Postoperative complications and survival after surgical resection of esophageal squamous cell carcinoma

Simultaneous curative resection may improve the long-term survival of patients diagnosed with colorectal liver metastases: A propensity score-matching study

BACKGROUND

The benefit of simultaneous curative resection in patients with colorectal liver metastases has been unclear. Adjuvant chemotherapy is still considered an effective and priority treatment for advanced-stage colorectal patients.

METHODS

We retrospectively collected patients with colorectal liver metastases from January 2012 to October 2023 at the Guangxi Medical University Cancer Hospital. The baseline information was compared between a simultaneous curative resection group and a palliative treatment group. Propensity score matching with a 1:1 ratio was applied to develop comparable cohorts of curative resection and palliative treatment resection. Kaplan-Meier survival and Cox regression analyses were performed to determine the impact of curative resection on survival of colorectal liver metastasis patients. Prognostic nomogram and a web-version calculator were developed based on the multivariate Cox regression method. Then, the concordance index (C-index), receiver operating characteristic, calibration plots, and decision curves analysis were applied to evaluate the prognostic performance of the nomogram.

RESULTS

A total of 716 patients with colorectal liver metastases were enrolled in the study, of whom 131 patients received curative resection. There was no significant difference in terms of baseline information between the curative resection group and the palliative treatment group after propensity score matching. Multivariable Cox regression analysis showed that curative resection was an independent prognostic factor affecting overall survival (P = .001, hazard ratio = 1.95, 95% confidence interval 1.30-2.91). Compared with patients who did not receive curative resection, patients who received simultaneous curative resection had a significant improvement in overall survival before and after propensity score matching (P < .0001 and P = .0047, respectively). Overall survival nomogram showed excellent predictive performance with the C-indexes of 0.686 (95% confidence interval 0.556-0.792). The areas under the receiver operating characteristic curves were 0.75 (95% confidence interval 64.43-96.05), 0.75 (67.22-82.58), and 0.76 (66.10-85.98) for predicting 1-, 3-, and 5-year survival, respectively. The calibration plots and decision curves analysis also indicated the good predictability of the predictive nomogram. Finally, subgroup analysis further demonstrated a favorable impact of curative resection on overall survival in colorectal liver metastasis patients after propensity score matching.

CONCLUSIONS

Simultaneous curative resection may improve the overall survival of patients with colorectal liver metastases and is an independent and effective indicator for predicting overall survival. The nomogram may provide a personalized treatment strategy.

Odontogenic carcinosarcoma: a comprehensive review of clinical and therapeutic insights

Malignant odontogenic tumors are rare, accounting for only 1%-6.1% of all odontogenic tumors. Among them, odontogenic carcinosarcoma (OCS) is an exceptionally rare and aggressive malignant neoplasm originating from dental tissues. First recognized by the World Health Organization (WHO) in 1992, OCS is characterized by high-grade biphasic malignant epithelial and mesenchymal components, contributing to its aggressive clinical behavior. OCS often presents with nonspecific symptoms such as pain, swelling, and loosening of teeth, which complicate early diagnosis. Its rarity adds to the diagnostic challenges, frequently leading to delays in identification. Histopathological evaluation remains the cornerstone for accurate diagnosis, distinguishing OCS from other odontogenic tumors through features like epithelial nuclear pleomorphism, mitotic activity, and mesenchymal sarcomatous differentiation. Management typically involves surgical resection with clear margins, while adjuvant therapies such as chemotherapy and radiation are considered in select cases. Recent advancements in molecular oncology and surgical techniques, including robotic-assisted procedures and 3D-printed reconstructive aids, offer promising avenues for improving patient outcomes. A multidisciplinary approach and ongoing research are essential to enhance diagnostic accuracy, refine treatment protocols, and improve the prognosis for patients affected by this rare malignancy. The primary objective of this review is to consolidate current knowledge on OCS, focusing on its diagnostic complexities, treatment strategies, and potential emerging therapies.

