Sequential multimodal treatments with chemotherapy and surgery for advanced soft tissue sarcoma may be associated with better survival than chemotherapy

BACKGROUND

In patients with advanced soft tissue sarcoma (STS), surgery had been reported to be associated with superior overall survival (OS). Chemotherapy details for such patients were less reported, and whether multimodal treatment with surgery and chemotherapy provides extra survival benefit remains unclear.

METHODS

We retrospectively reviewed patients with newly diagnosed advanced STS treated at National Taiwan University Hospital from January 1, 2011, to December 31, 2017. OS was calculated from the day of diagnosis of advanced STS to the day of death or last follow-up. Baseline patient characteristics and details regarding surgery and chemotherapy were recorded.

RESULTS

A total of 545 patients were diagnosed with STS from 2011 to 2017, of which 226 patients had advanced STS. The median age was 54.7 years, and 54% of patients were women. Approximately 38% of patients with advanced STS underwent surgery and exhibited a trend of longer OS compared with who did not (median = 18.6 vs. 11.9 months, p = 0.083). In the chemotherapy subgroup, the benefit of surgery was more prominent (median = 21.9 vs. 16.5 months, p = 0.037). Patients who received chemotherapy prior to surgery exhibited numerically longer OS than those who underwent surgery first (median = 33.9 vs. 18.3 months, p = 0.155). After adjusting other clinical factors, chemotherapy remained an independent factor associated with favourable OS.

CONCLUSION

Surgery may be more beneficial for the patients who receive chemotherapy. Our results support evaluation of sequential multimodal treatments strategy including surgery and chemotherapy in patients with advanced STS.

Evaluating postoperative recovery in uniportal versus needlescopic video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: a comparable study

Objectives

Primary spontaneous pneumothorax (PSP) is a common disease in young and thin male. Operation has been regarded as definitive treatment for it. However, the operative methods for those patients are under dispute. This study aims to directly compare the outcomes of uniportal VATS vs. needlescopic VATS in the treatment of PSP, focusing on postoperative pain and safety outcomes.

Methods

From July 2013 to December 2017, the patients who underwent video-assisted thoracic surgery for pneumothorax in National Taiwan University Hospital were retrospectively collected. The preoperative condition, surgical results, and postoperative outcomes was analyzed.

Results

There were 60 patients undergoing needlescopic VATS and 91 undergoing uniportal VATS during the study period. There was no significant difference between the patients who underwent needlescopic VATS and those who underwent uniportal VATS in their demographic and clinical characteristics. The post-operative pain score was significantly lower in the uniportal VATS group compared to the needlescopic VATS group at day 1 (2.65 ± 1.59 vs. 1.74 ± 1.35, p = 0.001).

Conclusion

Uniportal VATS offers an effective, safe alternative for PSP treatment, with benefits including reduced post-operative pain. Our findings support the use of uniportal VATS, supplemented by a wound protector, as a viable option for PSP patients.

A Prospective Study of Bevacizumab and Neoadjuvant Concurrent Chemoradiation in Locally Advanced Esophageal Squamous Cell Carcinoma: Paradoxical Increase in Circulating Vascular Endothelial Growth Factor-A and Effect on Outcome

PURPOSE/OBJECTIVE(S)

In the prior prospective biomarker study, high serum vascular endothelial growth factor-A (VEGF-A) was associated with a poor prognosis. We conducted a prospective phase II trial of adding Bevacizumab, an anti-VEGF-A monoclonal antibody, to neoadjuvant concurrent chemoradiation (neoCCRT) for patients with locally advanced esophageal squamous cell carcinoma (LA-ESCC). This prospective biomarker study aims to evaluate the expressions of angiogenesis-associated circulating biomarkers before and after neoCCRT and compare clinical outcomes for patients receiving platinum/5-fluorouracil (PF) with or without Bevacizumab.

MATERIALS/METHODS

Patients with biopsy-proven resectable non-T4 LA-ESCC were enrolled for the prospective phase II trial investigating PF-neoCCRT plus Bevacizumab (BPF group). A parallel patient cohort enrolled in a prospective biomarker study receiving PF-neoCCRT was included in the present analysis as the control group (PF group). Radiotherapy was delivered with 40 Gy in 20 fractions. All patients had restaging workups after enoCCRT and underwent radical esophagectomy if the disease remained resectable. Serums were collected before and after neoCCRT. The serum concentrations of angiogenesis-associated biomarkers were determined by the multiplex enzyme-linked immunosorbent assay. Survival analyses were performed by the Kaplan-Meier method. The t-test and log-rank test were used to compare differences in biomarker expression and survival between groups.

RESULTS

From 2016 to 2019, 43 patients (BPF/PF group: 21/22) were enrolled in the study. Twenty patients in each group had serum samples available for biomarker analysis. 15 out of 21 patients in the BPF group and 20 out of 22 patients in the PF group underwent radical esophagectomy. Six patients in the BPF group and nine patients in the PF group achieved pathological complete responses. The median overall survival for the BPF and PF group was 20.8 months and not-reached, respectively (hazard ratio = 1.33, long rank p = 0.58). In the BPF group, the serum VEGF-A level was significantly increased from an average value of 446 pg/mL to 723 pg/mL after neoCCRT (p = 0.037), while its level was decreased from 815 ng/mL to 380 pg/mL in the PF group (p = 0.104). In addition, the expression value of circulating Angiopoietin-1 was not changed in the BPF group (before neoCCRT, mean value = 828 pg/mL; after neoCCRT, mean value 762 pg/mL, p = 0.67). In contrast, serum Angiopoietin-1 level was reduced from an average value of 659 pg/mL before neoCCRT to 271 pg/mL after neoCCRT (p = 0.002) in the PF group.

CONCLUSION

The addition of Bevacizumab to PF-neoCCRT did not improve pathological or survival outcomes in patients with resectable LA-ESCC. Adding a single dose of Bevacizumab paradoxically increases circulating VEGF-A while maintaining the Angiopoietin-1 serum level after neoCCRT. Further investigation by using additional VEGF-A inhibition may be required to achieve sustained angiogenesis blocked for tumor control.

Stripping Massage and Literature Review in Post-Thoracoscopic Chest Pain Management

The aim of this randomized study was to investigate whether stripping massage (SM) of myofascial trigger points in the lower rhomboid muscle could alleviate chest pain in patients following thoracoscopic surgery. In addition, a literature review was conducted to assess the effectiveness of various pain management techniques. Sixty adult patients who reported a visual analog scale (VAS) score of 4 or higher were randomly assigned to receive conventional analgesics alone (conventional group) or combined with SM twice daily for 2 weeks (SM group). VAS scores and the use of additional analgesics were evaluated on postoperative days 1, 3, 7, 14, and 30. Using the PubMed and Cochrane Library databases, a review of current pain management techniques was carried out up to January 31, 2022. A subgroup analysis was also performed to examine the treatment effect during different surgical periods and techniques. Results showed that the SM group had significantly lower VAS scores on postoperative days 3, 7, 14, and 30 (p < 0.001), as well as a shorter hospitalization duration and reduced need for additional analgesics (p < 0.001). The literature review included a total of 20 studies (2,342 cases of chest pain relief after thoracoscopic surgery), which indicated that serratus anterior plane (SAP) blocks were commonly used as a perioperative approach to reduce pain and opioid consumption. SM and SAP can both serve as adjuvant treatments for chest pain in patients following thoracoscopic surgery, with SM being a safe and noninvasive pain control option after hospital discharge.

