Effects of en bloc esophagectomy on nutritional and immune status in patients with esophageal carcinoma

Modified En Bloc Esophagectomy for Squamous Cell Carcinoma After Neoadjuvant Chemoradiotherapy

BACKGROUND

The optimal type of esophagectomy and extent of lymphadenectomy for patients after neoadjuvant chemoradiotherapy (nCRT) for esophageal squamous cell carcinoma remain controversial. We hypothesized that a more radical resection is associated with better survival.

METHODS

Data of patients who received nCRT followed by resection for esophageal squamous cell carcinoma between 2012 and 2021 were analyzed. Modified en bloc esophagectomy (mEBE) involves total mediastinal lymphadenectomy and resection of all periesophageal node-bearing tissues. Perioperative outcomes and survival rates of mEBE were compared with those of conventional esophagectomy (CE).

RESULTS

A total of 238 patients were included. Compared with CE, mEBE was associated with a longer operative time, higher total number of resected lymph nodes, fewer complications, and less anastomotic leakage; length of stay was similar between the 2 groups. There was no difference in overall survival rates between patients with ypT0 N0 stage in the mEBE and CE groups; however, in patients with non-ypT0 N0 stage in the mEBE and CE groups, the 3-year overall survival rates were 58.5% and 28.5%, respectively (P < .001). On disease-free survival analysis, no difference was observed in patients with ypT0 N0 stage, whereas patients with non-ypT0 N0 stage after nCRT had significantly better disease-free survival after mEBE compared with CE (49.7% vs 27.2%; P = .017).

CONCLUSIONS

Survival after mEBE was significantly better than that after CE. The mEBE did not increase postoperative hospital stay and complication rates.

The Effects of Zinc Supplementation on C-Reactive Protein and Inflammatory Cytokines: A Meta-Analysis and Systematical Review

Zinc is known for anti-inflammatory and antioxidant roles. In this meta-analysis, we aim to evaluate the impact of zinc supplementation on inflammatory markers, acute-phase reactants, and serum zinc level during inflammatory and infectious diseases. PubMed, Scopus, and Web of Science databases were screened systematically with the terms "zinc supplementation" AND "CRP" OR "IL-1β" OR "IL-2" OR "IL-6" OR "IL-10" OR "IL-12" OR "TNF-α" OR "TGF-β" OR "IFN-γ" OR "WBC (clinical trial)" OR "macrophage (clinical trial)" OR "lymphocyte (clinical trial)" OR "neutrophil (clinical trial)" OR "virus (clinical trial)" OR "antiviral (clinical trial)" for all databases. A total of 2,258 publications were screened, and 73 articles had suitable data for the meta-analysis. Serum zinc level was significantly higher in supplementation group compared with controls [P = 0.0006, mean difference: 11.35 (4.84, 17.87)] (n = 37). Zinc supplementation downregulates acute-phase reactants, especially serum C-reactive protein (CRP) in adults [P < 0.00001, mean difference: -0.75 (-0.98, -0.52)] (n = 22) and pregnant women [FEM P < 0.00001, mean difference: -1.77 (-2.53, -1.00)] (n = 3) but not in children [REM P = 0.10, mean difference: -0.85 (-1.86, 0.17)] (n = 3). In subgroups analysis of chronic inflammatory diseases, serum CRP [REM P < 0.00001, mean difference: -0.57 (-0.76, -0.38)] were significantly lower in zinc-supplemented patients compared with no intervention group. Zinc supplementation (mg/day) correlated with serum interferon-gamma (IFN-γ) level (P = 0.018, r = 1,000). In the nonsupplemented group, serum zinc correlated with serum interleukin-6 (IL-6) level (P = 0.041, r = -0.829) and serum tumor necrosis factor alpha (TNF-α) level (P = 0.063, r = 0.730). Zinc intake correlated with serum zinc (P = 0.0428, r = 0.5115) and TNF-α (P = 0.0043, r = -0.9461). This meta-analysis shows that zinc supplementation improves CRP levels in adults and pregnant women. It might have modulatory effects on cytokine secretions and blood cells in inflammatory and infectious diseases. For the first time, we investigated the effects of zinc supplementation on inflammatory cytokine.

