Salvage esophagectomy combined with partial aortic wall resection following thoracic endovascular aortic repair

Preoperative management of patients with oesophageal cancer: Expert recommendations

The aim of this work is to establish recommendations for the preoperative evaluation and selection of patients with malignant oesophageal neoplasms, who are candidates for surgical resection with curative intent, based on the consensus established by a group of experts. Using the Delphi methodology and after 2 rounds of evaluation, responses were obtained from 37 experts to 47 questions about the preoperative management of oesophageal cancer, considering consensus if there was a mean score greater than 8 (range between 0-10). Of the respondents, 54% were women, with a mean age of 50.2 years, with more than 15 years of average experience in oesophageal surgery. In the preoperative evaluation, agreement was obtained on most of the recommendations, with the indication of a staging laparoscopy being the only one where it was not reached. In the preoperative optimisation, agreement was reached on nutritional, anaemia, physical status, respiratory and comorbidities evaluation, but no agreement was reached on recommending immunonutrition or echocardiography routinely. In the inoperability criteria were included ECOG greater than 1, impaired lung function, and/or Child B or C liver cirrhosis. Agreement was reached on considering unresectable tumours with invasion of the tracheobronchial tract, large vessels, and spinal column, multivisceral metastases, and/or peritoneal carcinomatosis. Therefore, the recommendations established in this manuscript may be useful to support decision-making in daily clinical practice, with a high degree of consensus that decisions regarding the management of these patients should be made on an individual basis and within a multidisciplinary committee of experts.

Surgical and long-term outcomes of combined organ resection for esophageal cancer invading adjacent organs: Experience of 90 consecutive cases

OBJECTIVE

To evaluate the feasibility of and long-term survival with combined organ resection for esophageal cancer (EC). The optimal treatment strategy for EC that is invading adjacent organs is not established.

METHODS

Ninety patients with EC invading adjacent organs who underwent combined organ resection after induction treatments during the time period 2003-2023 in our institute were eligible for the study. Short- and long-term outcomes were assessed, and survival analysis was performed to identify prognostic parameters in this cohort.

RESULTS

Most patients had primary tumors (78.9% vs 21.1% with recurrent disease). The resected organs were the trachea/bronchus in 75.6%, large vessels in 24.4%, and both in 5.6%. All but 1 patient underwent chemotherapy or chemoradiotherapy as prior induction treatment, and had R0 resection. The overall complication rate (Clavien-Dindo grade II or greater) was 54.4%, and in-hospital mortality was 2.2% (30- and 90-day mortality: 0% and 2.2%, respectively). Of the deaths, 47 (87.0%) were attributed to EC and 7 (13.0%) to other causes. Median disease-free survival was 6.5 months, and overall survival (OS) was 18.9 months. The 2-year OS values were 47.2% with trachea/bronchus resection, 38.4% with large-vessel involvement, and 37.5% if both were involved. Univariate analysis of OS demonstrated significant associations of operation time (hazard ratio [HR], 2.11; P = .0080), blood loss (HR, 2.85; P = .0003), all-layer tracheal resection (HR, 3.51; P = .0045), ypT (HR, 2.04; P = .022), and pathologic response (HR, 2.77; P = .0089).

CONCLUSIONS

If patient selection is highly selected, combined organ resection may be a feasible and promising option as a part of the multidisciplinary treatment for EC invading an adjacent organ.

Efficacy of thoracic endovascular aortic repair for aorto-esophageal fistula due to esophageal cancer: a systematic review and meta-analysis

Aorto-esophageal fistula (AEF) due to esophageal cancer (EC) is a life-threatening condition characterized by sudden hemorrhage, which often causes sudden death. To evaluate the efficacy and safety of thoracic endovascular aortic repair (TEVAR) for AEF due to EC, we performed a systematic review and meta-analysis. We searched the MEDLINE (PubMed) databases, the Cochrane Library databases, Ichushi-Web (the databases of the Japan Medical Abstract Society), and CiNii (Academic information search service of the National Institute of Information from Japan) from January 2000 to November 2023 for articles about TEVAR for an emergent aortic hemorrhage (salvage TEVAR [S-TEVAR]), and the prophylactic procedure (P-TEVAR). Six studies (140 cases) were eligible for meta-analysis. The 90-day mortality of S-TEVAR and P-TEVAR was 40% (95% CI 23-60, I2 = 36%) and 8% (95% CI 3-17, I2 = 0%), respectively. Post-S-TEVAR hemorrhagic and infectious complications were 17% (95% CI 3-57, I2 = 71%) and 20% (95% CI 5-57, I2 = 66%), respectively. Post-P-TEVAR hemorrhagic and infectious complications were 2% (95% CI 0-10, I2 = 0%) and 3% (95% CI 1-12, I2 = 0%), respectively. TEVAR for AEF due to EC may be a useful therapeutic option to manage or prevent hemorrhagic oncological emergencies.