Minimally Invasive Transhiatal Esophagectomy Using Antegrade Inversion Technique in Esophageal Cancer: 10-Year Experience from a Tertiary Care Center

Background: Esophageal cancer surgery aims for curative intent but carries high complication rates. Transthoracic esophagectomy is the dominant approach, however, transhiatal esophagectomy (THE) offers selective advantages in certain clinical scenarios. Minimally invasive THE (MI-THE) is an evolving technique with limited data. Methods: This retrospective study reviewed 38 patients with esophageal cancer who underwent MI-THE using "Antegrade Inversion Technique" between 2013 and 2023 at a tertiary care center. Perioperative outcomes were analyzed. Data were presented as mean with standard deviation, median with interquartile range, and percentages. Results: Most patients (86.8%) had early-stage cancer. Median operative time was 375 minutes, hospital stay was 8 days, and intensive care unit stay was 3 days. All patients achieved a negative resection margin. Pleural effusion (57.9%) was the most common complication, followed by pneumothorax (31.6%) and surgical site infection (15.8%). Anastomotic leak rate was 13.2%. There was no mortality. Conclusions: MI-THE appears safe and feasible with encouraging perioperative outcomes, particularly for early-stage disease and high-risk patients. While potentially offering advantages over open THE, further research is needed to definitively establish its role compared to traditional approaches.

Sex differences in survival following surgery for esophageal cancer: A systematic review and meta-analysis

The impact of sex on the prognosis of patients with esophageal cancer remains unclear. Evidence supports that sex- based disparities in esophageal cancer survival could be attributed to sex- specific risk exposures, such as age at diagnosis, race, socioeconomic status, smoking, drinking, and histological type. The aim of our study is to investigate the role of sex disparities in survival of patients who underwent surgery for esophageal cancer. A systematic review and meta-analysis of the existing literature in PubMed, EMBASE, and CENTRAL from December 1966 to February 2023, was held. Studies that reported sex-related differences in survival outcomes of patients who underwent esophagectomy for esophageal cancer were identified. A total of 314 studies were included in the quantitative analysis. Statistically significant results derived from 1-year and 2-year overall survival pooled analysis with Relative Risk (RR) 0.93 (95% Confidence Interval (CI): 0.90-0.97, I2 = 52.00) and 0.90 (95% CI: 0.85-0.95, I2 = 0.00), respectively (RR < 1 = favorable for men). In the postoperative complications analysis, statistically significant results concerned anastomotic leak and heart complications, RR: 1.08 (95% CI: 1.01-1.16) and 0.62 (95% CI: 0.52-0.75), respectively. Subgroup analysis was performed among studies with <200 and > 200 patients, histology types, study continent and publication year. Overall, sex tends to be an independent prognostic factor for esophageal carcinoma. However, unanimous results seem rather obscure when multivariable analysis and subgroup analysis occurred. More prospective studies and gender-specific protocols should be conducted to better understand the modifying role of sex in esophageal cancer prognosis.

Radiotherapy and chemoradiotherapy for postoperative recurrence in patients with esophageal squamous cell carcinoma

BACKGROUND

The optimal treatment for esophageal squamous cell carcinoma (ESCC) patients with postoperative recurrence remains controversial. We aimed to evaluate the effects of radiotherapy (RT) and chemoradiotherapy (CRT) on postoperative recurrence in ESCC patients.

METHODS

Recurrence ESCC patients who received salvage RT and CRT from January 2015 to January 2019 were retrospectively reviewed. Post-recurrence survival (PRS) and prognostic factors were evaluated by Kaplan-Meier and Cox proportional hazards models, respectively. Subgroup analyses were performed based on pathological lymph node (LN) status (negative/positive) to evaluate the differences in salvage treatments and toxic reaction.

