Clinical outcomes of surgical resection for recurrent lesion after curative esophagectomy for esophageal squamous cell carcinoma: a nationwide, large-scale retrospective study

Treatment strategies and long-term outcomes for patients with oligometastasis in esophageal squamous cell carcinoma after radical esophagectomy

BACKGROUND

Advancements in esophageal cancer treatment have not substantially reduced the high recurrence rate and poor survival outcomes following esophagectomy; however, patients with oligometastasis may benefit from aggressive local treatments.

METHODS

We performed curative esophagectomy in 714 patients with esophageal squamous cell carcinoma between 2007 and 2022. In total, 206 patients with recurrent lesions were enrolled in this study. Oligometastasis was defined as ≤ 5 lesions in a single organ or lymph node station. Treatments included surgery, chemoradiotherapy (CRT), chemotherapy, and radiotherapy. Disease-specific survival (DSS) was defined as the time from the initial recurrence to disease-related death or the last observation.

RESULTS

Among the patients, 109 had oligometastasis, most commonly in the lymph nodes (N = 84), followed by the lung (N = 8) and liver (N = 7). The DSS rate in patients with oligometastasis (5-year DSS: 37.5%) was significantly higher than that in patients with multiple metastases (3.3%) (P < 0.001). Metastatic lesions are more likely to be oligometastatic when a disease-free interval (DFI) is prolonged. In the oligometastasis cohort, surgery or CRT was associated with significantly improved survival outcomes, particularly among patients with a DFI of less than 9 months. The selection of treatment modalities was significantly influenced by the patient's performance status (PS), with better PS being associated with a greater likelihood of receiving surgery or CRT.

CONCLUSION

Aggressive local treatment should be considered for oligometastasis after esophagectomy to improve long-term survival. A good PS after esophagectomy is crucial for the effective treatment of oligometastatic lesions.

Multimodal therapy for oligometastases after curative esophagectomy for esophageal cancer

BACKGROUND

Oligometastases, defined as a limited metastatic disease, have been considered potential therapeutic targets of cancers. This study aimed to clarify the characteristics of oligometastatic recurrence and therapeutic strategy after curative esophagectomy for esophageal cancer.

METHODS

Clinical details, such as recurrence site, timing and contents of therapies for recurrence, and prognosis, were examined in 138 patients who experienced recurrence among 366 who underwent curative esophagectomy for esophageal cancer. Oligometastases were defined as three or fewer metastatic recurrence lesions within a single organ or lymph node (LN) station.

RESULTS

Oligometastases were identified in 36 patients (26%). The most common oligometastatic recurrence site was the LN (21 patients), followed by the lung (14 patients). In addition, the oligometastases group had a significantly better prognosis than the multiple metastasis group (P < 0.0001). Analysis for prognostic factors revealed that surgical resection for oligometastases had a significant prognostic impact on long-term survival after treatment for initial recurrence of esophageal cancer (P = 0.012).

CONCLUSION

Oligometastases serve as a prognostic factor for recurrent esophageal cancer after curative esophagectomy. The surgical resection of isolated oligometastatic recurrences, particularly pulmonary and cervical node metastases, combined with chemotherapy or radiotherapy, represents a promising treatment strategy with a survival benefit in recurrent esophageal cancer.

The impact of time to postoperative recurrence on the prognosis of patients with esophageal cancer post recurrence: exploratory analysis of OGSG 1003

BACKGROUND

The association between recurrence timing and prognosis in patients with locally advanced resectable esophageal cancer undergoing neoadjuvant chemotherapy (NAC) followed by esophagectomy remains unclear. This study aimed to clarify this association using multicenter prospective clinical trial data.

METHODS

Among 162 patients enrolled in a NAC phase II study comparing the efficacy of cisplatin and fluorouracil plus docetaxel with cisplatin and fluorouracil plus adriamycin, 64 patients with recurrence after R0 resection were included in this study. We evaluated the association between recurrence timing and overall survival after recurrence (OSr), along with clinicopathological factors associated with recurrence timing and OSr.

