Impact of curative treatment on the physical fitness of patients with esophageal cancer: A systematic review and meta-analysis

Integrating single-cell sequencing and machine learning to uncover the role of mitophagy in subtyping and prognosis of esophageal cancer

Globally, esophageal cancer stands as a prominent contributor to cancer-related fatalities, distinguished by its poor prognosis. Mitophagy has a significant impact on the process of cancer progression. This study investigated the prognostic significance of mitophagy-related genes (MRGs) in esophageal carcinoma (ESCA) to elucidate molecular subtypes. By analyzing RNA-seq data from The Cancer Genome Atlas (TCGA), 6451 differentially expressed genes (DEGs) were identified. Cox regression analysis narrowed this list to 14 MRGs with potential prognostic implications. ESCA patients were classified into two distinct subtypes (C1 and C2) based on these genes. Furthermore, leveraging the differentially expressed genes between Cluster 1 and Cluster 2, ESCA patients were classified into two novel subtypes (CA and CB). Importantly, patients in C2 and CA subtypes exhibited inferior prognosis compared to those in C1 and CB (p < 0.05). Functional enrichments and immune microenvironments varied significantly among these subtypes, with C1 and CB demonstrating higher immune checkpoint expression levels. Employing machine learning algorithms like LASSO regression, Random Forest and XGBoost, alongside multivariate COX regression analysis, two core genes: HSPD1 and MAP1LC3B were identified. A prognostic model based on these genes was developed and validated in two external cohorts. Additionally, single-cell sequencing analysis provided novel insights into esophageal cancer microenvironment heterogeneity. Through Coremine database screening, Icaritin emerged as a potential therapeutic candidate to potentially improve esophageal cancer prognosis. Molecular docking results indicated favorable binding efficacies of Icaritin with HSPD1 and MAP1LC3B, contributing to the understanding of the underlying molecular mechanisms of esophageal cancer and offering therapeutic avenues.

The course of physical fitness and nutritional status in patients following prehabilitation before esophageal cancer surgery: Results from the PRIOR study

INTRODUCTION

This study evaluates the course of physical fitness and nutritional status during curative therapy for esophageal cancer, after implementation of a prehabilitation program. Additionally, the impact of baseline physical fitness level and severe postoperative complications on the course of individual patients were explored.

MATERIALS AND METHODS

This multicenter, observational cohort study included patients with esophageal cancer following curative treatment. Prehabilitation, consisting of supervised exercise training and nutritional counseling was offered as standard care to patients after neoadjuvant therapy, prior to surgery. Primary outcome measures included change of exercise capacity, hand grip strength, self-reported physical functioning, Body Mass Index, and malnutrition risk from diagnosis to 2-6 months postoperatively. Analyses over time were performed using linear mixed models, and linear mixed regression models to investigate the impact of baseline level and severe postoperative complications.

RESULTS

Hundred sixty-eight patients were included (mean age 65.9 ± 8.6 years; 78.0 % male). All parameters (except for malnutrition risk) showed a decline during neoadjuvant therapy (p < .05), an improvement during prehabilitation (p < .005) and a decline postoperatively (p < .001), with a high heterogeneity between patients. Change in the outcomes from baseline to postoperatively was not different for patients with or without a severe complication. Better baseline physical fitness and nutritional status were significantly associated with a greater decline postoperatively (p < .001).

CONCLUSION

This study demonstrates a notable decline during neoadjuvant therapy, that fully recovers during prehabilitation, and a subsequent long lasting decline postoperatively. The heterogeneity in the course of physical fitness and nutritional status underlines the importance of individualized monitoring.

Association of Preoperative Physical Fitness With Post-Esophagectomy Pneumonia in Older With Locally Advanced Esophageal Cancer: An Exploratory Prospective Study

BACKGROUNDS

Currently, there is a lack of evidence of prehabilitation during neoadjuvant chemotherapy (NAC) to prevent pneumonia of older patients. This study aimed to investigate the association of preoperative physical fitness after NAC with post-esophagectomy pneumonia in older patients with locally advanced esophageal cancer (LAEC).