Prognostication and optimal criteria of circumferential margin involvement for esophageal cancer after chemoradiation and esophagectomy

Purpose

Circumferential radial margin (CRM) involvement by tumor after resection for esophageal cancer has been suggested as a significant prognostic factor. However, the prognostic value of CRM involvement after surgery with neoadjuvant concurrent chemoradiotherapy (CCRT) is unclear. This study aimed to evaluate the prognostic value of and survival outcomes in CRM involvement as defined by the Royal College of Pathologists (RCP) and the College of American Pathologists (CAP) for patients with esophageal cancer undergoing neoadjuvant CCRT and esophagectomy.

Methods

A total of 299 patients with esophageal cancer who underwent neoadjuvant CCRT followed by esophagectomy between 2006 and 2016 were enrolled in our study. The CRM status of the specimens obtained was determined pathologically according to both the CAP and RCP criteria. Survival analyses were performed and compared according to the two criteria.

Results

Positive CRM was found in 102 (34.1%) and 40 (13.3%) patients according to RCP and CAP criteria, respectively. The overall and progression-free survival rates were significantly lower in the CRM-positive group than in the CRM-negative group according to both the RCP and CAP criteria. However, under multivariate analysis, in addition to pathological T and N staging of the tumor, only CAP-defined CRM positivity was a significant prognostic factor with adjusted hazard ratios of 2.64 (1.56-4.46) and 2.25 (1.34-3.78) for overall and progression-free survival, respectively (P < 0.001).

Conclusion

In patients with esophageal cancer undergoing neoadjuvant CRT followed by esophagectomy, CAP-defined CRM positivity is an independent predictor of survival. Adjuvant therapy should be offered to patients with positive CRM.

Robotic-Assisted Thoracoscopic (RATS) Enucleation of Esophageal Mesenchymal Tumors and Foregut Cysts

Background: Esophageal mesenchymal tumors and foregut cysts are mostly benign lesions of the esophagus. Tumor enucleation is recommended for lesions with a risk of malignancy, or for the relief of clinical symptoms. Although robotic-assisted thoracoscopic enucleation of esophageal tumors and cysts has been demonstrated in sporadic case reports, its clinical role is yet to be elucidated. Methods: This study aimed to present the first case series in the literature for the perioperative and long-term clinical outcomes of robotic-assisted thoracoscopic enucleation. Results: A total of 19 patients who underwent robotic-assisted thoracoscopic enucleation of esophageal tumors and cysts from 2012 to 2019 were included in the study. The mean tumor/cyst size was 5.5 cm (1.5–22 cm). There were two cases shifting to minimally invasive esophagectomy (10.5%) due to intraoperative pathological confirmation of malignant gastrointestinal stromal tumors with mucosal invasion. Perioperative complication was detected in three (15.8%) cases, without 30-day or surgical mortality. There was no recurrence of tumor or symptoms in all patients during the clinical follow-up period (mean = 35 months). Conclusions: Robotic-assisted thoracoscopic enucleation of esophageal submucosal benign tumors is technically feasible and effective. Given its advantage in overcoming spatial limitations, it can become a widely accepted surgical option for such diseases.

Selection of minimally invasive surgical approaches for treating esophageal cancer

Minimally invasive esophagectomy has gradually been accepted as an active treatment option for surgery of esophageal cancer. However, there is no consensus about how to perform the procedures in the thoracic and abdominal phase including anastomosis in the neck (McKeown) or chest (Ivor Lewis), VATS, robotic‐assisted or reduced port approaches or various endoscopic abrasion techniques. Further studies to investigate the roles of these novel techniques are required to treat the various patient populations.

The management of postoperative upper alimentary tract fistulas: A single-center experience of endoscopic tissue glue repair and recommendations of a systematic review

BACKGROUND/PURPOSE

The appropriate management of postoperative upper alimentary tract fistula (UATF) remains uncertain. The efficacy of esophagogastroduodenoscopy (EGD) tissue glue repair in the treatment of patients with postoperative UATF was explored. We also conducted a systematic review of the literature regarding the inpatient management of UATF.

METHODS

Totally 24 patients received EGD tissue glue repair for postoperative UATF at our institute from April 2014 to April 2020. Independent characteristics of size of fistula, location of the UATF, complications, and recurrences were analyzed. PubMed and Cochrane Library databases were reviewed. A pooled analysis was performed, and subgroup analysis was conducted separately for different anatomic locations and techniques.

RESULTS

With a mean follow-up of 40 months, the fistula failed to close with EGD tissue glue repair in 2 of 24 patients (8.3%). Eight patients required repeated EGD tissue glue repair, which was more frequent in oral or thoracic UATF (p = 0.053), but all achieved a successful seal in the EGD tissue after glue repair alone (n = 22). The fistula size was correlated with the demand for repeated EGD tissue glue repair (p = 0.017). Besides, a total of 30 studies regarding 2356 cases of postoperative UATF between 2010 and 2021 were retrieved and analyzed. Several non-operative methods were generally accepted as the initial approach, with a non-inferior success rate compared to operative techniques.

CONCLUSIONS

The results suggest that no single approach toward UATF is superior in terms of success rate and healing time. The potential advantages of EGD tissue glue repair after drainage were more suitable for patients with postoperative UATF and multiple comorbidities.

Tracheal reconstruction with nail grafts: A novel approach

Background

Methods

Results

Conclusions

Drainless Thoracoscopic Lobectomy for Lung Cancer

OBJECTIVES: Drainless video-assisted thoracoscopic (VATS) wedge resection has been demonstrated as feasible in treating various lung diseases. However, it remains unknown whether this surgical technique can be effectively applied to lobectomy. In the current study, we evaluated the perioperative outcome of drainless, minimally invasive lobectomy in patients with lung cancer. METHODS: A total of 26 lung cancer patients who received surgery-performed pulmonary lobectomy were enrolled. The perioperative outcomes were analyzed based on a propensity score matching a comparison with those who had chest drainage. RESULTS: No major surgical morbidity and mortality was noted during the perioperative period. The mean of postoperative hospital stay was 5.08 ± 2.48 days. There was no significant difference in postoperative hospital stay between the two groups of patients. However, the presence of significant postoperative pain (VAS score > 30) on the first day after surgery was less in the drainless group (34.6% vs. 3.8%; p = 0.005). CONCLUSIONS: Our results demonstrated that drainless, minimally invasive lobectomy for selected lung cancer patients is feasible. Further evaluation of its impact on short- and long-term surgical outcomes is required in the future.

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.

Vicryl Mesh Coverage Reduced Recurrence After Bullectomy for Primary Spontaneous Pneumothorax

BACKGROUND

Although thoracoscopic stapled bullectomy is a standard procedure for primary spontaneous pneumothorax (PSP), the postoperative recurrence rate is high. We investigated whether using a Vicryl (Ethicon, Somerville, NJ) mesh to cover the staple line after bullectomy reduces the postoperative recurrence rate.