RESULTS

Among 64 patients, 46 (71.9%) and 59 (92.2%) experienced recurrence within 1 and 2 years after surgery, respectively. Groups based on recurrence timing, including ≤ 6, 6-12, and > 12 months, had median OSr of 3.6, 13.9, and 13.4 months, respectively. The prognosis was significantly poorer for patients with recurrence ≤ 6 months after surgery than for other patients (P < 0.001). Multivariate analysis revealed pathological lymph node staging as an independent factor associated with early recurrence (odds ratio: 3.46, 95% confidence interval: 1.47-8.02, P = 0.0045). On the other hand, multivariate analysis for factors associated with OSr revealed pT (hazard ratio [HR]: 1.91, 95%CI 1.26-2.88, P = 0.0022), early recurrence (HR: 6.88, 95%CI 2.68-17.6, P < 0.001), and treatment after recurrence, with both local treatment (HR: 0.47, 95%CI 0.22-0.98, P = 0.043) and chemotherapy (HR: 0.25, 95%CI 0.11-0.58, P = 0.0011) as independent prognostic factors.

CONCLUSION

Patients with advanced esophageal cancer experiencing recurrence within 6 months after esophagectomy following NAC have an extremely poor prognosis, suggesting that an advanced pN stage is associated with early recurrence.

Outcome research on esophagectomy analyzed using nationwide databases in Japan: evidences generated from real-world data

Esophagectomy for esophageal cancer is a highly invasive gastrointestinal surgical procedure. The National Clinical Database (NCD) of Japan, initiated in 2011, has compiled real-world data on esophagectomy, one of nine major gastroenterological surgeries. This review examines outcomes after esophagectomy analyzed using the Japanese big databases. Certification systems by the Japanese Society of Gastroenterological Surgery (JSGS) and the Japan Esophageal Society (JES) have shown that institutional certification has a greater impact on short-term surgical outcomes than surgeon certification. Minimally invasive esophagectomy has emerged as a viable alternative to open esophagectomy, although careful patient selection is crucial, especially for elderly patients with advanced tumors. The NCD has significantly contributed to the assessment and enhancement of surgical quality and short-term outcomes, while studies based on Comprehensive Registry of Esophageal Cancer in Japan (CRECJ) have provided data on patient characteristics, treatments, and long-term outcomes. The JES has conducted various questionnaire-based retrospective clinical reviews in collaboration with authorized institutions certified by JES. The Diagnosis Procedure Combination (DPC) database provides administrative claims data including itemized prices for surgical, pharmaceutical, laboratory, and other inpatient services. Analyzing these nationwide databases can offer precise insights into surgical quality for esophageal cancer, potentially leading to improved treatment outcomes.

Use machine learning to predict pulmonary metastasis of esophageal cancer: a population-based study

BACKGROUND

This study aims to establish a predictive model for assessing the risk of esophageal cancer lung metastasis using machine learning techniques.

METHODS

Data on esophageal cancer patients from 2010 to 2020 were extracted from the surveillance, epidemiology, and end results (SEER) database. Through univariate and multivariate logistic regression analyses, eight indicators related to the risk of lung metastasis were selected. These indicators were incorporated into six machine learning classifiers to develop corresponding predictive models. The performance of these models was evaluated and compared using metrics such as The area under curve (AUC), accuracy, sensitivity, specificity, and F1 score.

RESULTS

A total of 20,249 confirmed cases of esophageal cancer were included in this study. Among them, 14,174 cases (70%) were assigned to the training set while 6075 cases (30%) constituted the internal test set. Primary site location, tumor histology, tumor grade classification system T staging criteria N staging criteria brain metastasis bone metastasis liver metastasis emerged as independent risk factors for esophageal cancer with lung metastasis. Amongst the six constructed models, the GBM algorithm-based machine learning model demonstrated superior performance during internal dataset validation. AUC, accuracy, sensitivity, and specificity values achieved by this model stood at respectively at 0.803, 0.849, 0.604, and 0.867.

CONCLUSION

We have developed an online calculator based on the GBM model ( https://lvgrkyxcgdvo7ugoyxyywe.streamlit.app/)to aid clinical decision-making and treatment planning.

Predictive factors for intrathoracic anastomotic leakage and postoperative mortality after esophageal cancer resection

BACKGROUND

Esophageal cancer is currently one of the high-risk malignant tumors worldwide, posing a serious threat to human health. This study aimed to analyse the causes of postoperative mortality and intrathoracic anastomotic leakage(IAL) after esophagectomy.

METHODS

A retrospective analysis was conducted on 172 patients with esophageal cancer resection and focused on the preoperative and postoperative indicators. Cox regression analysis was performed to identify factors affected IAL and evaluated the potential factors on postoperative mortality. The Kaplan-Meier curve was applied to evaluate the effect of leakage on postoperative mortality after propensity score matching.