Changes in blood concentrations of trace metals in cancer patients receiving cisplatin-based chemotherapy

The administration of cisplatin (CDDP) may influence trace metal concentrations in body fluids. In order to test this hypothesis, the blood concentrations of trace metals were determined during the present study in eight Japanese esophageal and lung cancer patients receiving CDDP-based chemotherapy. The levels of manganese, iron (Fe), cobalt, copper, zinc (Zn), platinum and lead in the plasma were determined by inductively coupled plasma-mass spectrometry. In addition, the serum levels of Fe, transferrin and ferritin were evaluated. The baseline plasma concentration of Fe in patients with esophageal cancer was significantly lower than that in lung cancer patients (P=0.011), although there were no significant differences identified with respect to the plasma levels of other trace metals. The data obtained from six fasting patients without blood transfusion demonstrated that plasma concentrations of Fe increased 3.5-fold soon after CDDP treatment and returned to baseline levels ~10 days after therapy. The excessive Fe levels in the bloodstream induced changes in serum ferritin and transferrin levels. Furthermore, serum Zn levels increased 1.8-fold in the 1-3 days following CDDP treatment, and serum cystatin C levels transiently increased. These findings indicate that serum Fe and Zn levels may be useful to understanding the physiological responses in the early stages of CDDP-based chemotherapy, which may be associated with systemic inflammation and/or tissue distribution of CDDP.

Enteral nutrition enriched with eicosapentaenoic acid (EPA) preserves lean body mass following esophageal cancer surgery: results of a double-blinded randomized controlled trial

BACKGROUND

Esophagectomy represents an exemplar of controlled major trauma, with marked metabolic, immunologic, and physiologic changes as well as an associated high incidence of complications. Eicosapentaenoic acid (EPA) enriched enteral nutrition (EN) modulates immune function and limits catabolism in patients with advanced cancer, but its impact in the peri-operative period is unclear.

OBJECTIVES

To examine the effects of perioperative EPA enriched EN on the metabolic, nutritional, and immuno-inflammatory response to esophagectomy, and on postoperative complications.

METHODS

In a double-blind design, patients were randomized to a standard EN formula or a formula enriched with 2.2 g EPA/d for 5 days preoperatively (orally) and 21 days postoperatively (jejunostomy). Segmental bioelectrical impedance analysis was performed preoperatively and on POD 21. Postoperative complications were monitored, as well as the acute phase response, coagulation markers, and serum cytokines.

RESULTS

Fifty-three patients (28 EPA, 25 standard) completed the study, and both groups were well matched. Serum and peripheral blood mononuclear cell (PBMC) membrane EPA levels were significantly increased in the EPA group. There was no difference in the incidence of major complications. The EPA group maintained all aspects of body composition postoperatively, whereas patients in the standard EN group lost significant amounts of fat-free mass (1.9 kg, P = 0.030) compared with the EPA group [leg (0.3 kg, P = 0.05), arm (0.17 kg, P = 0.01), and trunk (1.44 kg, P = 0.03)]. The EPA group had a significantly (P < 0.05) attenuated stress response for TNFalpha, IL-10, and IL-8 compared with the standard group.

CONCLUSIONS

EPA supplemented early EN is associated with preservation of lean body mass post esophagectomy compared with a standard EN. These properties may merit longer-term study to address its impact on recovery of function and quality of life in models of complex surgery or multimodal cancer treatment regimens.

Effect of traditional Chinese medicine on survival and quality of life in patients with esophageal carcinoma after esophagectomy

OBJECTIVE

To explore the effect and possible mechanism of traditional Chinese medicine (TCM) on survival and quality of life (QOL) in patients with esophageal carcinoma after esophagectomy.

METHODS

Adopting prospective controlled method of study, the authors had 128 post-esophagectomy patients, hospitalized from February 2001 to February 2002, randomly divided into 3 groups: the TCM group, treated with TCM drugs alone; the chemotherapy group, with chemotherapy alone applied; and the synthetic group, treated with chemotherapy combined with Chinese medicine. Their survival rate and QOL were compared.