Therapeutic strategy aiming at R0 resection for borderline-resectable esophageal squamous cell carcinoma using induction chemotherapy with docetaxel, cisplatin, and 5-fluorouracil

OBJECTIVE

Treatment for borderline resectable (cT3br) esophageal squamous cell carcinoma (SCC) is currently undefined. This study aimed to analyze the outcome of treatment strategies including induction chemotherapy with docetaxel, cisplatin, and 5-fluorouracil (DCF) against T3br esophageal SCC.

METHODS

A total of 32 patients with cT3br esophageal SCC enrolled in this study were treated with two cycles of DCF induction therapy.

RESULTS

The overall response rate to DCF induction therapy was 62.5%, while the disease control rate was 93.8% (complete response (CR), three; partial response (PR), 17; stable disease (SD), 10; progressive disease (PD), 2). After DCF induction chemotherapy, 27 patients underwent conversion surgery (CS) and five patients underwent definitive chemoradiotherapy (CRT). Out of 27 patients who underwent CS, 17 underwent transthoracic esophagectomy and 10 underwent thoracoscopic esophagectomy. Anastomotic leakage occurred in five patients (18.5%) and pneumonia in four (14.8%). Recurrent laryngeal nerve paralysis and arrhythmia were observed in two patients (7.4%). The R0 resection rate was 81.5%. Among the five patients who underwent definitive CRT, only one patient (20.0%) achieved CR. Two patients (40.0%) had PR and two (40.0%) had PD. Salvage esophagectomy was performed in one patient after definitive CRT. The 1-, 3-, and 5-year overall survival rates were 75.0, 50.6, and 46.4%, respectively, whereas the 1-, 3-, and 5-year disease-free survival rates were 54.9, 38.8, and 38.8%, respectively.

CONCLUSION

DCF induction therapy and subsequent CS or definitive CRT are promising treatment strategies for cT3br esophageal SCC.

Surgical strategies for treatment of clinical T4 esophageal cancer in Japan

Definitive chemoradiation (dCRT) is the mainstay treatment for cStage IVa esophageal squamous cell carcinoma (ESCC) with good performance status (PS), according to standard practice guidelines. Salvage surgery may incur operation complications and risk of mortality. According to the esophageal cancer practice guidelines outlined by the Japan Esophageal Society, when a tumor is residual and recurrent, chemotherapy and palliative symptomatic treatment is continued. However, salvage operation has been selected as a therapeutic option for recurrent or residual tumors after dCRT. There is weak evidence for not recommending surgery for cStage IVa ESCC exhibiting residual disease following dCRT. It has been reported that during salvage surgery the only prognostic factor that is thought to be performed is complete resection (R0), but at the same time, salvage esophagectomy increases the incidence of postoperative complications and mortality. The phase II chemoselection study by Yokota T et al. in Japan showed that multidisciplinary treatment initiated by induction therapy, in which docetaxel is added to cisplatin and 5-fluorouracil, resulted in a good prognosis in the short term. In this review, we discuss the surgical strategy and future of unresectable clinical T4 (cT4) ESCC.