RESULTS

Univariable and multivariable Cox regression analysis showed that infection and high BMI were significant risk factors for IAL, patients with BMI over 24 kg/m2 in IAL group was two times higher than that of the group without IAL (95% CI = 1.01-6.38; P = 0.048). When patients were infected, the hazard ratios(HRs) of anastomotic leakage was twice that of patients without infection (95% CI = 1.22-4.70; P = 0.011). On the other hand, IAL was a significant cause of postoperative mortality, the 40-day postoperative mortality rate in the leakage group was significantly higher than the non leakage group (28.95% in leakage group vs. 7.46% in non leakage group, P<0.01). After propensity score matching, IAL still significantly affected postoperative mortality. The total length of hospital stay of the leakage group was inevitably longer than that of the non leakage group (22.19 ± 10.79 vs. 15.27 ± 8.59).

CONCLUSION

IAL was a significant cause of death in patients underwent esophageal cancer resection. Patients with high BMI over 24 kg/m2 and infection may be more prone to developing IAL after esophagectomy. IAL inevitably prolonged the length of hospital stay and increased postoperative mortality.

Prognostic Relevance of Recurrent Sites of Gastric Cancer Treated With Curative Resection: A Single Center Retrospective Study

PURPOSE

Gastric cancer treated with curative resection exhibits several recurrence patterns. The peritoneum is the most common site of recurrence. Some reports have indicated different prognostic influences according to the recurrence sites in other cancers, such as esophageal and colorectal cancers. This study investigated whether the recurrence sites influenced the prognosis of patients with recurrent gastric cancer.

MATERIALS AND METHODS

The data of 115 patients who experienced tumor recurrence after curative gastrectomy were retrospectively reviewed. The sites of recurrence were divided into 4 groups: lymph node (LN), peritoneum, other single organs, and multiple lesions. Clinicopathological features were compared between the sites of recurrence. Prognosis after resection and recurrence were also compared.

RESULTS

The peritoneum was the primary site of recurrence in 38 patients (33%). The tumor differentiation and pathological stages were significantly different. Survival after surgery did not show a statistically significant difference (hazard ratio [HR] of LN: 1, peritoneum: 1.083, other single organs: 1.025, and multiple lesions: 1.058; P=1.00). Survival after recurrence was significantly different (HR of LN, 1; peritoneum, 2.164; other single organs, 1.092; multiple lesions, 1.554; P=0.01), and patients with peritoneal and multiple lesion recurrences had worse prognosis. Furthermore, peritoneal recurrence seemed to occur later than that at other sites; the median times to recurrence in LN, peritoneal, other single-organ, and multiple lesions were 265, 722, 372, and 325 days, respectively.

CONCLUSIONS

The sites of gastric cancer recurrence may have different prognostic effects. Peritoneal recurrence may be less sensitive to chemotherapy and occur during the late phase of recurrence.

Risk Factors of Postoperative Complication and Hospital Mortality after Colorectal Perforation Surgery

Objectives

Colorectal perforation is associated with high morbidity and mortality rates after surgery. We investigated various clinical features of patients who underwent emergency surgery for colorectal perforation and explored the risk factors for postoperative complications and hospital mortality.

Methods

Data from 147 patients who underwent surgery for colorectal perforation were retrospectively reviewed. We investigated various clinical and operative factors, including inflammation-based prognostic scores (IBPSs), and evaluated the risk factors for postoperative complications and hospital mortality due to colorectal perforation.

Results

Among 147 patients, the most frequent postoperative complication was wound infection (32 cases, 21.8%), followed by intra-abdominal abscesses (27 cases, 18.4%) after surgery for colorectal perforation. Time from onset to surgery ≥ 2 days (Hazard ratio [HR] = 2.810, p = 0.0383) and prognostic nutritional index (PNI) < 30 (HR = 3.190, p = 0.0488) were identified as risk factors for intra-abdominal abscess, while neutrophil-lymphocyte ratio (NLR) < 6.15 (HR = 5.020, p = 0.0009) was identified as a risk factor for wound infection. Time from onset to surgery ≥ 2 days (HR = 7.713, p = 0.0492), severe postoperative complications (Clavien-Dindo grade ≥ IIIa) (HR = 10.98, p = 0.0281), and platelet-lymphocyte ratio (PLR) < 144 (HR = 18.84, p = 0.0190) were independent predictive factors for hospital mortality.