METHODS

Our single-blind, parallel-group, prospective, randomized controlled trial at 2 medical centers in Taiwan studied patients with PSP who were aged 15 to 50 years and required thoracoscopic bullectomy. On the day of operation, patients were randomly assigned (1:1) to receive Vicryl mesh (mesh group) or not (control group) after thoracoscopic bullectomy with linear stapling and mechanical apical pleural abrasion. Randomization was achieved using computer-generated random numbers in sealed envelopes. Our primary end point was the pneumothorax recurrence rate within 1 year after the operation (clinicaltrials.gov number, NCT01848860.) RESULTS: Between June 2013 and March 2016, 102 patients were assigned to the mesh group and 102 to the control group. Within 1 year after operation, recurrent pneumothorax was diagnosed in 3 patients (2.9%) in the mesh group compared with 16 (15.7%) in the control group (P = .005). The short-term postoperative results and hospitalization duration were comparable between the groups.

CONCLUSIONS

For thoracoscopic bullectomy with linear stapling and mechanical apical pleural abrasion, the use of a Vicryl mesh to cover the staple line is effective for reducing the postoperative recurrence of pneumothorax. Vicryl mesh coverage can be considered an optimal adjunct to the standard surgical procedure for PSP.

Comparison of several alternatives for the management of severe pectus excavatum in the Nuss procedure

BACKGROUND

The aim of this study was to assess the safety of several modified Nuss procedures for severe pectus excavatum (PE).

METHODS

Thirty-four patients with severe PE underwent the Nuss procedure: 10 underwent slanting-directed bar insertion (group A); 11 underwent standard Nuss procedure (group B); and 13 underwent Nuss procedure with subxiphoid assistance (group C). All the patients met the criteria of having a Haller index greater than 4.5, assessed from chest computed tomography. Besides, the transverse length of the most depressed point and the 2-intercostal left slant length between the heart and the anterior chest wall were measured.

RESULTS

All patients were followed up for 6-45 months (mean 31.4 ± 11.38 months). None of the patients suffered from injuries to the pericardium, heart or lungs. There were no significant differences in age, Haller's index, operation time and postoperative stay among the three groups. However, two patients in group B experienced bar rotation and subsequently required reoperation vs the other two groups (p < 0.001). The length of contact between the heart and the chest wall was shorter in the left slant axis (5.8 ± 0.33 cm) than in the transverse axis (7.3 ± 0.37 cm) in group A (p = 0.001).

CONCLUSION

A modified Nuss procedure of slanting steel bar insertion has shown to be a safe and effective approach for the correction of severe PE.

The genetic effect and molecular function of the SOCS5 in the prognosis of esophageal squamous cell carcinoma

Expression of cytokines and growth factors have been shown to be highly correlated with the prognosis of esophageal squamous cell carcinoma (ESCC), a deadly disease with poor prognosis. The suppressor of cytokine signaling (SOCS) family of proteins are key factors in regulating cytokines and growth factors. Yet the role of the SOCS proteins in ESCC is hardly investigated. We currently investigated the prognostic role of SOCS5 in ESCC. We analyzed the prognostic effects of 16 single nucleotide polymorphisms (SNPs) within the SOCS genes in 632 ESCC patients. We repeatedly observed that the 3 SNPs in SOCS5, SOCS5:rs3814039, SOCS5:rs3738890, and SOCS5: rs3768720, were significantly correlated with both overall (OS) and progression-free survival (PFS) of ESCC patients (rs3814039, p=0.032 for OS and p=0.009 for PFS; rs3738890, p=0.016 for OS, and p=0.008 for PFS; rs3768720, p=0.005 for OS and p=0.002 for PFS). SOCS5: rs3768720 was also significantly associated with distant metastasis (Ptrend=0.028). The luciferase assay revealed that SOCS5:rs3814039 and SOCS5: rs3768720 might influence the prognosis by regulating SOCS5 expression. Functional analysis demonstrated SOCS5 was able to regulate epidermal growth factor receptor (EGFR) expression and migration activity of ESCC cells. Furthermore, Patients with strong SOCS5 in normal tissues exhibited significantly better PFS (P=0.049) and reduced risk of distant metastasis (P=0.004) compared to those with weak SOCS5 expression. Overall, our study demonstrates the novel function of SOCS5 in ESCC prognosis. The genetic polymorphisms and expression of SOCS5 could serve as a novel therapeutic biomarker for improving the prognosis of ESCC.

Risk Factors and Genetic Biomarkers of Multiple Primary Cancers in Esophageal Cancer Patients

Esophageal cancer (EC) is a deadly cancer that frequently develops multiple primary cancers (MPCs). However, the risk biomarkers of MPC in EC have hardly been investigated. We retrospectively enrolled 920 subjects with primary EC and analyzed the possible risk factors as well as MPC single-nucleotide polymorphisms (SNPs) from blood DNA. A total of 184 subjects (20.0%) were confirmed to have MPC, 59 (32.8%) had synchronous MPC, and 128 (69.6%) had head and neck cancer. Elderly EC patients have an increased risk of having gastrointestinal cancer (Odds ratio, OR[95% CI]=6.70 [1.49-30.19], p=0.013) and a reduced risk of developing HNC (OR[95% CI]=0.44 [0.24-0.81], p=0.008). MPC risk was also associated with betel nut chewing (OR[95% CI]=1.63, 1.14-2.32], p=0.008), the A allele of ALDH2:rs671 (p=0.074 and 0.030 for GA and AA, respectively), the CC genotype in CISH:rs2239751 (OR[95% CI]=1.99 [1.2-3.32], p=0.008), and the G allele of ERCC5:rs17655 (p=0.001 and 0.090 for GC and CC, respectively). ADH1B:rs1229984 also correlated with MPC risk (p=0.117). Patients carrying four risk SNPs had a 40-fold risk of MPC (OR[95% CI]=40.25 [6.77-239.50], p<0.001) and a 12.57-fold risk of developing second primary cancer after EC (OR[95% CI]=12.57 [1.14-138.8], p=0.039) compared to those without any risk SNPs. In conclusion, hereditary variations in ALDH2, CISH, ERCC5, and ADH1B have great potential in predicting the incidence of MPC in EC patients. An extensive cancer screening program during clinical follow-up would be beneficial for patients with high MPC susceptibility.

Phase II study of pembrolizumab after chemoradiotherapy (CRT) as adjuvant therapy for locally advanced esophageal squamous cell carcinoma (LA-ESCC) patients at high risk of recurrence following preoperative CRT plus surgery

TPS259

Background: LA-ESCC is a potentially curable disease, for which preoperative CRT followed by esophagectomy is a standard-of-care. Previous studies have identified that close/involved margin and lymph node metastasis with extranodal invasion (ENI) in post-CRT surgical specimens are associated with increased risk of recurrence. In CheckMate-577 trial, adjuvant nivolumab significantly improved disease-free survival (DFS) in patients with esophageal cancer treated with preoperative CRT and surgery; in another trial (the “PACIFIC” trial), adjuvant durvalumab has significantly improved overall survival (OS) in stage III non-small cell lung cancer treated with definitive CRT. We hypothesize that adding pembrolizumab to CRT as an adjuvant therapy would improve the outcomes of LA-ESCC patients who are treated with preoperative CRT plus esophagectomy and with high-risk of recurrence. Methods: This single institution single-arm phase II study include patients with histologically confirmed LA-ESCC (AJCC 7th staging system:cT3-4aN0M0 or T1-4aN1-3M0) harboring at least one risk factor (closed/involved margin, ENI, or ypN2-3) in post-CRT surgical specimens. Patients with adenocarcinoma of esophagus or gastroesophageal junction or synchronously diagnosed with a squamous cell carcinoma of aero-digestive way other than ESCC are excluded. Patients enrolled will receive adjuvant weekly cisplatin–CRT (cisplatin, 30mg/m2 for 2 cycles every week; radiotherapy, 180-200 cGy/fraction for 10-13 times) followed by pembrolizumab (200 mg, every 3 weeks, for 18 cycles). The primary endpoint of this study is 1-year relapse-free survival (RFS) rate; and the key secondary endpoints include RFS, 3-year RFS rate, OS, 3-yr OS rate, toxicity and safety. The study, registered with clinical trial ID of NCT03322267, started patient enrollment in Aug 2018. As of Aug of 2020, 11 of 46 planned patients have been enrolled. Clinical trial information: NCT03322267.

