Abstract
The tumor–node metastasis (TNM) classification, originally developed in 1943 and subsequently adopted by the Union for International Cancer Control and the American Joint Committee on ...Cancer, is regularly updated based on new information and developments. The TNM classification system is the main tool used for both clinical and pathological staging of cancers worldwide. The 8th edition of the TNM classification for esophageal and esophagogastric junction (EGJ) cancer, released in 2017, was updated from the 7th edition based on additional data supplied by the Worldwide Esophageal Cancer Collaboration group. We summarize the main changes between the 7th and 8th editions of this TNM classification. Notable changes included separate clinical, pathological and pathological prognostic staging for adenocarcinomas and squamous cell carcinomas. Pathological prognostic staging was also improved by updating the T- and N-factors regarding histopathological differentiation and tumor location, respectively. The definition of EGJ cancer was changed from tumors centered within 5 cm to tumors within 2 cm of the EGJ. These updates to the TNM classification will help to improve the personalized management and treatment of patients with esophageal and EGJ cancers.
Esophageal squamous cell carcinoma (ESCC) is one of the most common malignancies worldwide, especially in East Asia. ESCC accounts for more than 90% of esophageal cancer. Currently, neoadjuvant ...therapy in combination with surgical resection is the mainstay of treatment. However, the overall survival rate of patients with locally advanced ESCC is not satisfactory even when treated following the standard treatment guidelines. With neoadjuvant chemoradiotherapy, chemotherapy, or emerging immunotherapy, continuous exploration of efficacy in relation to ESCC is expected to improve overall survival further. Here, we review and summarize current evidence for efficacy of preoperative therapy for locally advanced ESCC.
Background
The procedure of mediastinoscopic-assisted transhiatal esophagectomy (MATE) is only performed in a few institutions, despite this being the ultimate form of minimally invasive surgery for ...performing esophagectomy for esophageal and esophagogastric cancer in that it entails no chest wall trauma. We have developed a novel, universally applicable, surgical procedure for performing bilateral transcervical mediastinoscopic-assisted transhiatal laparoscopic esophagectomy (BTC-MATLE) that is an improvement on standard MATE surgery for esophageal and esophagogastric cancer.
Methods
The patient is placed in a supine position under general anesthesia with bilateral lung ventilation. BTC-MATLE combined with mediastinoscopic and transhiatal laparoscopic esophagectomy with total mediastinal lymph node dissection are performed synchronously. After lymph node dissection along both recurrent laryngeal nerves through bilateral cervical skin incisions, bilateral transcervical mediastinoscopic esophagectomy is performed to avoid collision outside the cervical region and ensure operability even in patients with narrow mediastimun. Laparoscopic gastric mobilization and subsequent lower esophageal mobilization meet the bilateral transcervical mediastinoscopic esophagectomy at the border of the middle and lower third of the esophagus. The gastric tube is pulled up into the cervical region via a posterior mediastinal route and anastomosed in the neck.
Results
BTC-MATLE was performed on 16 high-risk patients (Charlson Comorbidity Index ≥ 3 in 14 patients and two octogenarians with complex comorbidities). Median operation time and postoperative hospital stay were 231 min and 15 days, respectively. R0 resection was achieved in 15 patients (94%), and there were no in-hospital deaths.
Conclusions
BTC-MATLE, a procedure for performing minimally invasive esophagectomy, is likely to become the applicable form of MATE surgery for esophageal and esophagogastric cancer, even in high-risk patients because it is truly minimally invasive and has excellent short-term outcomes.
Background
Postoperative chylothorax sometimes follows thoracic esophagectomy for esophageal cancer. The effectiveness of octreotide treatment for it and factors that predict its response are ...unclear. This study aimed to evaluate the efficacy of octreotide for treating postoperative chylothorax following thoracic esophagectomy for esophageal cancer and factors that might predict successful treatment and allow chest drain removal.
Methods
We assessed 521 consecutive patients who underwent thoracic esophagectomy for esophageal cancer to investigate the efficacy of octreotide for postoperative chylothorax. Among those with postoperative chylothorax, one group (group A) underwent conservative management, and the other (group B) was treated conservatively with added octreotide administration. We evaluated the clinical outcomes after octreotide administration and assessed the factors associated with successful treatment.
Results
Among the 521 patients, 20 (3.8 %) developed postoperative chylothorax: five in group A and 15 in group B. Two of the five (20 %) group A patients and 13 of the 15 (86.6 %) group B patients were treated successfully (
p
= 0.03). Factors significantly associated with treatment failure were (1) chest drain output of >1,000 ml/day before treatment (
p
= 0.04); (2) no reduction in chest drainage by the second day of treatment (
p
= 0.016); (3) chest drainage of >1,000 ml/day through the second day of treatment (
p
= 0.006).