METHODS

This single-center exploratory prospective cohort study included 80 patients aged ≥ 65 years with LAEC scheduled for curative esophagectomy after NAC between 2021 and 2023. The post-NAC short incremental shuttle walk test (ISWT) by sex was established using the Youden index. The association of the post-NAC short ISWT with postoperative pneumonia was investigated via Firth's penalized logistic regression model with statistical significance set as two-tailed p < 0.05.

RESULTS

A total of 69 patients were analyzed. The mean post-NAC ISWT values were 353.5 m. Short ISWT distance was defined as ≤ 395 and ≤ 195 m for men and women, respectively. Postoperative pneumonia developed in 17 (25%) patients. Short post-NAC ISWT distance was significantly associated with postoperative pneumonia (adjusted odds ratio: 1.840, 95%CI: 1.760-28.440, p = 0.004).

CONCLUSIONS

Decline in physical fitness was associated with post-esophagectomy pneumonia, which may be a key targeted factor of prehabilitation during NAC for older patients with LAEC.

Identification of subgroups of patients with oesophageal cancer based on exercise intensity during prehabilitation

PURPOSE

To identify subgroups of patients with oesophageal cancer based on exercise intensity during prehabilitation, and to investigate whether training outcomes varied between subgroups.

MATERIALS AND METHODS

Data from a multicentre cohort study were used, involving participants following prehabilitation before oesophagectomy. Hierarchical cluster analysis was performed using four cluster variables (intensity of aerobic exercise, the Borg score during resistance exercise, intensity of physical activity, and degree of fatigue). Aerobic capacity and muscle strength were estimated before and after prehabilitation.

RESULTS

In 64 participants, three clusters were identified based on exercise intensity. Cluster 1 (n = 23) was characterised by fatigue and physical inactivity, cluster 2 (n = 9) by a low training capacity, despite high physical activity levels, and cluster 3 (n = 32) by a high training capacity. Cluster 1 showed the greatest improvement in aerobic capacity (p = 0.37) and hand grip strength (p = 0.03) during prehabilitation compared with other clusters.

CONCLUSIONS

This cluster analysis identified three subgroups with distinct patterns in exercise intensity during prehabilitation. Participants who were physically fit were able to train at high intensity. Fatigued participants trained at lower intensity but showed the greatest improvement. A small group of participants, despite being physically active, had a low training capacity and could be considered frail.

Effectiveness of prehabilitation during neoadjuvant therapy for patients with esophageal or gastroesophageal junction cancer: a systematic review

Progression of the physical weakness during neoadjuvant therapy (NAT) in patients with esophageal or gastroesophageal junction cancer is a serious problem; however, prehabilitation during NAT has the potential to overcome the unmet need. Nevertheless, systematic reviews on this topic have not been summarized. Therefore, this systematic review aimed to determine prehabilitation's effectiveness, acceptability, and safety during NAT for patients with esophageal or gastroesophageal junction cancer. An electronic search was performed in the MEDLINE, Web of Science, CENTRAL, CINAHL, and PEDro databases. A meta-analysis was conducted to assess the effectiveness of prehabilitation during NAT, along with a descriptive analysis of acceptance and safety. This study analyzed data from three randomized controlled trials (RCTs) and nine non-RCTs involving 664 patients. The meta-analysis of two RCTs demonstrated that prehabilitation during NAT may be more effective than usual care in enhancing tolerance to NAT and grip strength; moreover, one RCT and three non-RCTs revealed that prehabilitation may reduce the risk of postoperative complications. The adherence rates for exercise programs in two RCTs and seven non-RCTs were 55-76%. Additionally, two studies reported a 76% adherence rate for multimodal prehabilitation programs, including exercise, dietary, and psychological care. Six studies reported no serious prehabilitation-related adverse events during NAT. Prehabilitation during NAT may be a safe and beneficial intervention strategy for patients with esophageal or gastroesophageal junction cancer. However, the investigation of strategies to enhance adherence is essential. Furthermore, additional high-quality RCTs are needed to examine the effect of prehabilitation during NAT.

