SUMMARY
We report analytic and consensus processes that produced recommendations for pathologic stage groups (pTNM) of esophageal and esophagogastric junction cancer for the AJCC/UICC cancer staging ...manuals, 8th edition. The Worldwide Esophageal Cancer Collaboration provided data for 22,654 patients with epithelial esophageal cancers; 13,300 without preoperative therapy had pathologic assessment after esophagectomy or endoscopic treatment. Risk‐adjusted survival for each patient was developed using random survival forest analysis to identify data‐driven pathologic stage groups wherein survival decreased monotonically with increasing group, was distinctive between groups, and homogeneous within groups. The AJCC Upper GI Task Force, by smoothing, simplifying, expanding, and assessing clinical applicability, produced consensus pathologic stage groups. For pT1‐3N0M0 squamous cell carcinoma (SCC) and pT1‐2N0M0 adenocarcinoma, pT was inadequate for grouping; subcategorizing pT1 and adding histologic grade enhanced staging; cancer location improved SCC staging. Consensus eliminated location for pT2N0M0 and pT3N0M0G1 SCC groups, and despite similar survival, restricted stage 0 to pTis, excluding pT1aN0M0G1. Metastases markedly reduced survival; pT, pN, and pM sufficiently grouped advanced cancers. Stage IIA and IIB had different compositions for SCC and adenocarcinoma, but similar survival. Consensus stage IV subgrouping acknowledged pT4N+ and pN3 cancers had poor survival, similar to pM1. Anatomic pathologic stage grouping, based on pTNM only, produced identical consensus stage groups for SCC and adenocarcinoma at the cost of homogeneity in early groups. Pathologic staging can neither direct pre‐treatment decisions nor aid in prognostication for treatment other than esophagectomy or endoscopic therapy. However, it provides a clean, single therapy reference point for esophageal cancer.
We present a case of a young female patient with extraosseous Ewing's sarcoma (EES) arising in the lesser sac, as confirmed by membranous staining for CD99 and an ESWR1 gene translocation on ...fluorescence in situ hybridization. We also provide comprehensive review of the English literature of Ewing's sarcoma (ES) occurring in the gastrointestinal tract (GIT). A systematic review of the PubMed database was carried out with the following MeSH terms: Ewing's AND sarcoma AND (oesophagus, stomach, small bowel OR intestine, large bowel OR intestine, colon, sigmoid, rectum, pancreas, peritoneum, lesser sac, greater sac, liver and gallbladder). Fifty‐seven cases were collated from 46 articles. The most common overall symptom was pain (60.71 per cent), which occurred in patients as young as 2 years and as old as 72 years. The median age was 31 years, and the mean age was 29 years. No bimodal distribution was demonstrated. More females appeared to be affected than males. EES of the GIT is rare. It differs from ES with respect to patient age and sex. No standard therapy for EES has been widely adopted.
SUMMARY
We report analytic and consensus processes that produced recommendations for clinical stage groups (cTNM) of esophageal and esophagogastric junction cancer for the AJCC/UICC cancer staging ...manuals, 8th edition. The Worldwide Esophageal Cancer Collaboration (WECC) provided data on 22,123 clinically staged patients with epithelial esophageal cancers. Risk‐adjusted survival for each patient was developed using random survival forest analysis from which (1) data‐driven clinical stage groups were identified wherein survival decreased monotonically and was distinctive between and homogeneous within groups and (2) data‐driven anatomic clinical stage groups based only on cTNM. The AJCC Upper GI Task Force, by smoothing, simplifying, expanding, and assessing clinical applicability, produced (3) consensus clinical stage groups. Compared with pTNM, cTNM survival was “pinched,” with poorer survival for early cStage groups and better survival for advanced ones. Histologic grade was distinctive for data‐driven grouping of cT2N0M0 squamous cell carcinoma (SCC) and cT1‐2N0M0 adenocarcinoma, but consensus removed it. Grouping was different by histopathologic cell type. For SCC, cN0‐1 was distinctive for cT3 but not cT1‐2, and consensus removed cT4 subclassification and added subgroups 0, IVA, and IVB. For adenocarcinoma, N0‐1 was distinctive for cT1‐2 but not cT3‐4a, cStage II subgrouping was necessary (T1N1M0 IIA and T2N0M0 IIB), advanced cancers cT3‐4aN0‐1M0 plus cT2N1M0 comprised cStage III, and consensus added subgroups 0, IVA, and IVB. Treatment decisions require accurate cStage, which differs from pStage. Understaging and overstaging are problematic, and additional factors, such as grade, may facilitate treatment decisions and prognostication until clinical staging techniques are uniformly applied and improved.