Comparison of Clinical Outcomes between Salvage and Elective Thoracic Endovascular Aortic Repair in Patients with Advanced Esophageal Cancer with Aortic Invasion: A Retrospective Cohort Study

Aortoesophageal fistula (AEF) caused by esophageal cancer (EC) is a rare but life-threatening complication. However, the optimal management strategy remains undetermined. Previous cases have demonstrated that thoracic endovascular aortic repair (TEVAR) is effective for prophylactic management. In our study, we evaluated the management of AEF with elective TEVAR over salvage TEVAR. In our single-center retrospective cohort study, forty-seven patients with cT4M0 EC were included in this study, and we divided them into salvage (Group S) and elective (Group E) groups based on whether TEVAR was performed before the hemorrhagic AEF occurred. Our study outcomes included survival and complication rate after TEVAR. Group E showed better overall 90-day survival and aortic-event-free survival in 90-day and 180-day over Group S. More patients in Group E could receive subsequent chemoradiotherapy or esophagectomy. Significantly fewer AEF-related complications, including recurrent hemorrhagic events after TEVAR, hypoperfusion-related organ injury, and bloodstream infection, were noted in Group E. In patients with advanced EC-invading aorta, elective TEVAR offered an early overall and aortic-event-free survival benefit compared to salvage TEVAR. By reducing the AEF-related complications, elective TEVAR could provide more patients receiving subsequent curative-intent treatment.

The Long-Term Clinical Impact of Thoracic Endovascular Aortic Repair (TEVAR) for Advanced Esophageal Cancer Invading Aorta

Background

Advanced esophageal cancer invading the aorta is considered unsuitable for surgery with definitive chemotherapy or chemoradiation as the treatments of choice. In the current study, we evaluated the long-term clinical impact of combining thoracic endovascular aortic repair (TEVAR) with multimodality treatment in caring for such patients.

Methods

We evaluated 48 patients who had advanced esophageal cancer with aortic invasion. The oncological outcome, including overall survival (OS) and progression-free survival (PFS), after multimodality treatment with or without TEVAR is evaluated for these patients.

Results

Overall, 25/48 patients (52.1%) received a TEVAR procedure. There was no significant difference in OS (p = 0.223) between patients who did or did not receive TEVAR; however, patients who received TEVAR had significantly less local tumor recurrence (p = 0.020) and longer PFS (p = 0.019). This impact was most evident in patients who received both TEVAR and esophagectomy, with an incremental increase in hazard ratio (HR) for disease progression of 2.89 (95% confidence interval [CI] 0.86–9.96) and 4.37 (95% CI 1.33–14.33) observed under multivariable analysis, respectively, in comparison with patients who underwent only one or neither of these procedures (p = 0.005 for trend test).

Conclusion

TEVAR is a feasible procedure for esophageal cancers invading the aorta and can be used for curative-intent resection to improve local tumor control and PFS.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-10081-3.

Thoracic endovascular aortic repair for esophageal cancer invading the thoracic aorta: a questionnaire survey study

BACKGROUND

Locally advanced esophageal cancer occasionally invades the aorta, and hemorrhage from the esophagoaortic fistula can cause sudden death. Thoracic endovascular aortic repair (TEVAR) enables hemostasis in such cases, and prophylactic TEVAR can prevent fatal hemorrhagic events during treatment. However, its efficacy in Japan has not been evaluated. This study aimed to clarify the clinical significance of TEVAR in esophageal cancer patients.

METHODS

The Japan Esophageal Society conducted a questionnaire survey targeting authorized or semi-authorized member institutes of the Authorized Institutes for Board Certified Esophageal Surgeons. Patients who underwent TEVAR for esophageal cancer were identified from 19 institutes. Data on patient demographics, treatment performed, and survival rate were obtained using the questionnaire. The Kaplan-Meier method was used for survival analysis and to compare differences in survival rates between those who underwent TEVAR for hemorrhage and those for preoperative prophylaxis.

RESULTS

Of the 41 patients identified, 20 patients underwent TEVAR for hemorrhage or impending hemorrhage from the esophagoaortic fistula, while 21 patients underwent TEVAR as preoperative prophylaxis. The median survival time after TEVAR was 135 days in the hemorrhage or impending hemorrhage group and 378 days in the preoperative prophylaxis group. Eighteen patients underwent esophagectomy after TEVAR. No hemorrhagic event was observed during the perioperative period. The median survival time of the patients who underwent esophagectomy was 373 days. Some patients who achieved R0 resection obtained long-term survival.

CONCLUSION

TEVAR is an efficacious modality to control a life-threatening hemorrhage from esophagoaortic fistula and helps to prolong the survival of patients with locally advanced esophageal cancer invading the aorta.