RESULTS

A total of 170 patients were enrolled, with a median age of 60 years (range 43-77). No significant difference was found in the median PRS between the salvage RT and CRT groups (p > 0.05). Multivariate analysis revealed that TNM stage III and IV, macroscopic medullary type, and distant metastasis recurrence pattern were independent prognostic factors (all p < 0.05) for PRS. Salvage treatment was not associated with PRS (p = 0.897). However, in patients with negative LN, CRT was associated with prolonged survival (p = 0.043) and had no significant differences in toxic reactions compared to RT (p = 0.924). In addition, RT showed better prognoses (p = 0.020) and lower toxic reactions (p = 0.030) than CRT in patients with positive LNs.

CONCLUSIONS

Based on prognosis and toxic reactions, ESCC recurrence patients with negative LNs could benefit from CRT, but RT should be recommended for patients with positive LNs.

Radiologic Insertion of a Covered Esophageal Stent Using the Rendezvous Technique: A Case Report

In this report, we present a case of a radiotherapy-induced tracheoesophageal fistula treated with the fluoroscopy-guided insertion of a covered stent through the gastrostomy route using both the antegrade and retrograde approaches. The initial antegrade endoscopic and fluoroscopic stent insertion procedure failed due to severe esophageal stricture. Compared to the endoscopic approaches, fluoroscopy-guided radiologic procedures are generally less invasive and more successful because they allow for a better understanding of the anatomy outside the lumen during the procedure and enable the use of devices with smaller diameters.

Current status of indocyanine green fluorescent angiography in assessing perfusion of gastric conduit and oesophago-gastric anastomosis

Anastomotic leak (AL) remains a significant complication after esophagectomy. Indocyanine green fluorescent angiography (ICG-FA) is a promising and safe technique for assessing gastric conduit (GC) perfusion intraoperatively. It provides detailed visualization of tissue perfusion and has demonstrated usefulness in oesophageal surgery. GC perfusion analysis by ICG-FA is crucial in constructing the conduit and selecting the anastomotic site and enables surgeons to make necessary adjustments during surgery to potentially reduce ALs. However, anastomotic integrity involves multiple factors, and ICG-FA must be combined with optimization of patient and procedural factors to decrease AL rates. This review summarizes ICG-FA's current applications in assessing esophago-gastric anastomosis perfusion, including qualitative and quantitative analysis and different imaging systems. It also explores how fluorescent imaging could decrease ALs and aid clinicians in utilizing ICG-FA to improve esophagectomy outcomes.

Postoperative infectious complications are associated with diminished overall survival of patients undergoing resection for colorectal liver metastases

INTRODUCTION

Postoperative infectious complications (PIC) remain one of the most common complications after surgery. The influence of PIC on long-term survival for patients after liver surgery for colorectal liver metastases (CRLM) needs further investigation.

METHODS

Data of patients who underwent liver resection for CRLM between 2012 and 2017 at the Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin were evaluated. Overall survival (OS) was stratified according to the development of PIC. Independent predictors of PIC and diminished survival were identified using regression models.

RESULTS

Of 270 patients, eighty-four (31%) patients developed PIC including intraabdominal infections (n = 51, 61%), cholangitis (n = 5, 6%), pneumonia (n = 12, 14%), wound infections (n = 28, 33%), urinary tract infections (n = 5, 6%), or central line-associated bloodstream infections (n = 4, 5%). PIC were associated with a significantly diminished five-year OS (30% vs. 43%, p = 0.008). Age >65 years (p = 0.016, hazard ratio [HR] = 2.2, 95% confidence interval [CI] = 1.2-4.0), comorbidity (p = 0.019, HR [95% CI] = 2.4 [1.2-4.9]), simultaneous resection of primary tumor (p = 0.005, HR [95% CI] = 4.3 [1.6-11.9]), biliary drainage (p < 0.001, HR [95% CI] = 4.1 [2.0-8.5]), and length of procedure ≥272 min (p = 0.012, HR [95% CI] = 2.2 [1.2-4.1]) were independent predictors for the development of PIC. Body-mass index (BMI) > 30 kg/m2 (p = 0.002, HR [95% CI] = 2.4 [1.4-4.0]), postoperative major complications (p = 0.003, HR [95% CI] = 2.2 [1.3-3.8]), and 3- or 4-MRGN bacteria (p = 0.001, HR [95% CI] = 7.7 [2.2-27.3]) were independently associated with diminished OS.