Optimizing Recovery: A Comprehensive Case Report on Physiotherapy Rehabilitation in Esophagectomy Patients

Esophageal carcinoma (CA) represents a significant global health risk, attributable to its origin from esophageal epithelium, among many other associated risk factors. Its alarming rise in younger age groups, especially among females, is concerning, even though historically, it has been more common in older populations. This modification emphasizes how complex the interaction of genetic susceptibility, environmental factors, and lifestyle choices is in determining the course of a disease. It is impossible to overstate the importance of an early diagnosis and multidisciplinary care, especially for younger patients where delayed detection is expected. Through the use of evidence-based practices, physical therapy has emerged as a crucial part of the overall care of patients with esophageal cancer. The six-minute walk test (6MWT), a popular physiotherapy evaluation tool, can be used to evaluate functional ability and exercise tolerance. Understanding how well younger people can exercise using the 6MWT is significant since they have more excellent exercise capacity than older people. This test helps physiotherapists evaluate the improvement of a patient's exercise capacity before and after the rehabilitation. In this case study, the 31-year-old woman's incredible recovery from esophageal cancer was made possible by extensive cardio-respiratory physiotherapy rehabilitation, demonstrating the significant influence of this physiotherapeutic intervention on functional status and general well-being. Through this study, we contribute to the advancement of scientific knowledge as well as the caring, patient-centered ideology that guides oncology treatment today.

Treatment and Rehabilitation for Esophageal Cancer-Striving to Meet Obstacles and Long-term Impacts: A Qualitative Descriptive Study

BACKGROUND

Following esophagogastric cancer treatment, patients with esophageal cancer and their relatives struggle with adjusting to a new everyday life as they experience various challenges after treatment requiring rehabilitation. Health professionals must address long-term impacts on patients' health, everyday life, family functioning, and support needs.

OBJECTIVE

This qualitative descriptive study aimed to explore patients', relatives', and health professionals' experience with long-term impacts and rehabilitation after treatment for esophageal cancer.

METHODS

A qualitative approach based on a phenomenological-hermeneutical methodology was used. Two methods were selected in the study: focus group interviews with health professionals and individual interviews with patients and relatives. Inductive thematic analysis with inspiration from Braun and Clarke was used for data analysis.

RESULTS

Three main themes emerged from the data analysis: (1) forced into limitations in everyday life, (2) learning and navigating a new everyday life, and (3) rehabilitation accepting new normality.

CONCLUSION

Patients and relatives experience persistent long-term impacts after treatment for esophageal cancer, making rehabilitation strenuous and demanding. Relatives take considerable responsibility for the patients' rehabilitation but feel invisible and unsupported by health professionals. Health professionals acknowledge the severity of long-term impacts but fail to prepare patients and relatives for the impacts and do not see the relatives' need for support.

IMPLICATIONS FOR PRACTICE

The study emphasizes the need for a proactive approach in the healthcare system, addressing patients' and relatives' physical and psychological vulnerability. Cancer nurses need to prepare and involve patients and relatives in treatment, long-term impacts, and rehabilitation.

A Combat Journey of Rehabilitation in Pre- and Post-chemotherapy for Esophagus Carcinoma

Esophageal cancer is a malignant epithelial alteration that takes place in the middle or upper part of the esophagus. Given the escalating population of individuals who have successfully overcome esophageal cancer, the significance of addressing disease- and treatment-associated complaints and symptoms is increasingly pertinent. This highlights the necessity of interventions meant to enhance quality of life (QOL). We present the case of a 60-year-old female diagnosed with esophageal squamous cell carcinoma who presented with chief complaints of generalized weakness, breathlessness, and nausea. Patient-tailored physiotherapy pre-rehabilitation and post-rehabilitation, including strengthening exercises, breathing exercises, dyspnea-relieving positions, Mendelsohn maneuver, Shaker exercise, among others, were administered. These interventions proved effective in enhancing the patient's functional independence and QOL. Treatment commenced one week prior to the first chemotherapy session. Post-chemotherapy intervention was provided, and on the day of discharge, follow-up revealed improved strength and QOL.

