Body Composition and Clinical Outcomes in Esophageal Cancer Patients Treated with Immune Checkpoint Inhibitors

BACKGROUND

Obesity is associated with increased mortality in various cancers, but the relationship between obesity and clinical outcomes in unresectable or recurrent esophageal cancer who receive immune checkpoint inhibitors (ICIs) remains unknown. This study investigated the association between body composition and clinical outcomes in patients with unresectable or recurrent esophageal cancer who received ICIs.

METHODS

Utilizing an unbiased database of 111 unresectable or recurrent esophageal cancers, we evaluated the relationships between body composition (body mass index, waist circumference, psoas major muscle volume, and subcutaneous and visceral fat areas) at the initiation of ICI treatment and clinical outcomes including the disease control rate and progression-free survival (PFS).

RESULTS

Waist circumference was significantly associated with the disease control rate at the first assessment (P = 0.0008). A high waist circumference was significantly associated with favorable PFS in patients treated with nivolumab. In an univariable model, for 5-cm increase of waist circumference in the outcome category of PFS, univariable hazard ratio (HR) was 0.73 (95% confidence interval [CI], 0.61-0.87; P = 0.0002). A multivariable model controlling for potential confounders yielded a similar finding (multivariable HR, 0.56; 95% CI, 0.33-0.94; P = 0.027). We observed the similar finding in esophageal cancer patients treated with pembrolizumab+CDDP+5-FU (P = 0.048). In addition, waist circumference was significantly associated with the prognostic nutritional index (P = 0.0073).

CONCLUSIONS

A high waist circumference was associated with favorable clinical outcomes in ICI-treated patients with unresectable or recurrent esophageal cancer, providing a platform for further investigations on the relationships among body composition, nutrition, and the immune status.

Clinical impact of very early recurrence after conversion surgery for stage IV gastric cancer

Background

The development and improved response to chemotherapy has resulted in a survival benefit of conversion surgery (CS) for advanced gastric cancer (GC). However, this benefit is limited in some cases, such as in those with very early recurrence (VER). This study investigated the relationship between outcome and clinicopathological characteristics after CS for stage IV GC, and the risk factors for VER after CS.

Methods

We retrospectively studied 184 patients with stage IV GC who initially underwent chemotherapy, including 36 patients who underwent CS between May 2007 and January 2022. We evaluated the long-term outcome after CS for stage IV GC and the clinicopathological characteristics of the patients who underwent CS.

Results

Median survival times (MSTs) in the chemotherapy alone and CS groups were 13.4 and 36.5 months, respectively (p < 0.0001). Of the 27 patients who underwent R0 resection, 22 remained free of early recurrence and five experienced VER. MSTs in the VER and free of early recurrence groups were 15.2 and 44.1 months, respectively (p < 0.0001). Significantly more patients had liver metastasis before initial treatment in the VER group than in the FER group (p = 0.016). There were more patients with preoperative PNI <40 in the VER group (p = 0.046).

Conclusion

CS is an effective treatment for stage IV GC, but VER is associated with poor prognosis. We need to carefully consider the indications for CS, especially for patients with poor nutritional status and liver metastases.

Relationship between the severity of emphysematous change in the lung and morbidity after esophagectomy for esophageal cancer: A retrospective study on a novel strategy for risk prediction

BACKGROUND

Chronic obstructive pulmonary disease (COPD) prevalence increases post-esophagectomy morbidity. However, the association between COPD severity and post-esophagectomy morbidity remains unclear because of the lack of an objective method to classify COPD severity. Low attenuation volume ratio (LAVR) estimated using Ziostation2 may reflect the extent of emphysematous changes in the lungs and COPD severity, thereby predicting post-esophagectomy morbidity.

METHODS

A total of 776 patients who underwent curative McKeown esophagectomy for esophageal cancer between April 2005 and June 2021 were included. The patients were divided into high and low preoperative LAVR groups. Short-term outcomes between the groups were compared for patients who underwent open esophagectomy (OE) and minimally invasive esophagectomy (MIE).