Robotic-assisted single-incision gastric mobilization for minimally invasive oesophagectomy for oesophageal cancer: preliminary results

OBJECTIVES

With the gradual acceptance of robotic-assisted surgery to treat oesophageal cancer and the application of a single-port approach in several abdominal procedures, we adopted a single-port technique in robotic-assisted minimally invasive oesophagectomy during the abdominal phase for gastric mobilization and abdominal lymph node dissection.

METHODS

Robotic-assisted oesophagectomy and mediastinal lymph node dissection in the chest were followed by robotic-assisted gastric mobilization and conduit creation with abdominal lymph node dissection, which were performed via a periumbilicus single incision. The oesophagogastrostomy was accomplished either in the chest (Ivor Lewis procedure) or neck (McKeown procedure) depending on the status of the proximal resection margin.

RESULTS

The procedure was successfully performed on 11 patients with oesophageal cancer from January 2017 to December 2018 in our institute. No surgical or in-hospital deaths occurred, though we had one case each of anastomotic leakage, pneumonia and hiatal hernia (9%).

CONCLUSIONS

Robotic single-incision gastric mobilization for minimally invasive oesophagectomy for treating oesophageal cancer seems feasible. Its value in terms of perioperative outcome and long-term survival results awaits future evaluation.

A randomized phase II/III study of paclitaxel/cisplatin versus cisplatin/5-fluorouracil in neoadjuvant chemoradiotherapy (CRT) followed by surgery for patients with locally advanced esophageal squamous cell carcinoma (ESCC)

TPS4650

Background: Meta-analyses have shown the survival benefit of cisplatin/5-fluorouracil (PF) neoadjuvant CRT over surgery alone for patients with locally advanced ESCC. The CROSS study has demonstrated the statistically significant survival benefit of paclitaxel/carboplatin neoadjuvant CRT for patients with locally advanced esophageal cancer, especially ESCC. A network meta-analysis based on published phase III trials suggested that paclitaxel/platinum might be superior to PF as neoadjuvant CRT in patients with ESCC (Huang et al: Jpn J Clin Oncol. 2015;45:1023–8). However, a direct comparison of two CRT regimens in a prospective randomized clinical trial has not been performed in ESCC. We designed this clinical trial to test the hypothesis that paclitaxel-platinum is superior to PF as neoadjuvant CRT in patients with locally advanced ESCC. Methods: This single center open-label phase 2/3 study randomizes patients with histologically confirmed ESCC, T3/4aN0M0 or T1-3N1-3M0 (AJCC 7th edition), in 1:1 ratio, to receive TP (paclitaxel, 50 mg/m2/week; cisplatin 30 mg/m2/week; for 5 weeks) or PF (cisplatin 75 mg/m2, d1; 5-FU 1,000 mg/m2, d1-4; on week 1 and week 5)-neoadjuvant CRT (180 cGy/d, 5 days/week, for 5 weeks). Esophagectomy will be performed 6 to 10 weeks after completing CRT. All patients must be eligible to esophagectomy, with tumor length ≤8cm and tumor radial ≤5cm, with adequate organ functions, and have ECOG performance status of 0-2. In the phase 2 stage, 128 patients will be enrolled, assuming the pathologic complete response (pCR) rate of TP and PF as 45% and 25%, respectively, with a power of 80% and one-sided 10% significance level. If the primary endpoint of pCR is met, additional 120 patients will be enrolled for the phase III stage with overall survival as the primary endpoint, assuming the hazard ratio of TP versus PF as 0.65 with a power of 80% and a 5% significance level. The trial started patient enrollment in May, 2017. As of Jan of 2020, 52 of planned 128 patients for phase II part have been enrolled. Clinical trial information: NCT03623737 .

Suction Ventilation for Uniportal Video-Assisted Thoracic Surgery Without Endotracheal Intubation

The aim of this study is to describe the technique of pulmonary expansion by suction control from a surgical wound during nonintubated uniportal video-assisted thoracic surgery. Five patients developed oxygen desaturation intraoperatively even with facial mask ventilation. Oxygenation was completed after 3 minutes with the suction technique through the uniportal wound. All the patients underwent the operation under spontaneous ventilation, without conversion to endotracheal intubation. The suction ventilation technique can provide an alternative solution during deoxygenation conditions of nonintubated video-assisted thoracic surgery.

Cabozantinib (XL184) and R428 (BGB324) Inhibit the Growth of Esophageal Squamous Cell Carcinoma (ESCC)

Esophageal squamous cell carcinoma (ESCC) is a deadly disease for which no effective targeted therapeutic agent has been approved. Both AXL and c-MET have been reported to be independent prognostic factors for ESCC. Thus, inhibitors of AXL/c-MET might have great potential as targeted therapy for ESCC. In the current study, we evaluated the therapeutic potential of the AXL/c-MET selective inhibitors, R428 and cabozantinib, in cell and mouse xenograft models. We demonstrated that both R428 and cabozantinib significantly inhibited the growth of CE81T and KYSE-70 ESCC cells and showed by wound-healing assay that they both inhibited ESCC cell migration. In the animal model, ESCC xenograft models were established by injecting KYSE-70 cells with Matrigel into the upper back region of NOD-SCID male mice followed by treatment with vehicle control, R428 (50 mg/kg/day), cisplatin (1.0 mg/kg), or cabozantinib (30 mg/kg/day) for the indicated number of days. R428 alone significantly inhibited ESCC tumor growth compared to the vehicle; however, no synergistic effect with cisplatin was observed. Notably, the dramatic efficacy of cabozantinib alone was observed in the mouse xenograft model. Collectively, our study demonstrated that both cabozantinib and R428 inhibit ESCC growth in cell and xenograft models. The results reveal the great potential of using cabozantinib for targeted therapy of ESCC.

Improved prognosis with induction chemotherapy in pathological complete responders after trimodality treatment for esophageal squamous cell carcinoma: Hypothesis generating for adjuvant treatment

PURPOSE

To compare the locations of recurrences and survival outcomes in esophageal squamous cell carcinoma (ESCC) patients with pathological complete response (pCR) after neoadjuvant concurrent chemoradiotherapy (CCRT) with or without preceding induction chemotherapy (IC) followed by esophagectomy.

METHODS

Among 276 patients with locally advanced ESCC undergoing trimodality treatment during 2004-2014, 94 (34.1%) with pCR were eligible. The cohort included 26 patients undergoing IC before CCRT (IC group), and 68 patients who did not receive IC (non-IC group).