Conclusions
For patients with esophageal cancer who undergo thoracic esophagectomy, octreotide can be an effective treatment for postoperative chylothorax.
Background
Despite advances in minimally invasive surgery, postoperative pneumonia after esophagectomy remains a frequent complication. Sarcopenia, defined as low muscle strength and quantity, has ...been associated with adverse surgical outcomes in numerous cancers. The recent definition and diagnostic criteria for sarcopenia have emphasized muscle strength rather than muscle quantity as the primary indicator of sarcopenia, although most studies have focused only on muscle quantity. This study aimed to determine the association of muscle strength and quantity with postoperative pneumonia after thoracoscopic–laparoscopic esophagectomy (TLE).
Methods
This retrospective, single-center, observational study investigated 161 men undergoing TLE for esophageal cancer between May 2017 and October 2019. Handgrip strength (HGS) and skeletal muscle mass index (SMI) were used respectively as proxy for muscle strength and quantity. The SMI was assessed using preoperative computed tomography at the L3 vertebral level. Predictors of postoperative pneumonia were determined using multivariate analysis.
Results
The study subjects had TLE performed for squamous cell carcinoma (
n
= 131), adenocarcinoma (
n
= 24), and other cancers (
n
= 6). Postoperative pneumonia developed in 28 patients (17.4%). In the multivariate analysis, HGS was significantly associated with postoperative pneumonia (odds ratio OR, 1.21; 95% confidence interval CI, 1.08–1.35;
p
= 0.001. No association was found between SMI and postoperative pneumonia (
p
= 0.964). Comparison of the areas under the receiver operating characteristic curves for postoperative pneumonia prediction showed that the value for HGS was significantly higher than for SMI (0.79 vs 0.65, respectively;
p
= 0.012).
Conclusions
Low HGS was a significant predictor of postoperative pneumonia after TLE for esophageal cancer.
The purpose of the present study was to identify a biomarker that can predict the response to preoperative chemoradiotherapy (PCRT) in esophageal cancer patients. Twenty-five serum samples collected ...from patents with esophageal cancer before PCRT (responder = 13, non-responder = 12) were analyzed by quantitative proteomics, and 248 proteins were identified. Among them, the serum levels of leucine-rich alpha-2-glycoprotein 1 (LRG1) were significantly different (p < 0.01) and well discriminated (area under the curve (AUC) of the receiver operating characteristic (ROC) curve >0.8) between responder and non-responder groups. The combination of LRG1 with C-reactive protein (CRP) and soluble interleukin-6 receptor (sIL-6R), which were previously reported as biomarkers predicting PCRT response, further improved the predictive performance, providing an AUC of greater than 0.9. The present results suggest that LRG1 and its combination with CRP and sIL-6R are promising biomarker candidates to predict response to PCRT in esophageal cancer patients.
Background
In this matched-cohort study, we investigated the short-term outcome of robot-assisted minimally invasive esophagectomy (RAMIE) compared with conventional minimally invasive thoracoscopic ...esophagectomy (MIE) in esophageal cancer patients.
Methods
One hundred eighty-nine patients with thoracic esophageal cancer scheduled to undergo thoracic esophagectomy between 2020 and 2021 were assigned to either RAMIE or MIE. Then, we retrospectively evaluated the postoperative surgical complications between two groups in a propensity-matched analyzation.
Results
Based on the propensity-matched score, 50 patients who underwent RAMIE or MIE were selected. Thoracic surgery time in RAMIE/MIE group were 233.1/173.3 min (
p
< 0.01), respectively. No significant intergroup differences were observed regarding incisional anastomotic leakage (RAMIE group 4.0% vs. MIE group 6.0%) and pneumonia (RAMIE group 8.0% vs. MIE group 12.0%;
p
= 0.68). The respective incidences of recurrent laryngeal nerve paralysis were 34.0 and 8.0% in the MIE and RAMIE groups, respectively (
p
< 0.01). In the matched cohort, no differences were observed between the groups in the success accomplishment of the clinical management pathway (RAMIE group 94.0% vs. MIE group 88.0%).
Conclusions
Although patients who underwent RAMIE had longer operation times, the incidence of recurrent laryngeal nerve paralysis was lower than with MIE. Further study in a prospective multi-institutional setting are required to confirm the superiority of RAMIE compared with MIE.
Background
sophageal cancer has a low incidence, and the anatomy is difficult to understand during esophagectomy. This necessitates a precise and lengthy operation. Therefore, the establishment of a ...training system in esophageal surgery is of critical importance. In this study, we compared the short-term outcomes of minimally invasive esophagectomy (MIE) performed by consultants versus trainees and explored the factors that impacted the thoracic operation time for each group.