RESULTS

In the TCM group, the chemotherapy group and the synthetic group, the respective 3-year relapse and remote metastasis rate were 71.4%, 76.7%, 53.4%, respectively (chi(2) = 6.53, P < 0.05); the 1-year survival rate 42.9%, 46.5%, 72.1%; 2-year survival rate 28.6%, 27.9%, 55.8%, and 3-year survival rate 26.2%, 23.1%, 37.2%, respectively. And the QOL improving rate was 69.0%, 37.2%, 58.1%, respectively, all showing significant difference among them (chi(2) = 6.10, all P < 0.05). Moreover, immune function was increased in the TCM and the synthetic groups.

CONCLUSION

Integrative Chinese and Western medicinal treatment was the beneficial choice for post-operational patients with esophageal carcinoma. However, long time use of simple Chinese medicine was also advisable, especially for those in poverty.

Pathogenesis and classification of cancer around the gastroesophageal junction--not so different in Japan

Japanese patients with early adenocarcinoma of the esophagus have well-preserved gastric acid secretion, consistent with other parts of the world, reinforcing the likely importance of the luminal environment for pathogenesis. Progress in researching carcinomas that occur around the gastroesophageal junction would be facilitated by consensus-based review of the inadequate approaches currently used for classification of these tumors with subsequent development and widespread adoption of improved criteria.

Clinical outcomes of extended esophagectomy with three-field lymph node dissection for esophageal squamous cell carcinoma

OBJECTIVE

Opinions are conflicting about 3-field lymph node dissection (3FLND) during esophagectomy for esophageal cancer. In the current study, we sought to determine the prevalence of cervical and upper thoracic lymph node metastasis in patients with squamous cell carcinoma of the thoracic esophagus and to determine the impact of 3FLND on mortality, morbidity, survival, and recurrence rate.

MATERIALS AND METHODS

Among 287 patients with squamous cell carcinoma of the thoracic esophagus seen between November 1985 and December 2001, 141 (49%) underwent extended esophagectomy with 3FLND (cervical, mediastinal, and abdominal lymph node dissection). Patients were observed and clinicopathologic information collected prospectively on all patients until death or August 2002. The median follow-up was 41 months, ranging from 10 to 173 months.

RESULTS

Hospital mortality and morbidity rates were 6.4% and 80%, respectively. Thirty-four of 70 node-positive patients had cervicothoracic nodal involvement. Sixteen patients (11%) had nodal involvement confined only to the cervicothoracic nodes, and no patients with lower thoracic esophageal carcinoma showed cervicothoracic involvement alone. The frequency of cervical nodal disease was correlated with nodal status within the mediastinum (P <0.01). The 1-, 3-, and 5-year overall survival rates for all 141 patients were 76%, 58%, and 48%, respectively. Among significant variables verified by univariate analysis, independent prognostic factors for overall survival determined by multivariate analysis were number of lymph node metastasis (P <0.01), amount of blood transfusion (P <0.05), length of operation (P <0.05), and presence of pulmonary complications (P <0.05).

CONCLUSIONS

Extended esophagectomy with 3FLND can be performed with an acceptable mortality. Metastases frequently involved the upper thoracic and cervical lesions, and cervical nodal disease was correlated with thoracic nodal status. 3FLND proved to be an important staging system in 11% of patients. An excellent overall survival suggests a superiority of 3FLND when performed at experienced centers.

En-bloc esophagectomy for esophageal cancer

BACKGROUND

The operative approach for esophageal cancer varies from simple palliative resection to extended esophagectomy with 3-field lymph-node dissection or en-bloc esophagectomy (EBE) depending on tumor and patient status and surgical strategy of the surgeon. The merits and demerits of such EBE are yet to be determined.

METHODS

A literature review was done regarding EBE for esophageal cancer.

RESULTS

Twenty articles describing EBE were reported from experienced institutions during the last 20 years and were selected for this study. The conclusions drawn from those articles showed that EBE would be a safe procedure with acceptable morbidity and low mortality rates when performed by an experienced surgeon. When strict patient selection criteria were maintained, this procedure decreased locoregional recurrence and improved long-term survival rates.

CONCLUSIONS

EBE would be the treatment of choice in selected patients presenting with esophageal cancer. Development of meticulous preoperative risk assessment and optimum postoperative care may further improve the acceptability of this procedure with minimum morbidity and acceptable mortality rates.