SUMMARY
We report analytic and consensus processes that produced recommendations for neoadjuvant pathologic stage groups (ypTNM) of esophageal and esophagogastric junction cancer for the AJCC/UICC ...cancer staging manuals, 8th edition. The Worldwide Esophageal Cancer Collaboration provided data for 22,654 patients with epithelial esophageal cancers; 7,773 had pathologic assessment after neoadjuvant therapy. Risk‐adjusted survival for each patient was developed. Random forest analysis identified data‐driven neoadjuvant pathologic stage groups wherein survival decreased monotonically with increasing group, was distinctive between groups, and homogeneous within groups. An additional analysis produced data‐driven anatomic neoadjuvant pathologic stage groups based only on ypT, ypN, and ypM categories. The AJCC Upper GI Task Force, by smoothing, simplifying, expanding, and assessing clinical applicability, produced consensus neoadjuvant pathologic stage groups. Grade and location were much less discriminating for stage grouping ypTNM than pTNM. Data‐driven stage grouping without grade and location produced nearly identical groups for squamous cell carcinoma and adenocarcinoma. However, ypTNM groups and their associated survival differed from pTNM. The need for consensus process was minimal. The consensus groups, identical for both cell types were as follows: ypStage I comprised ypT0‐2N0M0; ypStage II ypT3N0M0; ypStage IIIA ypT0‐2N1M0; ypStage IIIB ypT3N1M0, ypT0‐3N2, and ypT4aN0M0; ypStage IVA ypT4aN1‐2, ypT4bN0‐2, and ypTanyN3M0; and ypStage IVB ypTanyNanyM1. Absence of equivalent pathologic (pTNM) categories for the peculiar neoadjuvant pathologic categories ypTisN0‐3M0 and ypT0N0‐3M0, dissimilar stage group compositions, and markedly different early‐ and intermediate‐stage survival necessitated a unified, unique set of stage grouping for patients of either cell type who receive neoadjuvant therapy.
Abstract
Background
MIE is becoming more common and is considered safe. There are few studies supporting laparoscopy in favor of laparotomy for the abdominal part of a three-field esophagectomy and ...long term survival data are scarce. The objective was to compare open esophagectomy (OE), with hybdrid thoracoscopic-laparotomic esophagectomy (HMIE) and minimally invasive esophagectomy (MIE) with regard to surgical outcomes, postoperative complications and survival.
Methods
A prospective database of esophageal resection for cancer at a single centre identified 243 OE, 688 HMIE and 80 MIE procedures. Propensity scores were used to match 80 patients in each group adjusting for age, gender, weight, clinical stage, neoadjuvant treatment, and year of surgery.
Results
Respiratory complications were more common after OE (49%) than after MIE (31%, P = 0.02). Median operative time was longer for MIE (330 minutes) versus HMIE or OE (both 300 minutes, P < 0.001). Median length of stay was shorter following MIE (12 days) compared with HMIE (14 days) and OE (15 days), P = 0.001. There were no significant differences between groups with respect to other complications, median number of lymph nodes examined (22–23 for all groups), or R0 resection rate (range 85–91%) for all groups. There was no difference in 5-year overall survival between groups.
Conclusion
Compared with OE and HMIE, MIE was associated with shorter length of stay and fewer respiratory complications, but longer operative time. Thus, there may be additional benefit for MIE without comprising oncological outcomes.
Disclosure
All authors have declared no conflicts of interest.
Laparoscopic fundoplication (LF) is the standard surgical procedure for the treatment of gastro-oesophageal reflux disease (GORD). Laparoscopic Roux-en-Y gastric bypass (LRYGB) is commonly performed ...to achieve weight loss in obese patients, but it also has anti-reflux properties. Hence, in the obese population suffering from GORD, LRYGB could be an alternative to LF. The aim of this trial will be to compare LF and LRYGB in an obese population presenting with GORD and being considered for surgery.
This will be an investigator-initiated randomized clinical trial. The research population will be obese patients (BMI 30-34.9 with waist circumference more than 88 cm (women) or more than 102 cm (men), or BMI 35-40 with any waist circumference) referred to a public hospital for consideration of anti-reflux surgery. The primary aim of the study will be to determine the efficacy of LF compared with LRYGB on subjective and objective control of GORD. Secondary aims include determining early and late surgical morbidity and the side-effect profile of LF compared with LRYGB and to quantify any non-reflux benefits of LRYGB (including overall quality of life) compared with LF.
This trial will determine whether LRYGB is effective and acceptable as an alternative to LF for the surgical treatment of GORD in obese patients Registration number: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12622000636752p (https://www.anzctr.org.au/).