RESULTS

A total of 219 (28%) patients were classified into the high LAVR group. High LAVR was significantly associated with disadvantageous patient characteristics such as advanced age, heavy smoking, and impaired respiratory function. Patients with high LAVR had a significantly higher incidence of severe morbidity and pneumonia after OE. High LAVR was an independent risk factor for severe morbidity (odds ratio [OR], 2.52; 95% confidence interval [CI]: 1.237-5.143; p = 0.011) and pneumonia (OR, 2.12; 95% CI: 1.003-4.493; p = 0.049) after OE. Meanwhile, LAVR was not correlated with the incidence of post-MIE morbidity.

CONCLUSIONS

LAVR may reflect COPD severity and predict severe morbidity and pneumonia after OE, but not after MIE. Less invasiveness of MIE may alleviate the effects of various disadvantageous backgrounds associated with high LAVR on worse short-term outcomes.

Relationship between gut microbiome Fusobacterium nucleatum and LINE-1 methylation level in esophageal cancer

BACKGROUND

We previously demonstrated the relationship of human microbiome Fusobacterium nucleatum with unfavorable clinical outcomes and inferior chemotherapeutic responses in esophageal cancer. Global DNA methylation is associated with the occurrence and development of various cancers. In our previous study, LINE-1 hypomethylation (i.e., global DNA hypomethylation) was associated with a poor prognosis in esophageal cancer. As the gut microbiota may play crucial roles in the DNA methylation of host cells, we hypothesized that F. nucleatum might influence LINE-1 methylation levels in esophageal cancer.

METHODS

We qualified the F. nucleatum DNA using a quantitative PCR assay and LINE-1 methylation via a pyrosequencing assay using formalin-fixed paraffin-embedded specimens from 306 esophageal cancer patients.

RESULTS

Intratumoral F. nucleatum DNA was detected in 65 cases (21.2%). The LINE-1 methylation scores ranged from 26.9 to 91.8 (median = 64.8) in tumors. F. nucleatum DNA was related to the LINE-1 hypomethylation of tumor lesions in esophageal cancer (P < 0.0001). The receiver operating characteristic curve analysis showed that the area under the curve was 0.71 for F. nucleatum positivity. Finally, we found that the impact of F. nucleatum on clinical outcomes was not modified by LINE-1 hypomethylation (P for interaction = 0.34).

CONCLUSIONS

F. nucleatum alters genome-wide methylation levels in cancer cells, which may be one of the mechanisms by which F. nucleatum affects the malignant behavior of esophageal cancer.

Textbook outcome contributes to long-term prognosis in older adults with gastric cancer

PURPOSE

Textbook outcome (TO) is a composite quality measurement of short-term outcomes for evaluating surgical procedures. We investigated whether TO can be used to predict outcomes after curative gastric cancer (GC) surgery in older adults.

METHODS

We retrospectively analyzed 492 consecutive patients who underwent curative gastrectomy for GC from 2005 to 2017. Among these, 141 advanced-age patients were eligible. The patients were divided into two groups: those who achieved TO (a-TO group) and those who failed to achieve TO (f-TO group). In accordance with previous reports, TO consisted of eight metrics. We evaluated the association between TO and long-term survival.

RESULTS

TO was achieved 73 (52%) patients. The patients in the f-TO group had a significantly higher body mass index (P = 0.01), longer surgery time (P = 0.03), and more blood loss (P = 0.001). The metric with the lowest achievement rate was "no postoperative severe complication." The patients in the f-TO group had significantly shorter overall survival than those in the a-TO group (P = 0.03). Multivariable Cox regression analyses of overall survival revealed that an American Society of Anesthesiologists physical status classification of 3 (hazard ratio [HR], 3.28; 95% confidence interval [CI], 1.79-5.98; P < 0.0001) and f-TO (HR, 1.92; 95% CI, 1.09-3.39; P = 0.02) were significantly associated with poor overall survival.

CONCLUSION

TO can be used to predict outcomes after curative GC surgery in patients of advanced age.

Intratumour Fusobacterium nucleatum and immune response to oesophageal cancer

BACKGROUND

Experimental evidence suggests a role of intratumour Fusobacterium nucleatum in the aggressive behaviour of gastrointestinal cancer through downregulating anti-tumour immunity. We investigated the relationship between intratumour F. nucleatum and immune response to oesophageal cancer.