Potential prophylactic measures against postoperative immunosuppression: could they reduce recurrence rates in oncological patients?

BACKGROUND

Removing the primary tumor is indispensable for eliminating the major pool of metastasizing cells, but the surgical procedure itself is suspected of promoting metastases. This adverse effect is attributed to several mechanisms acting in synergy, including mechanical release of tumor cells, enhanced angiogenesis, secretion of growth factors, and immunosuppression. Here we provide new insights into mechanisms of postoperative immunosuppression and assess the assumptions underlying the hypothesis that, by suppressing cell-mediated immunity (CMI), surgery may render the patient vulnerable to metastases that otherwise could have been controlled.

METHODS

An extensive review of relevant articles in English identified by using the MEDLINE database and cross-referencing.

RESULTS

Current literature suggests that (1) CMI can control minimal residual disease, especially if surgery is performed early; (2) major surgery transiently but markedly suppresses CMI through multiple mechanisms now better understood; (3) surgical stress promotes experimental metastasis through immunosuppression, but the clinical evidence remains indirect because of ethical limitations.

CONCLUSIONS

Minimizing postoperative immunosuppression seems feasible, may limit recurrence, and should be introduced into the broader array of considerations when planning oncological surgeries. In the short run, physicians could try to avoid immunosuppressive anesthetic approaches, inadvertent hypothermia, excessive blood transfusions, and untended postoperative pain. When feasible, minimally invasive surgery should be considered. In the long run, clinical trials should evaluate prophylactic measures, including perioperative immunostimulation and several antagonists to cytokines and hormones specified herein.

Correlation of pre-operative nutritional condition with post-operative complications in surgical treatment for oesophageal carcinoma

AIMS

The relationship between the pre-operative nutritional condition and the outcome of the surgical treatment in patients with oesophageal carcinoma has been discussed diversely. The aim of the current study was to demonstrate the relationship between pre-operative nutritional condition and post-operative complications and prognosis following surgical treatment for oesophageal carcinoma.

METHODS

Two hundred and fifty-eight patients with oesophageal carcinoma treated with oesophageal resection and reconstruction were selected. The correlation of pre-operative values of prognostic nutritional index (PNI) with the incidence of post-operative complications and prognosis of the patients was investigated.

RESULTS

The mean pre-operative value of PNI in patients with post-operative complications (41.8+/-5.4) was significantly lower than that in patients without post-operative complications (46.5+/-5.3; P<0.0001). The survival in patients with higher PNI value was significantly more favourable than that in patients with lower PNI value (P=0.0001).

CONCLUSIONS

Pre-operative assessment of the nutritional condition could provide predictive information for post-operative complications in patients with oesophageal carcinoma.

Significance of preoperative elevation of serum C-reactive protein as an indicator of prognosis in esophageal carcinoma

BACKGROUND

Preoperative elevation of serum C-reactive protein (CRP) has been reported to be a prognostic indicator in gastric carcinoma and colorectal carcinoma. The aim of this study was to establish the significance of preoperative elevation of serum CRP as an indicator of prognosis in patients with esophageal carcinoma.

METHODS

Two hundred sixty-two patients with esophageal carcinoma who had been treated by esophageal resection and reconstruction of digestive tracts were evaluated, excluding patients with neoplasms in other organs. Preoperative serum CRP was measured, and the relation between the elevation of serum CRP and the clinicopathological factors and prognosis of the patients was investigated.

RESULTS

The mean size of the tumors and the proportions of lymph node metastasis and lymphatic invasion were significantly larger in patients with preoperative elevation of serum CRP than in patients without preoperative elevation of serum CRP (5.8 +/- 2.5 cm versus 4.8 +/- 2.5 cm, P <0.01, 59.5% versus 35.4%, P <0.001, and 35.7% versus 23.6%, P <0.05, respectively). 1-, 3-, and 5-year survival rates in patients with preoperative elevation of serum CRP (60.6%, 18.4%, and 11.5%, respectively) were significantly lower than those in patients without preoperative elevation of serum CRP (88.7%, 70.9%, and 68.4%, respectively; P <0.0001). Multivariate analysis demonstrated that the preoperative elevation of serum CRP was an independent prognostic factor in esophageal carcinoma (P <0.0001).