CONCLUSIONS

PIC are associated with diminished OS after resection for CRLM. Age >65 years, comorbidities, simultaneous resection of the primary tumor, and biliary drainages were identified as independent risk factors for the development of PIC. High BMI, postoperative major morbidity and 3-/4-MRGN bacteria were independently predictive of worse OS. These factors need to be considered in perioperative management for patients with CRLM.

Overall Survival Following Anastomotic Leakage After Surgery for Carcinoma of the Esophagus and Gastroesophageal Junction: A Systematic Review

The effect of anastomotic leakage, in patients who underwent surgery for carcinoma of the esophagus and gastroesophageal junction, on overall survival (OS) is a debated and controversial topic. The aim of this systematic review was to clarify the impact of anastomotic leakage on long-term survival of patients with esophageal cancer undergoing esophagectomy. A systematic literature review was carried out from 2000 to 2022. We chose articles reporting data from patients who underwent surgery for carcinoma of the esophagus and gastroesophageal junction. Data regarding 1-, 3- and 5-year OS were analyzed. Twenty studies met the inclusion criteria, yielding a total of 9,279 patients. Analyzing data from selected studies, anastomotic leakage was found to be associated with decreased OS in 5,456 cases while in the remaining 3,823 it had no impact on long term survival (p<0.05). However, this result did not emerge from the other studies considered in the systematic review. Anastomotic leakage is a severe postoperative complication, which seems to have an impact on overall survival. However, the topic remains debated and not supported by all case series included in this systematic review.

Fluorescent lymphography for thoracic duct identification: Initial experience of a simplified and feasible ICG administration

INTRODUCTION

Indocyanine green (ICG) lymphography can be performed to obtain realtime fluorescent images of the thoracic duct (TD). The injection of ICG into the inguinal nodes usually is ultrasound-guided. Our hypothesis was to simplify the ICG administration until making it executable by unqualified personnel without ultrasound guidance.

MATERIAL AND METHODS

From October 2019 to October 2021 we enroled 18 patients. ICG was injected with a 25 Gauge needle in the subcutaneous tissue of the inguinal region bilaterally 14-16 h before surgery.

RESULTS

The TD was visualised in every case considered. The easy switching between fluorescence and white light visualization facilitated the identification and dissection of the TD avoiding involuntary injuries.

CONCLUSIONS

The simplified ICG administration to identify TD during oesophagectomy is easy to perform, does not require specifically trained staff, is not time demanding and has comparable results to the procedure performed under ultrasound guide.

Anastomotic leakage following resection of the esophagus-introduction of an endoscopic grading system

Background

Malignant tumors of the esophagus are the sixth leading cause of cancer-related deaths worldwide. Postoperative leakage of the esophago-gastrostomy leads to mediastinal sepsis, which is still associated with a high morbidity and mortality rate. The aim of this study was to describe the endoscopic view of the different severity grades of an anastomotic leakage.

Methods

Patients

Between June 2016 and September 2018, 144 patients were operated upon in the Department of Surgery, University of Munich, Germany.

Among these patients, 34 (23.6%) presented with a leakage of the anastomosis.

Endoscopy

In this retrospective analysis, the focus is to describe different patterns of leakage of the anastomosis.

Results

We studied 34 patients in whom post-esophagectomy leakage of the anastomosis was detected and treated with an endoluminal vacuum sponge system. The leakage healed in 26 of 29 patients (success rate 89.7%).

With the increasing severity of leakage, the treatment time and the in-hospital mortality correspondingly increased. Furthermore, the incidence of the development of a fistula to the tracheobronchial system increased with higher grades of leakage.

Conclusions

Exact descriptions of leakage are necessary to compare the cases and to prove post-treatment improvement. This is, to our knowledge, the first publication to present a leakage grading score in patients after esophagectomy including reconstruction with a gastric tube.