METHODS

Utilising an unbiased database of 300 resected oesophageal cancers, we measured F. nucleatum DNA in tumour tissue using a quantitative polymerase chain reaction assay, and evaluated the relationship between the abundance of F. nucleatum and the densities of T cells (CD8 + , FOXP3 + and PDCD1 + ), as well as lymphocytic reaction patterns (follicle lymphocytic reaction, peritumoural lymphocytic reaction, stromal lymphocytic reaction and tumour-infiltrating lymphocytes) in oesophageal carcinoma tissue.

RESULTS

F. nucleatum was significantly and inversely associated only with the peritumoural lymphocytic reaction (P = 0.0002). Compared with the F. nucleatum-absent group, the F. nucleatum-high group showed a much lower level of the peritumoural lymphocytic reaction (univariable odds ratio, 0.33; 95% confidence interval, 0.16-0.65; P = 0.0004). A multivariable model yielded a similar finding (multivariable odds ratio, 0.34; 95% confidence interval 0.16-0.69; P = 0.002).

CONCLUSIONS

Intratumour F. nucleatum is associated with a diminished peritumoural lymphocytic reaction, providing a platform for further investigations on the potential interactive roles between intratumour F. nucleatum and host immunity.

Frailty Assessed by the Clinical Frailty Scale is Associated with Prognosis After Esophagectomy

BACKGROUND

The Clinical Frailty Scale (CFS) is a simple and validated tool for assessing frailty, and higher CFS scores are correlated with worse perioperative outcomes after cardiovascular surgery. However, the relationship between the CFS scores and postoperative outcomes after esophagectomy remain unclear.

METHODS

We retrospectively analyzed data from 561 patients with esophageal cancer (EC) who underwent resection from August 2010 to August 2020. We defined a CFS score of ≥4 as indicative of frailty; thus, patients were classified into frail patients (CFS scores of ≥4) and non-frail patients (CFS scores of ≤3). The Kaplan-Meier method was used to describe the overall survival (OS) distributions with the log-rank test.

RESULTS

Of the 561 patients, 90 (16%) had frailty and 471 (84%) did not. Frail patients had a significantly older age, lower body mass index, higher American Society of Anesthesiologists physical status classification, and greater cancer progression than non-frail patients. The 5-year survival rate was 68% in non-frail patients and 52% in frail patients. OS was significantly shorter in frail than non-frail patients (p = 0.017 by log-rank test). In particular, OS was significantly shorter in frail patients with clinical stage I-II EC (p = 0.0024 by log-rank test) but was not correlated with frailty in patients with clinical stage III-IV EC (p = 0.87 by log-rank test).

CONCLUSIONS

Preoperative frailty was associated with shorter OS after resection of EC. The CFS score may be a prognostic biomarker for patients with EC, especially early-stage EC.

C-Reactive Protein Levels After Esophagectomy are Associated with Increased Surgical Complications and Poor Prognosis in Esophageal Squamous Cell Carcinoma Patients

BACKGROUND

C-reactive protein (CRP) levels are reported to predict complications and survival after surgery in various cancers. However, the relationship between postoperative CRP levels and short- and long-term outcomes of esophageal squamous cell carcinoma (ESCC) patients after esophagectomy is unclear.

METHOD

We reviewed the records of 543 ESCC patients who underwent subtotal esophagectomy with gastric conduit reconstruction at Kumamoto University Hospital between August 2010 and July 2021. Blood tests for CRP were done on postoperative days (PODs) 1, 3, 5 or 6, and 7 or 8.

RESULTS

The mean CRP levels on day 1, day 3, day 5/6, and day 7/8 were 6.68 ± 0.13 mg/dL, 11.49 ± 0.27 mg/dL, 7.48 ± 0.26 mg/dL, and 5.38 ± 0.22 mg/dL, respectively. Mean CRP levels were highest on day 3, and CRP levels after day 3 correlated with grade >2 complications based on the Clavien-Dindo classification. Receiver operating characteristic curve analysis established the optimal cut-off value for CRP day 3 levels to be 12.19 mg/dL. Multivariate logistic regression analyses found that high CRP day 3 levels significantly correlated with grade >2 complications (odds ratio [OR] 3.77, 95% confidence interval [CI] 2.56-5.35; p < 0.001). Moreover, high day 7/8 CRP levels (>3.52) correlated with postoperative survival, and based on multivariate logistic regression analyses, were significantly associated with poor prognosis (hazard ratio 1.67, 95% CI 1.14-2.43; p = 0.008).