SUMMARY
To address uncertainty of whether pathologic stage groupings after neoadjuvant therapy (ypTNM) for esophageal cancer share prognostic implications with pathologic groupings after ...esophagectomy alone (pTNM), we report data—simple descriptions of patient characteristics, cancer categories, and non–risk‐adjusted survival—for pathologically staged cancers after neoadjuvant therapy from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty‐three institutions from six continents submitted data using variables with standard definitions: demographics, comorbidities, clinical cancer categories, and all‐cause mortality from first management decision. Of 7,773 pathologically staged neoadjuvant patients, 2,045 had squamous cell carcinoma, 5,686 adenocarcinoma, 31 adenosquamous carcinoma, and 11 undifferentiated carcinoma. Patients were older (61 years) men (83%) with normal (40%) or overweight (35%) body mass index, 0‐1 Eastern Cooperative Oncology Group performance status (96%), and a history of smoking (69%). Cancers were ypT0 (20%), ypT1 (13%), ypT2 (18%), ypT3 (44%), ypN0 (55%), ypM0 (94%), and G2‐G3 (72%); most involved the distal esophagus (80%). Non–risk‐adjusted survival for yp categories was unequally depressed, more for earlier categories than later, compared with equivalent categories from prior WECC data for esophagectomy‐alone patients. Thus, survival of patients with ypT0‐2N0M0 cancers was intermediate and similar regardless of ypT; survival for ypN+ cancers was poor. Because prognoses for ypTNM and pTNM categories are dissimilar, prognostication should be based on separate ypTNM categories and groupings. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient, cancer, and treatment characteristics and should direct 9th edition data collection.
Abstract
Background
Several studies have been suggesting that neutrophil-lymphocyte ratio (NLR), as it reflects systemic inflammation, could help predict survival in oesophageal and junctional ...carcinomas. Therefore, we aimed to determine whether baseline NLR holds prognostic and predictive value in oesophageal and junctional adenocarcinomas (OAC) for patients treated with neoadjuvant chemotherapy (nCT) followed by surgery.
Methods
We studied the data of 144 included patients that received nCT, all identified from a prospectively maintained database. Pre-treatment haematology reports were used to calculate the baseline NLR, dividing absolute neutrophil count by absolute lymphocyte count. Multiple ways of grouping patients based on NLR were tried, including determining the optimal cut-off value based off a ROC-curve and the standard threshold for elevated NLR (> 5). NLR quartiles were used to display possible differences between groups in relation to overall survival (OS), disease-free survival (DFS) and pathological response according to Mandard score. Cox regression analysis was performed to determine independent prognostic factors for OS.
Results
The ROC-curve showed that NLR has no discriminating power for survival status (area under the curve = 0.460) and therefore no optimal cut-off value could be determined. Also, using the most frequently used threshold for elevated NLR (≥ 5) to group patients did not lead to a difference in OS (P = 0.112). Median OS times for NLR quartiles were 65 (Q1), 32 (Q2), 45 (Q3) and 46 months (Q4), with no significant difference (P = 0.926). DFS showed no difference between groups either, with median DFS times of 30 (Q1), 22 (Q2), 38 (Q3) and 23 months (Q4, P = 0.973). Pathological response according to Mandard score did not vary between NLR quartiles (P = 0.925). In addition, NLR was not associated with OS in univariate analysis (P = 0.518). Multivariate analysis showed that both pathological N- and M-stage, and number of involved nodes were independent prognostic indicators for OS.
Conclusion
The present study shows that, in contrast to other recently published papers, baseline NLR holds no prognostic or predictive value for OAC patients treated with nCT. This result strongly questions the validity of NLR as a prognostic indicator and its clinical usefulness.
Disclosure
All authors have declared no conflicts of interest.
Abstract
Background
Multimodality treatment of patients with esophageal adenocarcinoma (EAC) improve survival, but the optimal treatment strategy remains undetermined. The aim of this study was to ...compare outcomes in patients undergoing neoadjuvant chemotherapy (nCT) and neoadjuvant chemoradiotherapy (nCRT) for EAC.
Methods
Patients who underwent nCT or nCRT followed by surgery for EAC were identified from a prospective database (2000–2017) and included in this study. After propensity score matching, we compared the impact of the treatments on postoperative complications, in-hospital mortality, pathological outcomes and survival rates.
Results
Of the 396 eligible patients, 262 patients were analysed following propensity score matching. This resulted in 131 patients in the nCT group versus 131 patients in the nCRT group. There were no significant differences between the nCT and nCRT groups for overall complications (59% vs 57%, P = 0.802) or in-hospital mortality (2% vs 0%, P = 0.156). Patients who had nCRT had more R0 resections (93% vs. 83%, P = 0.013), and a higher pathological complete response rate (15% vs. 5%, P < 0.001). The pattern of recurrence was similar (P = 0.753) and there were no differences in 5-year disease-free survival rates (nCT vs nCRT; 39% vs 39%, P = 0.879) or 5-year overall survival rates (nCT vs nCRT; 44% vs 33%, P = 0.645).
Conclusion
In this study no differences between nCT and nCRT were seen in postoperative complications and in-hospital mortality in patients treated for EAC. Inspite of improved complete resection and pathological response there was no difference in the overall survival between the treatment modalities.
Disclosure
All authors have declared no conflicts of interest.
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