This new grading system needs to be tested in further analyses, with a special focus on prospective analysis.

The ideal approach for treatment of cT1N+ and cT2Nany esophageal cancer.: a NCDB analysis

BACKGROUND

Neoadjuvant therapy followed by surgery is recommended for locally advanced esophageal cancer. With the inaccuracies of clinical staging particularly for cT1N+ and cT2Nany tumors, some have proposed consideration of surgery followed by adjuvant treatment. Our objective is to evaluate the efficacy of neoadjuvant therapy vs surgery followed by adjuvant therapy, and to identify the ideal sequence of treatment in patients with cT1N+ and cT2Nany tumors.

METHODS

We performed an analysis utilizing the National Cancer Database (2006-2015) identifying all patients with cT1N+ and cT2Nany esophageal cancer undergoing esophagectomy. The treatment was stratified as: neoadjuvant therapy (NT), adjuvant therapy (AT) and combination therapy of neoadjuvant and adjuvant (CT) groups and outcomes were analyzed.

RESULTS

We identified 2795 patients with 81.9% (n=2289) receiving NT, 10.2% (n=285) AT, and 7.9% (n=221) CT. There were no significant differences noted in survival among AT, NT, and CT group in cT1N+(P=0.376), cT2N-(P=0.436), cT2N+(P=0.261) esophageal cancer by multivariate analysis using Cox regression model. This relationship held true in both squamous cell carcinoma and adenocarcinoma.

CONCLUSION

In clinical T1N+, T2Nany patients, there was no evident superiority of NT over AT. Surgery followed by adjuvant therapy can be considered to be an alternative option in these patients. Further prospective studies are needed to validate these findings.

Preoperative Radiochemotherapy in Esophageal Squamous Cell Cancer with 5-Fluorouracil/Cisplatin or Carboplatin/Paclitaxel: Treatment Practice over a 20-Year Period and Implications for the Individual Treatment Modalities

Simple Summary

We retrospectively studied outcomes in patients treated with preoperative radiochemotherapy and surgery for esophageal squamous cell cancer. We put a special focus on the comparison of patients treated with 5-fluorouracil/cisplatin (‘Walsh’) or carboplatin/paclitaxel (‘CROSS’). First, the higher age and more comorbidities of ‘CROSS’ patients, along with a shorter intensive care/intermediate care unit stay, might reflect an improvement in supportive and surgical/perioperative procedures in the periods. Second, the ‘CROSS’ patients experienced more hematologic toxicity and were less likely to complete chemotherapy as per protocol. This indicates that efforts should be taken to guide patients through a toxic treatment regimen. Third, the negative prognostic impact of radiochemotherapy-related toxicities and the duration of the intensive care/intermediate care unit stay underlines that further optimization of treatment procedures remains an important goal. Toxicity profiles could be improved by tailoring the regimen to individual patients (e. g., careful use of the taxane-based regimen in elderly patients).

Abstract

We retrospectively studied outcomes in patients treated with preoperative radiochemotherapy and surgery for esophageal squamous cell cancer. We put special focus on the comparison of patients treated with 5-fluorouracil/cisplatin (‘Walsh’) or carboplatin/paclitaxel (‘CROSS’). We compared characteristics between patients treated according to ‘Walsh’ vs. ‘CROSS’. Cox regression was performed to test for an association of parameters with outcomes. Study eligibility was met by 90 patients. First, the higher age and more comorbidities of the ‘CROSS’ patients, along with a shorter intensive care/intermediate care stay, might reflect an improvement in supportive and surgical/perioperative procedures over the periods. Second, the ‘CROSS’ patients experienced more hematologic toxicity and were less likely to complete chemotherapy as per protocol. This indicates that efforts should be taken to guide patients through a toxic treatment regimen by supportive measures. Third, the negative prognostic impact of radiochemotherapy-related toxicities (i.e., dysphagia and hematologic toxicities) and the duration of the intensive care/intermediate care unit stay underlines that further optimization of treatment procedures remains an important goal. We found no differences in tumor downstaging and survival between treatment regimen. Toxicity profiles could be improved by tailoring the regimen to individual patients (e.g., careful use of the taxane-based regimen in elderly patients).