CONCLUSION

Our findings suggest CRP day 3 levels as a potential biomarker for predicting postoperative complications and that CRP day 7/8 levels have potential prognostic value for ESCC patients after esophagectomy.

Immune-related adverse events and prognosis in patients with upper gastrointestinal cancer treated with nivolumab

Background

Immune checkpoint inhibitors (ICIs) are increasingly being used for the treatment of upper gastrointestinal cancers [esophageal cancer and gastric cancer (GC)]. They cause imbalances in immunological tolerance, resulting in immune-related adverse events (irAEs). Although irAEs have been reported to be associated with the efficacy of ICIs in some cancers, the relationship between irAEs and prognosis of upper gastrointestinal cancers remains unknown. This study aimed to investigate the prognostic impact of irAEs in patients with advanced or recurrent upper gastrointestinal cancer treated with nivolumab.

Methods

We retrospectively divided the patients (n=96) who received nivolumab into two groups: the irAEs group (n=41) and non-irAEs group (n=55), according to the Common Terminology Criteria for Adverse Events ver. 5.0.

Results

irAEs were significantly associated with good performance status and high serum albumin levels (all P<0.05). The irAEs group had a significantly longer overall survival (OS) than the non-irAEs group [log-rank P=0.003; univariate hazard ratio (HR) =0.36, 95% confidence interval (CI) =0.21-0.65, P<0.01; multivariate HR =0.47, 95% CI =0.26-0.88, P=0.018]. Importantly, in both esophageal cancer and GC, the irAEs group experienced favorable clinical outcomes compared with the non-irAEs group. In the multivariate analysis, male sex (P<0.01), presence of irAEs (P=0.018), and good pretreatment performance status (P<0.01) were independent prognostic factors.

Conclusions

Among patients with upper gastrointestinal cancer treated with nivolumab, the prognosis of patients who developed irAEs was better than that of patients who did not develop irAEs. Long-term continuation of nivolumab by early detection of irAEs and an appropriate response to irAEs are important.

Pan-immune-inflammation Value and Prognosis in Patients With Esophageal Cancer

Mini-abstract

The pan-immune-inflammation value was associated with clinical outcomes and tumor-infiltrating lymphocytes in 866 esophageal cancers. Systemic immune competence may influence patient prognosis through local immune response.

Objective

To examine the relationship between the pan-immune-inflammation value (PIV), tumor immunity, and clinical outcomes in 866 patients with esophageal cancer.

Background

The PIV, calculated from all immune-inflammatory cells in the peripheral blood count, is a recently proposed marker for clinical outcomes in some types of cancers. Nonetheless, the prognostic significance of PIV in esophageal cancer remains unclear.

Methods

In the derivation cohort (n = 433), we set the optimal cutoff value using a time-dependent receiver operating characteristic (ROC) curve. In the validation cohort (n = 433), the relationships between the PIV, tumor-infiltrating lymphocytes (TILs), CD8 expression by immunohistochemical staining, and patient prognosis were examined.

Results

The area under the ROC curve for the PIV at 5 years was 0.631 in the derivation cohort. The validation cohort, divided into PIV-low cases (n = 223) and PIV-high cases (n = 210), showed significantly worse overall survival (log-rank P = 0.0065; hazard ratio [HR]: 1.48; 95% confidence interval [CI]: 1.12-1.98; P < 0.001; multivariate HR: 1.41; 95% CI: 1.05-1.90; P = 0.023). The prognostic effect of the PIV was not significantly modified by any clinical characteristics (P for interaction > 0.05). The PIV-high cases were significantly associated with a low TIL status (P < 0.001) and low CD8-positive cell counts (P = 0.011).

Conclusions

The PIV was associated with clinical outcomes in esophageal cancer, supporting its role as a prognostic biomarker. Considering the relationship between the PIV and TILs, systemic immune competence may influence patient prognosis through a local immune response.