Application of Nanoparticles in Cancer Treatment: A Concise Review

Timely diagnosis and appropriate antitumoral treatments remain of utmost importance, since cancer remains a leading cause of death worldwide. Within this context, nanotechnology offers specific benefits in terms of cancer therapy by reducing its adverse effects and guiding drugs to selectively target cancer cells. In this comprehensive review, we have summarized the most relevant novel outcomes in the range of 2010-2023, covering the design and application of nanosystems for cancer therapy. We have established the general requirements for nanoparticles to be used in drug delivery and strategies for their uptake in tumor microenvironment and vasculature, including the reticuloendothelial system uptake and surface functionalization with protein corona. After a brief review of the classes of nanovectors, we have covered different classes of nanoparticles used in cancer therapies. First, the advances in the encapsulation of drugs (such as paclitaxel and fisetin) into nanoliposomes and nanoemulsions are described, as well as their relevance in current clinical trials. Then, polymeric nanoparticles are presented, namely the ones comprising poly lactic-co-glycolic acid, polyethylene glycol (and PEG dilemma) and dendrimers. The relevance of quantum dots in bioimaging is also covered, namely the systems with zinc sulfide and indium phosphide. Afterwards, we have reviewed gold nanoparticles (spheres and anisotropic) and their application in plasmon-induced photothermal therapy. The clinical relevance of iron oxide nanoparticles, such as magnetite and maghemite, has been analyzed in different fields, namely for magnetic resonance imaging, immunotherapy, hyperthermia, and drug delivery. Lastly, we have covered the recent advances in the systems using carbon nanomaterials, namely graphene oxide, carbon nanotubes, fullerenes, and carbon dots. Finally, we have compared the strategies of passive and active targeting of nanoparticles and their relevance in cancer theranostics. This review aims to be a (nano)mark on the ongoing journey towards realizing the remarkable potential of different nanoparticles in the realm of cancer therapeutics.

Patients Undergoing Systemic Anti-Cancer Therapy Who Require Surgical Intervention: What Surgeons Need to Know

As part of routine cancer care, patients may undergo elective surgery with the aim of long-term cure. Some of these patients will receive systemic anti-cancer therapy (SACT) in the neoadjuvant and adjuvant settings. The majority of patients, usually with locally advanced or metastatic disease, will receive SACT with palliative intent. These treatment options are expanding beyond traditional chemotherapy to include targeted therapies, immunotherapy, hormone therapy, radionuclide therapy and gene therapy. During treatment, some patients will require surgical intervention on an urgent or emergency basis. This narrative review examined the evidence base for SACT-associated surgical risk and the precautions that a surgical team should consider in patients undergoing SACT.

State of the art of enhanced recovery after surgery (ERAS) protocols in esophagogastric cancer surgery: the Western experience

Enhanced recovery after surgery (ERAS) programs provide a framework to standardize care processes and improve outcomes. The results of this multimodal and multidisciplinary approach based on actions focused on reducing physiological surgical stress in the preoperative, intraoperative, and postoperative periods are beneficial in reducing morbidity and hospital stay, without increasing readmissions across different surgical settings. The implementation of ERAS in resection procedures of esophageal and gastric cancer has been challenging due to the complexity of these surgical techniques and the high risk of complications. Despite the limited evidence of ERAS in esophagectomy operations, systematic reviews and meta-analysis have confirmed a reduction of pulmonary complications and hospital stay without increasing readmissions. In gastrectomy operations, the implementation of ERAS reduces the use of nasogastric tubes and intraabdominal drains, facilitates early diet, and reduces the length of hospital stay, without increasing complications. There is, however, wide heterogeneity and absence of standardization in the number and definition of the ERAS components. The development of ERAS consensus guidelines including procedure-specific components may reduce this variability. Regardless growing evidence of the effectiveness of ERAS, the adherence rate is still low. The commitment of the multidisciplinary team and leadership is critical in the application and refinement of ERAS protocols in parallel with periodic audits. Pre- and post-habilitation methods are emerging concepts to be incorporated in ERAS protocols.

Adequate Management of Postoperative Complications after Esophagectomy: A Cornerstone for a Positive Outcome

BACKGROUND

Esophagectomy for cancer is one of the most complex procedures in visceral surgery. Postoperative complications negatively affect the patient's overall survival. They are not influenced by the histology type (adenocarcinoma (AC)/squamous cell carcinoma (SCC)), or the surgical approach (open, laparoscopic, or robotic-assisted). Among those dreadful complications are anastomotic leak (AL), esophago-respiratory fistula (ERF), and chylothorax (CT).

METHODS

In this review, we summarize the methods to avoid these complications, the diagnostic approach, and new therapeutic strategies.