Conclusions

Time from onset to surgery and IBPSs such as PNI, NLR, and PLR, may be associated with postoperative complications and hospital mortality due to colorectal perforation.

Oligometastases of Esophageal Squamous Cell Carcinoma: A Review

Patients with oligometastases show distant relapse in only a limited number of regions. Local therapy such as surgical resection, radiotherapy, chemoradiotherapy, and radiofrequency ablation for the relapsed sites may thus improve patient survival. Oligometastases are divided into oligo-recurrence and sync-oligometastases. Oligo-recurrence indicates a primary lesion that is controlled, and sync-oligometastases indicate a primary lesion that is not controlled. The management of oligo-recurrence and sync-oligometastases in esophageal squamous cell carcinoma has not been clearly established, and treatment outcomes remain equivocal. We reviewed 14 articles, including three phase II trials, that were limited to squamous cell carcinoma. Multimodal treatment combining surgical resection and chemoradiotherapy for oligo-recurrence of esophageal squamous cell carcinoma appears to be a promising treatment. With the development of more effective chemotherapy and regimens that combine immune checkpoint inhibitors, it will become more likely that sync-oligometastases that were unresectable at the initial diagnosis can be brought to conversion surgery. Currently, a randomized, controlled phase III trial is being conducted in Japan to compare a strategy for performing definitive chemoradiotherapy and, if necessary, salvage surgery with a strategy for conversion surgery in patients who can be resected by induction chemotherapy.

Survival after Lung Metastasectomy from Esophageal Cancer: Results from a Multi-Institutional Database

To clarify the clinical impact and to identify prognostic predictors of surgical intervention for pulmonary metastasis from esophageal cancer, a registry database analysis was performed. From January 2000 to March 2020, patients who underwent resection of pulmonary metastases from primary esophageal cancer at 18 institutions were registered in a database developed by the Metastatic Lung Tumor Study Group of Japan. An amount of 109 cases were reviewed and examined for the prognostic factors for pulmonary metastasectomy of metastases from esophageal cancer. As a result, five-year overall survival after pulmonary metastasectomy was 34.4% and five-year disease-free survival was 22.1%. The multivariate analysis for overall survival revealed that initial recurrence site, maximum tumor size, and duration from primary tumor treatment to lung surgery were selected as the significant prognostic factors (p = 0.043, p = 0.048, and p = 0.037, respectively). In addition, from the results of the multivariate analysis for disease free survival, number of lung metastases, initial recurrence site, duration from primary tumor treatment to lung surgery, and preoperative chemotherapy for lung metastasis were selected as the significant prognostic factors (p = 0.037, p = 0.008, p = 0.010, and p = 0.020, respectively). In conclusion, eligible patients with pulmonary metastasis from esophageal cancer selected based on the identified prognostic predictors would be good candidates for pulmonary metastasectomy.

Patterns of failure after salvage chemoradiotherapy for postoperative loco-regional recurrent esophageal cancer: 20-year experience in a single institution in Japan

PURPOSE

The purpose of the present study was to evaluate patterns of recurrence after salvage chemoradiotherapy (SCRT) for postoperative loco-regional recurrent esophageal cancer.

METHODS

We reviewed records for 114 patients with postoperative loco-regional recurrent esophageal cancer treated by platinum-based chemoradiotherapy between 2000 and 2020, and we evaluated the patterns of failure in patients who had recurrence again or who had been observed for 2 years or more after SCRT at the last observation date.

RESULTS

One hundred and three patients were enrolled in this study. The median observation period for survivors was 60 months. Fifty-three patients died of esophageal cancer and nine patients died of other diseases. The 5-year overall survival rate, cause-specific survival rate and disease-control rate were 43.7%, 45.3% and 37.0%, respectively. Sixty-five patients had failure after SCRT. In those patients, 26 patients had only distant organ or non-regional lymph node metastases, 26 patients had only loco-regional failure, and 13 patients had both. Of those 65 patients, 64 patients showed failure within 42 months after SCRT. Of 39 patients with loco-regional failure, failure in the irradiated field was observed in 28 patients. Of those 28 patients, 27 patients showed failure within 24 months and the other patient showed failure at 26.5 months.

CONCLUSIONS

The patterns of failure after SCRT for patients with postoperative loco-regional recurrent esophageal cancer were shown. The patterns of failure suggest that follow-up for at least 4 years after SCRT should be performed for those patients.