Effect of anastomotic leaks on long-term survival after oesophagectomy for oesophageal cancer: systematic review and meta-analysis

INTRODUCTION

Long-term survival after curative surgery for oesophageal cancer surgery remains poor, and the prognostic impact of anastomotic leak (AL) remains unknown. A meta-analysis was conducted to investigate the impact of AL on long-term survival.

METHODS

A systematic electronic search for articles was performed for studies published between 2001 and 2020 evaluating the long-term oncological impact of AL. Meta-analysis was performed using the DerSimonian-Laird random-effects model to compute hazard ratios and 95% confidence intervals.

RESULTS

Nineteen studies met the inclusion criteria, yielding a total of 9885 patients. Long-term survival was significantly reduced after AL (HR: 1.79, 95% CI: 1.33-2.43). AL was associated with significantly reduced overall survival in studies within hospital volume Quintile 1 (HR: 1.35, 95% CI: 1.12-1.63) and Quintile 2 (HR: 1.83, 95% CI: 1.35-2.47). However, no significant association was found for studies within Quintile 3 (HR: 2.24, 95% CI: 0.85-5.88), Quintile 4 (HR: 2.59, 95% CI: 0.67-10.07), and Quintile 5 (HR: 1.29, 95% CI: 0.92-1.81). AL was significantly associated with poor long-term survival in patients with associated overall Clavien Dindo Grades 1-5 (HR: 2.17, 95% CI: 1.31-3.59) and severe Clavien Dindo Grades 3-5 (HR: 1.42, 95% CI: 1.14-1.78) complications.

CONCLUSIONS

AL has a negative prognostic impact on long-term survival after restorative resection of oesophageal cancers, particularly in low-volume centers. Future efforts must be focused on strategies to minimize the septic and immunological response to AL with early recognition and treatment thus reducing the impact on long-term survival.

Esophageal cancer treatment costs by phase of care and treatment modality, 2000-2013

BACKGROUND

Detailed cost estimates are not widely available for esophageal cancer. Our study estimates phase-specific costs for esophageal cancer by age, year, histology, stage, and treatment for older patients in the United States and compares these costs within stage and treatment modalities.

METHODS

We identified 8061 esophageal cancer patients in the Surveillance, Epidemiology, and End Results-Medicare database for years 1998-2013. Total, cancer-attributable, and patient-liability costs were calculated based on separate phases of care-staging (or surgery), initial, continuing, and terminal. We estimated costs by treatment modality within stage and phase for esophageal adenocarcinoma and squamous cell carcinoma separately. We fit linear regression models using log transformation to determine cost by age and calendar year. All costs are reported in 2018 US dollars.

RESULTS

Overall, mean (95% CI) monthly total cost estimates were high during the staging ($8953 [$8385-$9485]) and initial phases ($7731 [$7492-$7970]), decreased over the continuing phase ($2984 [$2814-$3154]), and increased substantially during the 6-month terminal phase ($18 150 [$17 211-$19 089]). This pattern of high staging and initial phase costs, decreasing continuing phase costs, and increasing terminal phase costs was seen in all stages. The highest staging costs were in stages III ($9249, $8025-$10 474) and II ($9171, $7642-$10 699). The highest initial phase cost was in stage IV, $9263 ($8758-49 768), the lowest continuing phase cost was in stage I, $2338 ($2160-$2517), and the highest terminal phase costs were in stages II ($20 533, $17 772-$23 293) and III ($20 599, $18 268-$22 929). The linear regression models showed that cancer-attributable costs remained stable over the study period and were unaffected by age for most histology, stage, and treatment modality subgroups.

CONCLUSIONS

Our estimates demonstrate that esophageal cancer costs can vary widely by histology, stage, and treatment. These cost estimates can be used to guide future resource allocation for esophageal cancer care and research.