Methods
We have introduced standardized MIE surgical techniques to our trainees in 2016. Our procedure consists of a laparoscopic phase and a thoracoscopic phase and is systematically designed to be learned in a step-by-step manner in each phase. We retrospectively identified 308 patients who underwent MIE from April 2016 to April 2018. The patients were divided into those who underwent MIE by consultants and those who underwent MIE by trainees. The preoperative background factors, operation-related factors, and postoperative complications were compared between the two groups. We also assessed the association between a prolonged thoracic operation time and tumor-and patient-related factors in each of the consults and trainees.
Results
Significantly more patients had stage ≥ III cancer in the consultant than trainee group. However, the postoperative complications were comparable, specifically pneumonia (11% vs. 18%), anastomotic leakage (11% vs. 13%), and mortality (0.6% vs. 1.3%). There was no significant difference in the lymph node yield (20 vs. 17) or R0 resection rate (94% vs. 91%) between the two groups. However, the trainees had a significantly longer thoracic operation time (143 ± 34 vs. 190 ± 28 min) and significantly greater blood loss (93 vs. 183 ml). Oncological factors were correlated with a prolonged thoracic operation time in the consultants, but not in the trainees.
Conclusions
Under standardized surgical management using a stepwise educational program, performance of MIE by trainees has no impact on short-term outcomes.
Background
Although the advantage of minimally invasive esophagectomy (MIE) over open esophagectomy (OE) in planned esophagectomy is being established, the utility of salvage MIE (S-MIE) remains ...unclear. We aimed to investigate the feasibility and advantage of S-MIE compared with salvage OE (S-OE).
Methods
We retrospectively assessed 82 patients who underwent salvage esophagectomy after definitive chemoradiotherapy for thoracic esophageal cancer between January 2007 and April 2020. Perioperative factors and postoperative complications were compared between the S-OE group (
n
= 62) and the S-MIE group (
n
= 20). Logistic regression analysis was performed to analyze the factors associated with postoperative complications.
Results
Regarding the patients’ preoperative characteristics, the S-OE group had a significant number of grade ≥ cT3 patients vs the S-MIE group (69% vs 35%, respectively;
p
= 0.006), whereas ycT rates were comparable. Compared with S-OE, S-MIE had comparable operative time, number of harvested thoracic lymph nodes, and R0 resection, but significantly less estimated blood loss (150 ml and 395 ml, respectively;
p
= 0.003). Regarding postoperative complications, total complications (79% vs 50%;
p
= 0.01) and pneumonia (48.3% vs 20%;
p
= 0.02) rates were significantly lower with S-OE vs S-MIE, respectively. On multivariate analysis, S-MIE was an independent factor associated with postoperative pneumonia (odds ratio: 0.29, 95% confidence interval: 0.06–0.99;
p
= 0.04) and total complications (odds ratio: 0.26, 95% confidence interval: 0.07–0.86;
p
= 0.02).
Conclusion
S-MIE was feasible for salvage esophagectomy, with favorable short-term outcomes vs S-OE regarding postoperative pneumonia and total complications.
The combination of docetaxel, cisplatin, and 5‐fluorouracil (DCF) as preoperative treatment for esophageal squamous cell carcinoma (ESCC) has not been investigated. We carried out a multicenter phase ...II feasibility study of preoperative chemotherapy with DCF for ESCC. Patients with clinical stage II/III ESCC (International Union Against Cancer TNM classification system, 6th edition) were eligible. Chemotherapy consisted of i.v. docetaxel (70–75 mg/m2) and cisplatin (70–75 mg/m2) on day 1, and continuous infusion of fluorouracil (750 mg/m2/day) on days 1–5. Antibiotic prophylaxis on days 5–15 was mandatory. This regimen was repeated every 3 weeks with a maximum of three cycles allowed. After completion of chemotherapy, esophagectomy with extended lymphadenectomy was carried out. The primary endpoint was the completion rate of protocol treatment. Forty‐two eligible patients were enrolled. During chemotherapy, the most common grade 3 or 4 toxicities were neutropenia (83%), anorexia (7%), and stomatitis (5%). Forty‐one (98%) patients underwent surgery. The completion rate of protocol treatment was 90.5% (38/42). No treatment‐related death was observed and the incidence of operative morbidity was tolerable. According to RECIST, the overall response rate after the completion of DCF was 64.3%. Pathological complete response was achieved in 17%. The estimated 2‐year progression‐free survival and overall survival were 74.5% and 88.0%, respectively. Although these data are preliminary, preoperative DCF was well tolerated. Antitumor activity was highly promising and warrants further investigation. This trial was registered with University Hospital Medical Information Network (no. UMIN000002396).
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