RESULTS

In the last 20 years, both centralization of the medical care, and the development of endoscopy and radiology have positively influenced the management of postoperative complications. For the purpose of their prevention, perioperative measures have been applied. The treatment includes conservative, endoscopic, and surgical approaches.

CONCLUSIONS

Post-esophagectomy complications are common. Prevention measures should be known. Early recognition and adequate treatment of these complications save lives and lead to better outcomes.

The Role of Prehabilitation in Modern Esophagogastric Cancer Surgery: A Comprehensive Review

Simple Summary

Surgery is the only potentially curative treatment option for esophagogastric cancer. Although esophagectomy/gastrectomy remains associated with major surgical trauma and significant morbidity. Prehabilitation has emerged as a novel strategy to improve postoperative outcomes by preparing patients for a surgery-associated physiological challenge. We discuss current knowledge and the results of studies on the role of prehabilitation in esophagogastric cancer surgery.

Abstract

Esophagogastric cancer is among the most common malignancies worldwide. Surgery with or without neoadjuvant therapy is the only potentially curative treatment option. Although esophagogastric resections remain associated with major surgical trauma and significant postoperative morbidity. Prehabilitation has emerged as a novel strategy to improve clinical outcomes by optimizing physical and psychological status before major surgery through exercise and nutritional and psychological interventions. Current prehabilitation programs may be unimodal, including only one intervention, or multimodal, combining the benefits of different types of interventions. However, it still is an investigational treatment option mostly limited to clinical trials. In this comprehensive review, we summarize the current evidence for the role of prehabilitation in modern esophagogastric cancer surgery. The available studies are very heterogeneous in design, type of interventions, and measured outcomes. Yet, all of them confirm at least some positive effects of prehabilitation in terms of improved physical performance, nutritional status, quality of life, or even reduced postoperative morbidity. However, the optimal interventions for prehabilitation remain unclear; thus, they cannot be standardized and widely adopted. Future studies on multimodal prehabilitation are necessary to develop optimal programs for patients with esophagogastric cancer.

Skeletal muscle wasting during neoadjuvant therapy as a prognosticator in patients with esophageal and esophagogastric junction cancer: A systematic review and meta-analysis

BACKGROUND

Considerable controversies exist regarding the severity of skeletal muscle wasting (SMW) during neoadjuvant therapy (NAT) and its impact on therapeutic outcomes in patients with esophageal or esophagogastric junction cancer (EC/EGJC). This systematic review and meta-analysis aimed to resolve these issues. Particularly, the prognostic value of SMW during NAT was compared to pre-NAT and pre-surgery sarcopenia status.

METHODS

We searched PubMed, Embase, and Cochrane Library databases through October 13th, 2021 to identify cohort studies focusing on SMW during NAT and therapeutic outcomes in EC/EGJC patients. Both neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy were studied. A meta-analysis was conducted to quantify SMW and increased sarcopenia during NAT. Therapeutic outcomes include perioperative morbidities and survival profiles. A separate meta-analysis investigating the impacts of pre-NAT/pre-surgery sarcopenia on therapeutic outcomes was synchronously performed.

RESULTS

Twenty-five studies with 2706 participants were included in this review. The pooled SMW during NAT were -2.47 cm²/m² in skeletal muscle index and -0.23 cm²/m² in psoas muscle index, with wasting proportion reaching 4.44%. The pooled prevalence rate of sarcopenia increased from 53.1% before NAT to 65.8% before surgery. Neoadjuvant chemoradiotherapy, advanced age, and being male were identified as risk factors for severe SMW during NAT. Notably, severe SMW during NAT showed a greater hazard ratio (HR) than pre-NAT and pre-surgery sarcopenia in predicting overall survival (HR 1.92, P < 0.001; HR 1.17, P = 0.036; and HR 1.28, P = 0.011, respectively) and recurrence-free survival (HR 1.51, P = 0.002; HR 1.27, P = 0.008; and HR 1.38, P = 0.006, respectively). However, severe SMW during NAT was not significantly associated with perioperative morbidities.

CONCLUSIONS

SMW during NAT is a novel prognosticator that is different from sarcopenia for poor survival in EC/EGJC patients. Interventions aiming at maintaining skeletal muscle during NAT are anticipated to promote therapeutic outcomes.