CONCLUSIONS

The preoperative serum elevation of CRP can be a marker of the malignant potential of the tumor and an independent prognostic indicator in esophageal carcinoma.

Expression and up-regulation of interleukin-6 in oesophageal carcinoma cells by n-sodium butyrate

Recently, the serum level of interleukin (IL)-6 has been shown to correlate with disease progression and prognosis of cancer patients. However, the available information about the source and the pathophysiological regulation of IL-6 in cancer cells is limited. Thus, in this study, we tried to identify the source and the clinical roles of serum IL-6 in patients with oesophageal squamous cell carcinoma (ESCC), and then further to characterize the biological regulation of IL-6 in ESCC cell lines. Sera and tissue specimens from 80 consecutive patients with ESCC were collected between 1993 and 1997. Additionally, three ESCC cell lines were used for in vitro study. The concentration of serum IL-6 was measured by enzyme-linked immunosorbent assay (ELISA), and correlated the survival time with measured IL-6 level. Expressions of IL-6, IL-6R alpha (IL-6 receptor alpha) and gp130 in pathological sections and cell lines were characterized by immunological staining. Detection of IL-6 mRNA was determined by in situ hybridization (ISH) and reverse transcription-polymerase chain reaction (RT-PCR). Up-regulation of IL-6 by n-sodium butyrate (n-BT) was studied in ESCC cell lines. The levels of serum IL-6 in patients with ESCC were significantly higher than those in the healthy controls. Serum levels of IL-6 were also shown to correlate with disease progression and survival. However, sCD8 levels and lymphocyte counts in the peripheral blood were not parallel to the changed pattern of serum IL-6. In pathological sections and ESCC cell lines, message of IL-6 was identified by ISH in cancer cells. Expression of IL-6 mRNA was further confirmed with RT-PCR in ESCC cell lines. Although IL-6 was detected in some ESCC cell lines, IL-6 gene expression and protein production could be induced or enhanced by n-BT treatment in all three cell lines. The serum levels of IL-6 are frequently elevated at diagnosis of ESCC, and are associated with poor prognosis. IL-6 that could be produced by cancer cells is up-regulated by n-BT.

Prognosis of esophageal squamous cell carcinoma: analysis of clinicopathological and biological factors

OBJECTIVE

Esophageal squamous cell carcinoma (ESCC) is rather common among the Chinese, but the therapeutic outcome is dismal. Knowledge of the prognostic factors in cancerous patients may influence therapeutic strategy. However, systemic analyses of clinicopathological and biological factors for patients with ESCC are few, and the results are controversial.

METHODS

Between 1985 and 1996, 117 patients undergoing en bloc esophagectomy and gastric substitution were enrolled. None had neoadjuvant treatment. Postoperative adjuvant therapy was provided for patients at and beyond stages IIa. Clinical responses were followed routinely. Flow cytometry was used to measure DNA ploidy and synthesis-phase fraction (SPF) of the resected esophageal tissues from all patients. Immunohistochemistry was also used to examine the expression of proliferating cell nuclear antigen (PCNA), epidermoid growth factor receptor (EGFR), HER-2/neu, and p53 in the pathological sections. Clinical correlation was evaluated by chi2 with Fisher's exact test, and survival by log-rank test.

RESULTS

The overall survival rates were 74% for 1 yr, 48% for 3 yr, and 38% for 5 yr. TNM tumor staging, the number of diseased lymph nodes (N < or = 3 or N > 3), degree of cell differentiation, DNA ploidy, SPF, and lymphovascular invasion were more useful than biological markers, such as PCNA, EGFR, HER-2/neu, and p53, for the prognosis of ESCC. Multivariate analysis revealed significant correlation of tumor staging and number of diseased lymph nodes with patient survival after surgery.

CONCLUSIONS

En bloc esophagectomy may provide a rather satisfactory survival rate for patients with early stage ESCC. However, for patients with distant lymph node metastasis and those with more than three lymph nodes involved, radical surgical resection, even combined with postoperative chemoradiotherapy, cannot improve survival. The prognostic value of biological markers, including PCNA, EGFR, HER-2/neu, and p53, however, is limited.