750 individual measurements of perfusion. These regions represented the anastomosis site and adjacent areas 1 cm and 2 cm proximal and distal to this. The results were expressed as mean perfusion units (PUs).
Results: After mobilization, there were significant decreases in perfusion in all the subjects between each time point and in all areas of the colon scanned. Median perfusion at the anastomosis site was 491 PUs before mobilization, and this fell to 212 PUs after mobilization, representing a decrease of 57%; the median within-person decrease was also 57% (p < 0.01). There was a gradient of reduced perfusion between the area 2 cm proximal to the mesenteric division (median within-person fall 25%; p < 0.05) and the area 2 cm distal to the mesenteric division (median within-person fall 84%; p < 0.01). After resection of the specimen, perfusion increased slightly at the anastomosis site to a median of 240 PUs (median within-person fall 41%; p < 0.01), but 2 cm proximal to this, median perfusion remained depressed at 330 PUs.
Conclusions: This new technique can be used intraoperatively and appears to overcome the limitations of single-point laser Doppler flowmetry. In this small preliminary study, it measured large decreases in colonic perfusion during mobilization, and it may have widespread clinical applications.
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GEOZS, IJS, NUK, OILJ, SBCE, SBJE, UL, UM, UPUK
A prospective, randomized comparison of the result of endoscopic laser therapy and that of placement of self-expandable metallic endoprostheses was performed to determine which method provides the ...best palliation of dysphagia in patients with inoperable esophageal carcinoma.
Sixty patients participated in the study. Twenty-three were randomly assigned to undergo plastic-covered stent placement, 19 to undergo uncovered stent placement, and 18 to undergo laser therapy. The quality of swallowing was assessed with the dysphagia score, which ranged from 0 for normal swallowing to 4 for complete dysphagia.
The mean improvement in dysphagia score was 2 and ranged from -1 to 3 in patients who underwent placement of plastic-covered stents, was 2 and ranged from 0 to 4 in those who underwent placement of uncovered stents, and was 1 and ranged from 0 to 2 in those who underwent laser therapy. Six of 23 (26%) plastic-covered stents migrated, whereas none of the uncovered stents did so (P < .02). Tumor ingrowth through uncovered stents occurred in five of 19 patients (26%).
Placement of metallic esophageal endoprostheses is substantially better than endoscopic laser therapy for palliation of dysphagia in patients with inoperable esophageal carcinoma. Use of uncovered and plastic-covered metallic stents provides equal palliation in patients with dysphagia.
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