RESULTS

At a median follow-up of 51.4 months (95% confidence interval; 42.9-62.1), 19 patients experienced recurrences. There was a trend toward fewer distant failures in the IC group (0% vs.14.7%, p = 0.057), while locoregional recurrence was similar (7.7% vs. 7.4%). IC was associated with significantly improved survivals with the 5-year RFS and OS rates for the IC group of 85.1% and 90.5%, respectively, compared to of 46.2% and 48.1% for the non-IC group (p = 0.008 for RFS, and p = 0.015 for OS). By multivariable analyses, IC remained the only significant factor associated with survivals (HR:0.18 for RFS, p = 0.020 and HR:0.18 for OS, p = 0.025). The effect of IC in the whole cohort, irrespective of pathological response, was also assessed. Patients with non-pCR in the IC group had a trend toward worse survivals compared to the non-IC group CONCLUSIONS: In ESCC patients with pCR after trimodality treatment, IC was associated with favorable survivals. The benefits of IC might be a hypothesis generation for adjuvant treatment for patients with pCR.

Management of Patients With Circumferential Intramural Esophageal Dissection

A novel minimally invasive endoscopic drainage technique using a double-tube system improves the feasibility and safety of conservative treatment in spontaneous esophageal intramural dissection (EID). Two patients with spontaneous EID underwent double-tube system placement through esophagogastroduodenoscopy. One tube was inserted into the submucosal layer with continuous suction, and another nasoduodenal tube was simultaneously inserted for enteral nutritional support. Given the ease of placement and the success of this simple double-tube system method, this technique may provide a new, low-risk, and cost-effective treatment modality for patients with EID.

Number of Resected Lymph Nodes and Survival of Patients with Locally Advanced Esophageal Squamous Cell Carcinoma Receiving Preoperative Chemoradiotherapy

BACKGROUND

The association of extended lymph node (LN) dissection with improved outcomes in patients with locally advanced esophageal squamous cell carcinoma (ESCC) who received preoperative chemoradiotherapy (CRT) followed by surgery is debatable.

PATIENTS AND METHODS

We reviewed data from patients with esophageal cancer enrolled in three phase II clinical trials of preoperative paclitaxel and cisplatin-based CRT during 2000-2012. Patients with ESCC who underwent planned esophagectomy were enrolled. The number of resected LNs and other clinicopathological factors were analyzed regarding their impact on progression-free (PFS) and overall (OS) survival using Cox proportional hazards model.

RESULTS

In total, 139 patients were included. The median PFS and OS were 24.4 and 31.8 months, respectively. The median number of resected and positive LNs were 19 (range=2-96) and 0 (range=0-9), respectively. The mean number of positive LNs did not differ significantly among quartile groups of total resected LNs (quartile 1: 2-12, 2: 13-19, 3: 20-29, and 4: 30-96). The resected LN number analyzed as dichotomies divided by the median or as continuous variables was not associated with PFS or OS. However, in an exploratory analysis, patients of quartiles 2 and 3 had longer PFS and OS than those with quartiles of 1 and 4 in multivariate analysis (p=0.019 and 0.005, respectively).

CONCLUSION

Although extensive LN dissection was not associated with improved survival, resection of 13-29 LNs was associated with improved survival in patients with locally advanced ESCC receiving preoperative paclitaxel and cisplatin-based CRT.

Perioperative management and outcomes of minimally invasive esophagectomy: case study of a high-volume tertiary center in Taiwan

Background

Mortality and complication rates for surgical esophagectomy remain high despite progress in surgical techniques and perioperative care. Minimally invasive surgery and intraoperative goal-directed fluid management are gaining popularity in Taiwan; however, perioperative complications and short-term outcomes have been rarely reported. In this retrospective study, we analyzed the surgical procedures performed as well as the perioperative outcomes and treatments after esophagectomy in a high-volume medical center in Taiwan. The goals of this study are to compare the complications and the following treatment between different surgical procedures and to analyze if any preoperative coexisting disease and anesthesia conduct might be associated with postoperative complications and hospitalization course.

Methods

We retrospectively reviewed the data of all patients who had undergone esophagectomy and reconstruction in 2015. Patient characteristics, type of surgery performed, method of anesthesia, postoperative hospitalization course, and additional surgical interventions were reviewed and analyzed.

Results

In total, 64 patients were included. Among them, 58 patients (90.6%) were reported squamous cell carcinoma, 33 patients (51.6%) received McKeown minimally invasive esophagectomy (MIE), and 20 (31.3%) received Ivor-Lewis MIE. The most common postoperative complications were pulmonary complications (18.7%), such as empyema and pleural effusion, dysrhythmias (14.1%), anastomosis leakage (14.1%), vocal cord paralysis (9.4%), gastric tube stenosis (4.7%), chyle leakage (4.7%), and acute kidney injury (AKI, 4.7%). Twenty-five percent of patients received secondary operative interventions for the aforementioned complications. Postoperative arrhythmia (P=0.042), pulmonary complications (P=0.009), and AKI (P=0.015) were significantly associated with prolonged intensive care unit (ICU) stays. Thirty-day and 90-day mortality rates were 3.1% and 4.7% respectively. Patients with preoperative arrhythmias have a higher risk of developing post-operative dysrhythmia (P=0.013) and lung complications (P=0.036). Patients with an underlying heart disease are at higher risk of post-op AKI (P=0.002) and second surgical intervention (P=0.013). Chronic kidney diseases are associated with post-op dysrhythmia (P=0.013), lung complications (P=0.036) and post-op AKI (P≤0.01). Although McKeown MIE bore a significantly longer surgical time and higher intraoperatively-infused crystalloid than did Ivor Lewis MIE, there were no significant differences regarding postoperative cardiothoracic complications and patient outcomes.

Conclusions

Postoperative outcomes of McKeown MIE and Ivor-Lewis MIE were comparable in our center and short term outcomes were similar to those in previous reports. However, despite neoadjuvant concurrent chemoradiation therapy (CCRT), the use of minimally invasive techniques, and well-controlled anesthesia, the incidence of perioperative complications remains high. Our results suggest that patients with preoperative comorbidity of arrhythmia, heart diseases, and CKD are associated with more common post-operative complications. Furthermore, postoperative dysrhythmias, pulmonary complications, and AKI warrant special anesthetic and surgical care to prevent prolonged ICU stay.

Twenty-years of lung transplantation in Taiwan: Effects of cumulative institutional experience on early outcomes

BACKGROUND/PURPOSE

Lung transplantation in Taiwan began in 1991, but the experience was limited and diverse in the early years. We examined the cumulative institutional experience of the largest lung transplant cohort in Taiwan.

METHODS

A retrospective review of lung transplantations performed at a single institution from December 1995 through August 2016 was conducted. For comparative purposes, the cohort was divided into halves, with an early group (undergoing lung transplantation in the first decade) vs a late group (undergoing lung transplantation in the second decade). Standardized donor selection, organ procurement, and preservation protocols for brain-dead donors were applied. The outcomes measured were 30-day mortality and actuarial survival using the Kaplan-Meier method.

RESULTS

The cohort included 50 recipients in the early group and 42 recipients in the late group. Compared with the early group, recipients in the late group were significantly older (38.8 ± 11.6 vs 44.8 ± 13.4 years, p = 0.024) and more of them required mechanical ventilation before transplant (26.0% vs 66.7%, p < 0.001). There were more female donors (12.0% vs 33.3%, p = 0.021) and gender-matched donors (34.0% vs 61.9%, p = 0.012) in the late group. A total of 87 recipients (94.6%) had cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO) support during transplant, and CPB was used significantly less in the late group. Graft procedures (14.0% vs 47.6%, p < 0.001), delayed chest closure (0% vs 21.4%, p < 0.001), and early tracheostomy (24.0% vs 52.4%, p = 0.005) were performed more in the late group. The durations of hospital and ICU stays were comparable in both groups, but the 30-day mortality was significantly lower in the late group (30.0% vs 2.4%, p = 0.001).

