Clinical relevance of histologic subtypes in locally advanced esophageal carcinoma treated with pre-operative chemoradiotherapy: Experience of a monographic oncologic centre

Incidence and management of esophageal cancer recurrence to regional lymph nodes after curative esophagectomy

Up to 50% of patients treated with curative esophagectomy for esophageal cancer will develop recurrence, contributing to the dismal survival associated with this disease. Regional recurrence may represent disease that is not yet widely metastatic and may therefore be amenable to more-aggressive treatment. We sought to assess all patients treated with curative esophagectomy for esophageal cancer who developed regional recurrence. We retrospectively identified all patients who underwent esophagectomy for esophageal adenocarcinoma and esophageal squamous cell carcinoma at a single institution from January 2000 to August 2019. In total, 1626 patients were included in the study cohort. As of June 2022, 595 patients had disease recurrence, which was distant or systemic in 435 patients (27%), regional in 125 (7.7%) and local in 35 (2.2%). On multivariable analysis, neoadjuvant chemoradiation with a total radiation dose <45 Gy (hazard ratio [HR], 3.5 [95% CI, 1.7-7.3]; P = .001), pathologic node-positive disease (HR, 1.9 [95% CI, 1.3-3.0]; P = .003) and lymphovascular invasion (HR, 1.6 [95% CI, 1.0-2.5]; P = .049) were predictors of isolated nodal recurrence, whereas increasing age (HR, 0.97 [95% CI, 0.96-0.99]; P = .001) and increasing number of excised lymph nodes (HR, 0.98 [95% CI, 0.95-1.00]; P = .021) were independently associated with decreased risk of regional recurrence. Patients treated with a combination of local and systemic therapies had better survival outcomes than patients treated with systemic therapy alone (P < .001). In patients with recurrence of esophageal cancer limited to regional lymph nodes, salvage treatment may be possible. Higher radiation doses and more-extensive lymphadenectomy may reduce the risk of regional recurrence.

ESOPHAGEAL CANCER MORTALITY IN BRAZIL: A TIME-SERIES ANALYSIS FROM THE GLOBAL BURDEN OF DISEASE STUDY

BACKGROUND

In the world, around 450,000 new cases of esophageal cancer are diagnosed each year.

OBJECTIVE

To evaluate the trend of esophageal cancer mortality rates in Brazil between 1990-2017.

METHODS

A time series study using data on mortality from esophageal cancer in residents ≥30 years in Brazil from 1990 to 2017. Data was estimated by the Global Burden of Disease (GBD) study and analyzed according to sex, age group and federal unit of Brazil. The standardized rates according to age were calculated by the direct method using the standard GBD world population. Annual average percentage change and 95% confidence interval (95% CI) were calculated for mortality by Joinpoint regression.

RESULTS

The age-standardized mortality rate in males was 20.6 in 1990 and 17.6/100,000 in 2017, increasing according to age, being 62.4 (1990) and 54.7 (2017) for ≥70 years. In women, the age-standardized mortality rate was 5.9 in 1990 and 4.2/100,000 in 2017. There was a reduction in mortality rates in all age groups and both sexes with great variation among the states.

CONCLUSION

Despite the high mortality rates for esophageal cancer in Brazil, the trend was decreasing, but with regional differences. Mortality was around four times higher in men.

Synchronous Esophageal and Lung Cancers - Is Combined Anatomic Resection Appropriate?

BACKGROUND

This study evaluates the safety and feasibility of combined resection for patients with synchronous pulmonary and esophageal cancer.

METHODS

Patients undergoing esophagectomy between 1997 and 2019 were identified from prospectively collected databases at three tertiary referral centers, and those with combined anatomic lung resection at the same setting were identified. This cohort was then matched in a 1:3 ratio to esophagectomy alone cases, based on age, sex, pathologic stage, neoadjuvant therapy, and surgical procedure. Demographic data, peri-operative data, post-operative complications were compared. Statistical analysis included unpaired t-test, Fisher's exact or chi-squared test and Gehan-Breslow analysis.

RESULTS

Of 4729 esophagectomies, combined anatomic lung resection was performed in 18 patients with discrete pulmonary lesions. Matching yielded 49 patients who underwent esophagectomy only and was statistically similar compared to patients undergoing combined resections. Ivor Lewis esophagectomy and lobectomy were the most frequent procedures. Combined resections did not have a higher overall complication rate than esophagectomy alone, rather these patients had fewer overall complications (56% vs 84%; p=0.02). Specifically, there was not difference in anastomotic leak (17% vs. 18%) or pulmonary complications (39% vs. 33%) between combined resection and esophagectomy alone. No post-operative mortality was identified, and median overall survival was 4.1 years versus 6.5 years (p=0.10).

CONCLUSIONS

Patients with synchronous localized lung and esophageal cancer, although rare, should not be biased towards non-surgical therapy, as the morbidity associated with combined esophagectomy and anatomic lung resection does not differ significantly from esophagectomy alone in this highly selected group of patients.

Comparison of the effect of postoperative radiotherapy with surgery alone for esophagus squamous cell carcinoma patients: A meta-analysis

BACKGROUND

This meta-analysis was conducted to evaluate the effect of postoperative radiotherapy for patients having esophagus squamous cell carcinoma after radical surgery.

METHODS

A comprehensive research was performed in Pubmed, Embase and Cochrane Library electronic databases from inception until December 10, 2017. We collected all published full articles about comparison of surgery plus postoperative radiotherapy with surgery alone.

RESULTS

Four randomized-controlled trials (RCTs) with 1050 participants and 8 non-randomized-controlled trials with 3248 participants were included and evaluated separately. The risk ratio rate and its 95% confidence interval (CI) were calculated. Both RCTs and non-randomized-controlled trials (NRCTs) groups showed a significant increase in 3-year overall survival (OS) rate (RRRCT = 0.89, 95% CI: 0.80-0.99; RRNRCT = 0.82, 95% CI: 0.76-0.88) and decrease locoregional recurrence rate (RRRCT = 0.53, 95% CI: 0.43-0.66; RRNRCT = 0.47, 95% CI: 0.32-0.69) after postoperative radiotherapy compared with surgery alone. The 5-year OS rate in the group of NRCTs was markedly enhanced (RR = 0.87, 95% CI: 0.82-0.92), while that of the RCTs group was not enhanced in a significant way (RR = 0.84, 95% CI: 0.70-1.02). Subgroup analysis based on pathological lymph node status revealed that postoperative radiotherapy could improve OS regardless of pathological lymph node status (pathological lymph node positive patients: RR5-year os-RCT = 0.81, 95% CI: 0.70-0.93; RR5-year os-NRCT = 0.87, 95% CI: 0.80-0.94; Pathological lymph node negative patients: RR3-year os-RCT = 0.76, 95% CI: 0.59-0.96; RR3-year os-NRCT = 0.52, 95% CI: 0.30-0.89). No effect on distant recurrence rate was detected. Adverse effects induced by postoperative radiotherapy were comparatively modest and tolerable.

CONCLUSION

Polled results yielded that postoperative radiotherapy was promising in improving OS and reducing the locoregional recurrence rate. More large-scale up-to-date RCTs are needed to further validate the use of postoperative radiotherapy in modern practice.