CONCLUSION

Although the results were undesirable in the first decade of the transplant program, the cumulative institutional experience led to significantly improved outcomes in the second decade of the transplant program.

Genetic polymorphisms of ATG5 predict survival and recurrence in patients with early-stage esophageal squamous cell carcinoma

Esophageal squamous cell carcinoma (ESCC) is a deadly disease with high risk of tumor recurrence even among patients with an early pathologic stage of tumor. In the current study, we investigate the association between 20 SNPs of the ATG5 gene and prognosis of patients with early-stage ESCC. A total of 305 patients diagnosed with early-stage ESCC were enrolled in the study and randomly assigned to a training set (n=93) or replication set (n=212). The genotypes of candidate SNPs (single nucleotide polymorphisms) within ATG5 were analyzed and correlated with the prognosis of ESCC patients. We repeatedly demonstrated that 3 SNPs in ATG5, rs1322178, rs3804329, and rs671116, were significantly correlated with the prognosis of patients with early-stage ESCC (HR[95 % CI]=2.01[1.19-3.40], p=0.009 for ATG5: rs1322178; HR[95 % CI]=1.88 [1.08-3.26], p=0.025 for ATG5:rs3804329; HR[95 % CI]=1.73[1.24-2.42], p=0.001 for ATG5:rs671116, in combined group). Both rs1322178 and rs3804329 can predict early distant metastasis of patients. Furthermore, increased expression of ATG5 was observed in ESCC tumor tissue as compared to adjacent normal tissue. Moreover, higher levels of ATG5 expression in both normal and tumor tissues exhibited a trend to correlate with poor prognosis of patients. However, the expression of ATG5 did not correlate with these 3 relevant prognostic SNPs. We concluded that hereditary genetic polymorphisms and gene expression of ATG5 can serve as prognostic predictors of patients with early-stage ESCC.

Robot-assisted thoracic surgery for complex procedures

Background

As an option for minimally invasive thoracic surgery, robot-assisted thoracic surgery (RATS) has shown comparable perioperative outcomes to those achieved by traditional video-assisted thoracic surgery (VATS). It is unknown whether RATS might have any potential benefits in more complex thoracic surgical procedures, which usually require open surgery instead of VATS. The current study presents a preliminary result regarding the use of RATS in complex thoracic operations in an attempt to address this unresolved question.

Methods

Data from a prospectively collected and maintained surgical database were collected on patients who underwent RATS between February 2012 and August 2014. We defined complex RATS as those operations involving difficult dissections, complex sutures or excision of very large tumors (>8 cm) which would have required open surgery in our hospital before the introduction of RATS. The characteristics and peri-operative outcomes of patients receiving complex RATS were reviewed.

Results

Of the 120 patients undergoing RATS, 30 of them were classified as having undergone complex RATS, 21 to remove lung tumors and 9 to remove mediastinal tumors. The indications for complex RATS included 21 difficult dissections, 10 complex sutures, and 7 very large tumors (8 patients had two indications). There are three conversions to thoracotomy for pulmonary arterial bleeding. There was one mortality resulted from post-pneumonectomy pulmonary hypertension and sepsis. Patients with difficult dissection had longer operative time and hospital stay, and more bleeding and postoperative morbidity.

Conclusions

RATS for complex thoracic procedures is feasible, especially for complex suturing and excision of very large mediastinal tumors, but more attention is needed for patients needing difficult dissections. Advanced preparation for conversion is necessary during this difficult operation.

Do We Need to Add Postoperative Radiotherapy in Patients Undergoing Trimodality Therapy for Esophageal Squamous Cell Carcinoma with Positive Lymph Nodes Disease?

BACKGROUND

The role of adjuvant radiotherapy for positive lymph nodes (LN) in patients with esophageal cancer who received neoadjuvant concurrent chemoradiotherapy (CCRT) is not well established. This study is aimed at determining the impact of positive LN and the survival benefit of postoperative radiotherapy (PORT) after CCRT plus surgery on esophageal cancer patients.

METHODS

Seventy patients with positive LN after neoadjuvant CCRT followed by esophagectomy were enrolled in the study. Patients were grouped into surgery alone following neoadjuvant CCRT (n = 41) and surgery plus PORT following neoadjuvant CCRT (n = 29) groups. The preoperative radiation dose was 36-45 Gy (mean 40 Gy) and the postoperative radiation dose was 20 Gy in 10 fractions.

RESULTS

The 5-year survival rate and mean survival was 40% and 58.6 ± 53.9 months for patients with a pathologic complete response (pCR) compared with 8.3% and 22.7 ± 35.5 months, respectively, for non-pCR patients (p = 0.026). Local and distant recurrent patterns were similar for patients who did and did not receive PORT (p = 0.876). The mean survival did not differ significantly between the 2 groups (p = 0.889). Pathological complete response to CCRT was the only significant factor influencing survival (p = 0.026).

CONCLUSIONS

Postoperative RT did not improve survival in patients with positive LN after CCRT followed by curative surgery for esophageal cancer.

A phase II study of early FDG-PET evaluation after one-cycle chemotherapy in patients with locally advanced esophageal squamous cell carcinoma treated with neoadjuvant chemoradiotherapy: Final report

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Background: The optimal use of the metabolic tumor response measured by 18fluorodeoxyglucose positron emission tomography (FDG-PET) in the treatment of esophageal cancer is currently unknown. We launched a phase II clinical trial to evaluate the early metabolic response to one-cycle chemotherapy in locally advanced esophageal squamous cell carcinoma (ESCC) patients, who subsequently received neoadjuvant chemoradiation (neo-CRT) followed by surgery. Methods: ESCC patients with stage T3 or N1M0 or M1a (AJCC, 6th edition) were enrolled to receive one-cycle chemotherapy, day 1 and 8 doses of paclitaxel, cisplatin, and 24-hour infusional 5-fluorouracil and leucovorin, followed by paclitaxel/cisplatin- based 40Gy neo-CRT and surgery. FDG-PET was performed at baseline and day 14 of the one-cycle chemotherapy. The primary endpoint is pathological complete response (pCR) to neo-CRT. We hypothesized that early PET responders, defined as > 35% reduction of maximum standardized uptake value (SUVmax) from the baseline, would significantly improve pCR. Results: Between Feb 2008 and Mar 2012, 66 patients (M: F = 61: 5) were enrolled. Their clinical stages were: II or III, 56; IVA, 10. Forty seven received surgery. The pCR rate per surgical population was 34.0%. The median progression-free survival (PFS) and overall survival (OS) for the whole study group was 16 months (95% CI 9-27) and 22 months (95% CI 16-40), respectively. A total of53 patients were evaluable for PET response. The early PET response was not associated with high pCR rate or better survivals. However, in an exploratory analysis, the post-chemotherapy SUVmax was an independent prognostic factor for pCR, PFS and OS. A predictive model for pCR composed of weight loss and the post-chemotherapy SUVmaxwas established with an AUC of 0.84. Conclusions: Our study failed to validate the predictive value of predefined early PET response to one-cycle chemotherapy for pCR to neo-CRT in locally advanced ESCC patients. However, the FDG-PET SUVmax after one-cycle chemotherapy may have prognostic and predictive significance, and may be explored in further studies. Clinical trial information: NCT01034332.

Early Postoperative Endoscopy for Evaluation of the Anastomosis after Esophageal Reconstruction

BACKGROUND

Anastomotic leaks significantly affect hospital stay after esophageal surgery. Here, we investigated the efficacy of early endoscopy for predicting anastomotic healing and leaks after esophageal reconstruction.

METHODS

A total of 65 consecutive esophageal cancer patients treated by cervical esophagogastrostomy underwent routine endoscopy between postoperative days 5 and 7. The anastomosis was scored for the degree of ischemia, stenosis, and torsion of the anastomotic axis. Independent associations between ischemia, stenosis, and torsion of the proximal esophagus and the risk of the anastomotic leak were examined using Spearman's rank correlation method.

RESULTS

Assessment of the degree of mucosal ischemia in 65 patients shows well healing in 35, patch ischemia in 20, diffuse ischemia in 10, no necrosis in any patient. Stenosis was classified as 0 to 10% in 40 patients, 11 to 20% in 12, 21 to 80% in 11, and 81 to 100% in 2. The degree of torsion of the anastomotic axis was classified as 0 to 10 degrees in 52 patients, 11 to 90 degrees in 8, and 91 to 180 degrees in 5. With rising endoscopy scores, there was an increase in risk for leaks (score > 4.5, sensitivity 100%, and specificity 83.8%).

CONCLUSIONS

Early postoperative endoscopy facilitates the management of esophagogastrostomy anastomosis to predict leaks.

Comparison of single- and multi-incision minimally invasive esophagectomy (MIE) for treating esophageal cancer: a propensity-matched study

OBJECTIVE

To compare the perioperative outcome of minimally invasive (MIE) esophagectomy performed with a single- or a multi-incision in treating esophageal cancer.

METHOD

Patients with esophageal cancer who underwent MIE from 2006 to 2016 were evaluated. A 3-4-cm incision was created in both the thoracoscopic and the laparoscopic phases during the single-incision MIE procedures. A propensity-matched comparison was made between the two groups of patients.

RESULTS

We analyzed a total of 48 pairs of patients with propensity-matched from the cohort of 360 patients undergoing MIE during 2006-2015. There is no statistical difference in terms of postoperative ICU and hospital stay, number of dissected lymph nodes and presence of major surgical complications (anastomotic leakage and pulmonary complications) between the two groups of patients. The pain score one week after surgery was significantly lower in the single-incision group (p < 0.05). There was no surgical mortality in the single-incision MIE group.

CONCLUSION

Minimally invasive esophagectomy performed with a single-incision approach is feasible for treating patients with esophageal cancer, with a comparable perioperative outcome with that of multi-incision approaches. The postoperative pain one week after surgery was significantly reduced in patients undergoing single-incision MIE.

Preoperative computed tomography-guided dye injection to localize multiple lung nodules for video-assisted thoracoscopic surgery

BACKGROUND

Preoperative computed tomography (CT)-guided localization of small lung nodules is important for accurate and efficient video-assisted thoracoscopic surgery (VATS). Resection of multiple small pulmonary nodules in one VATS procedure can aid in patient management. The aim of this study was to evaluate the usefulness of CT-guided Patent Blue V (PBV) dye localization in patients with multiple pulmonary nodules who underwent VATS.

METHODS

This retrospective study was conducted from January 2013 to December 2015. One hundred consecutive patients (59.9±10.5 years of age) with 217 nodules who underwent preoperative CT-guided PBV dye localization for multiple (2 to 4) nodules before VATS were enrolled.

RESULTS

The mean nodule size was 0.8±0.4 cm, with a mean depth from the pleura or fissure of 0.7±0.7 cm. The mean procedure duration was 50±20 minutes. The mean amount of injected PBV dye was 0.2±0.1 mL per nodule. The overall success rate was 99% by nodule. Failed localization of two nodules in two patients was due to poor dye visualization (n=1) and significant pneumothorax (n=1). Cases of hemorrhage (24%) were mild and asymptomatic, and none of the patients had hemoptysis. None of the cases of pneumothorax (40%) required chest tube placement before VATS. One (1%) patient developed anaphylaxis. The mean post-operative hospital stay was 6.4±4.4 days.

CONCLUSIONS

CT-guided PBV dye localization for multiple small pulmonary nodules before VATS is a safe, feasible, and accurate method with high success rate. This approach makes it easy to perform multiple nodule resections during one VATS operation.

Thoracoscopic Mesh Repair of Diaphragmatic Defects in Hepatic Hydrothorax: A 10-Year Experience

BACKGROUND

The objective was to analyze the outcomes of thoracoscopic mesh repair for hepatic hydrothorax (HH) at our institution during the past 10 years.

METHODS

A total of 63 patients with refractory HH who underwent thoracoscopic mesh onlay reinforcement to repair diaphragmatic defects from January 2005 to December 2014 were included in the study. Mesh covering alone was used in 47 patients and mesh with suturing was used in 16 patients. Patient demographics, Child-Pugh class, and model for end-stage liver disease (MELD) score were evaluated to predict morbidity and mortality.

RESULTS

Of the patients (mean age, 60.4 ± 15 years; 31 men and 32 women), 14.3% had concomitant underlying diseases of renal insufficiency, 34.9% had diabetes mellitus, and 4.8% had pneumonia. Diaphragmatic blebs were the most common diaphragmatic defects (29 of 63 [46%]). After a median 20.5 months of follow-up examinations, 4 patients experienced recurrence. The 1-month mortality rate was 9.5% (6 of 63 patients). On multivariable analysis, underlying impaired renal function (p = 0.039) and MELD scores (p = 0.048) were associated with increased 3-month mortality in 16 patients. Contrary to the rising Child-Pugh score (p = 0.058), rising MELD scores represented an increase in kidney or liver failure and mortality. The main causes of 3-month mortality were septic shock (n = 6), acute renal insufficiency (n = 4), gastrointestinal bleeding (n = 4), hepatic encephalopathy (n = 1), and ischemic bowel (n = 1).

CONCLUSIONS

Thoracoscopic mesh repair for refractory HH improves symptoms and lowers the recurrence rate.

Single-incision laparo-thoracoscopic minimally invasive oesophagectomy to treat oesophageal cancer†

OBJECTIVES

Single-incision thoracoscopic and laparoscopic procedures have been applied in treating various diseases. However, it is unknown whether such procedures are feasible in treating oesophageal cancer.

METHODS

Minimally invasive oesophagectomy (MIO) with a single-incision approach in the thoracoscopic and laparoscopic procedures was attempted in 16 patients with oesophageal cancer.

RESULTS

One patient was converted to laparotomy and a four-port thoracoscopic procedure due to bleeding. Of the patients successfully treated with a single-port MIO, 6 underwent a McKeown procedure and 9 an Ivor Lewis procedure, including 3 cases of total laryngopharyngo-oesophagectomy with cervical pharyngogastrostomy. The mean ventilator usage of the patients after surgery was 0.3 ± 0.6 days, the mean intensive care unit (ICU) stay was 3.8 ± 3.1 days and the mean number of dissected lymph nodes was 28.6 ± 14.6. One delayed anastomotic leakage occurred, and another patient developed a trachea-oesophageal fistula induced by surgical clip-related tissue erosion, both of which were successfully treated by the placement of an oesophageal stent. No pulmonary complications or surgical mortalities occurred in the study. Minor complications developed in 2 patients, 1 experiencing pneumothorax and 1 postoperative delirium. When compared with traditional MIO in our series (n = 315), no statistical difference was found among patients receiving single-port MIO in terms of ventilator usage, ICU stay and the number of dissected lymph nodes.

CONCLUSIONS

Single-port MIO seems to be a feasible option for treating patients with oesophageal cancer, which requires further evaluation and follow-up in the future.

Hepatoesophageal Fistula After Radiofrequency Ablation for Hepatic Metastasis

Although surgical resection remains the treatment of choice for hepatic tumors, radiofrequency ablation has emerged as a reliable alternative. Radiofrequency ablation is both less invasive and can be repeated after short intervals in cases of multiple lesions that cannot be treated with surgical resection. Liver abscess, which may progress to internal enteral fistula, is the most common complication of radiofrequency ablation. Here we present the first case report in the literature of a rare complication of hepatoesophageal fistula after radiofrequency ablation for colon cancer with liver metastasis. This case was well managed with percutaneous abscess drainage, antibiotics, and separation of the hepatoesophageal fistula using an esophageal stent.

A Walk-and-Eat Intervention Improves Outcomes for Patients With Esophageal Cancer Undergoing Neoadjuvant Chemoradiotherapy

BACKGROUND

Preserving functional walking capacity and nutritional status is important for patients with esophageal cancer, but no effective intervention is available, particularly during active treatment.

METHODS

This pilot randomized controlled trial tested the effects of a walk-and-eat intervention for patients with esophageal cancer undergoing neoadjuvant chemoradiotherapy. Participants with locally advanced esophageal cancer stage IIB or higher (n = 59) were randomly assigned to receive the walk-and-eat intervention (n = 30; nurse-supervised walking three times per week and weekly nutritional advice) or usual care (n = 29; control group) during 4-5 weeks of chemoradiotherapy. Primary endpoints were changes in distance on the 6-minute walk test, hand-grip strength, lean muscle mass, and body weight between initiation and completion of intervention.

RESULTS

Participants (mean age: 59.6 years) were mostly male (92.9%) with squamous cell carcinoma (96.4%). During chemoradiotherapy, participants who received the walk-and-eat intervention had 100-m less decline than controls in walk distance (adjusted p = .012), 3-kg less decrease in hand-grip strength (adjusted p = .002), and 2.7-kg less reduction in body weight (adjusted p < .001), regardless of age. The intervention group also had significantly lower rates of need for intravenous nutritional support and wheelchair use.

CONCLUSION

The nurse-led walk-and-eat intervention is feasible and effective to preserve functional walking capacity and nutritional status for patients with esophageal cancer undergoing neoadjuvant chemoradiotherapy.

Long-term outcome after bilateral lung transplantation - a retrospective study from a low-volume center experience

Background

The aim of this study is to review the long-term outcomes of bilateral lung transplantation (BLTx) in our institution and examine the potential issues that may influence outcomes in a low-volume center.

Methods

A retrospective review of BLTx performed in our institution between July 2006 and December 2012 was conducted. Standardized donor selection, procurement, and preservation protocols for brain-dead donors were applied. Measured outcomes were in-hospital mortality and actuarial survival using the Kaplan-Meier method.

Results

Twenty-five consecutive patients (13 male, 12 female) underwent BLTx with a mean age of 41.8 ± 13.5 years. Before LTx, the mean body mass index was 18.3 ± 3.1 kg/m2. Seven of these patients (28%) required oxygen supplementation at rest before LTx, while the remaining patients (72%) required noninvasive mechanical ventilation (n = 6, 24%), invasive mechanical ventilation (n = 9, 36%) or extracorporeal membrane oxygenation (ECMO) (n = 3, 12%). The lung grafts were procured from brain-dead donors with the mean age of 26.8 ± 11.4 year and the best PaO2 / FiO2 ratio of 513 ± 77 before procurement. All cross match results between same-race donors and recipients were negative. The percentage of same-sex matching and CMV mismatching were 64% and 4%, respectively. The mean time listed on the transplant list was 308 ± 261 days. The mean ischemic time for the first and second grafts were 222 ± 62 and 361 ± 67 minutes. During transplantation, 22 (88%) patients depended on ECMO and one (4%) on cardiopulmonary bypass support. All but two patients (82%) were discharged home in good condition; two (8%) patients died within 3 months after BLTx. The cumulative survival rates at 1-, 2-, 3-, and 5-years were 88%, 83%, 72%, and 72%, respectively.

Conclusions

Although the comparatively few annual LTx performed is consistent with the low donation rate, our single-center growing experience demonstrates that good post-lung transplant outcomes can be achieved at a low-volume LTx center.

Intrapleural Epinephrine Irrigation for Massive Malignant Hemothorax

Massive malignant hemothorax (MMH) is a rare and serious complication encountered in the field of oncology and can be life threatening. It is often difficult and complex to manage. Herein, we present cases of four patients who had MMH and in whom a hemothorax was successfully stopped via continuous intrapleural irrigation with epinephrine (5-mg epinephrine/1,000-mL normal saline, infused at 100 mL/h) instead of a conventional surgical approach. Although no patient deaths were attributed to intractable bleeding, two deaths were related to multiple organ failure. Despite the limited number of cases, this method was a convenient, effective, and inexpensive alternative to open surgical or thoracoscopic drainage for MMH.

Association of miRNA-related genetic polymorphisms and prognosis in patients with esophageal squamous cell carcinoma

BACKGROUND

Esophageal squamous cell carcinoma (ESCC) is a deadly disease with a poor prognosis. The single nucleotide polymorphisms (SNPs) involved in microRNA (miRNA) functions are potential biomarkers for prognosis of various human cancers. We investigated the association of the miRNA-related SNPs with the prognosis of ESCC.

METHODS

A total of 504 patients with ESCC were enrolled. The genotypes of 18 miRNA-related SNPs were analyzed from the genomic DNA of peripheral leukocytes and were correlated with the prognosis of patients randomly assigned to a training set (n = 129) or an independent replication set (n = 375).

RESULTS

In the training group, only the rs4919510 SNP of the mir-608 gene was significantly associated with clinical outcome (CG vs. GG, hazard ratio [HR] 0.47, 95 % confidence interval [CI] 0.27-0.82, P = 0.008 for death, HR 0.47, 95 % CI 0.29-0.77, P = 0.002 for recurrence). The association for overall survival was confirmed in an independent replication group (CG vs. GG, HR 0.74, 95 % CI 0.56-0.97, P = 0.031 for death). Two other SNPs, rs14035 of RAN and rs7813 of GEMIN4, showed a borderline significant association with the prognosis of ESCC. In a combined analysis, we demonstrated the cumulative effect of the mir-608, RAN, and GEMIN4 polymorphisms on the clinical outcome of ESCC (HR 1.40, 95 % CI 1.18-1.67, P trend < 0.001 for mortality, HR 1.30, 95 % CI 1.10-1.53, P trend = 0.002 for recurrence). The cumulative effect was more evident in patients receiving concurrent chemoradiotherapy.

CONCLUSIONS

The hereditary genetic polymorphisms of mir-608, RAN, and GEMIN4 can serve as predictors for clinical outcome in ESCC patients treated with concurrent chemoradiotherapy.