PD-L1 and PD-L2 expression status in relation to chemotherapy in primary and metastatic esophageal squamous cell carcinoma

Immune checkpoint inhibitors have shown efficacy in various cancers. Although programmed death ligand 1/2 (PD‐L1/L2) expressions have been demonstrated as predictive biomarkers of response to immune checkpoint inhibitors and prognostic markers, whether PD‐L1/L2 expression is altered in esophageal squamous cell carcinoma during the therapeutic course is unclear. Whether PD‐L1/L2 expression in metastatic or recurrent lesions is consistent with that in primary tumors is also unknown. This study included 561 surgically resected esophageal squamous cell carcinomas and PD‐L1/L2 expression was evaluated by immunohistochemistry. We investigated the influence of chemotherapeutic drugs (cisplatin and fluorouracil) on PD‐L1/L2 expression and PD‐L1/L2‐related pathways in vitro. We also examined PD‐L1/L2 expression in 18 surgically resected lymph node metastases and 10 recurrent lesions compared with primary lesions. The positive rate of PD‐L1 was significantly higher in patients with preoperative chemotherapy than in those without preoperative therapy. The positive rate of PD‐L2 expression showed no significant difference between patient groups. Cisplatin increased PD‐L1 expression in cancer cell lines in vitro, but decreased PD‐L2 in some cell lines. The effects of cisplatin on phosphorylated signal transducer and activator of transcription 1/3 (pSTAT1/3) also differed depending on cell lines. Fluorouracil increased PD‐L1 and PD‐L2 expression. PD‐L1/L2 expression in lymph node metastases and recurrent lesions did not always match expression in primary lesions. PD‐L1/L2 expression may be altered by preoperative chemotherapy, and PD‐L1 /L2 expression in primary lesions does not always match that of metastatic/recurrent lesions. Thus, one‐time evaluation is not sufficient to evaluate PD‐L1/L2 expression as a biomarker in esophageal cancer.

Clinical Significance of Pretreatment Red Blood Cell Distribution Width as a Predictive Marker for Postoperative Morbidity After Esophagectomy for Esophageal Cancer: A Retrospective Study

Background

Clinical significance of red blood cell distribution (RDW) as a predictive marker for the incidence of postoperative morbidity after esophagectomy for esophageal cancer has not been established.

Methods

This study included 634 consecutive patients who underwent three-incisional esophagectomy with lymphadenectomy for esophageal cancer between April 2005 and November 2020. Correlation between pretreatment RDW and patient background, cancer background, and short-term outcome after esophagectomy were retrospectively investigated.

Results

Eighty patients (12.6%) had a high pretreatment RDW (> 14.2), which correlated with malnutrition estimated by body mass index, hemoglobin, total lymphocyte count, albumin, and total cholesterol. High pretreatment RDW was an independent risk factor for postoperative severe morbidity of grade IIIb or higher based on the Clavien–Dindo classification (hazard ratio [HR] 3.90, 95% confidence interval [CI] 1.707–8.887; p = 0.0012) and reoperation (HR 4.39, 95% CI 1.552–12.390; p = 0.0053) after open esophagectomy (OE). However, RDW was not associated with postoperative morbidity incidence after minimally invasive esophagectomy (MIE).

Conclusions

Pretreatment RDW may be a surrogate marker for nutritional status and could be a predictive marker for postoperative severe morbidity, reoperation, and possibly pneumonia after OE. On the contrary, the lower invasiveness of MIE may have reduced the effect of pretreatment malnutrition on morbidity incidence, which could explain the insignificant relationship between RDW and poor short-term outcomes in MIE.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-10719-2.

Treatment strategies and outcomes for elderly patients with locally advanced squamous cell carcinoma of the esophagus

PURPOSE

A multidisciplinary treatment strategy for locally advanced esophageal squamous cell carcinoma (ESCC) is required to achieve prolonged survival. We aimed to clarify the differences in treatment strategies for locally advanced ESCC and the outcomes of elderly (aged ≥ 75 years) vs. younger patients (aged < 75 years).

METHODS

We compared the treatment strategy selection and the outcomes of 40 elderly and 160 younger patients with cStage II/III ESCC diagnosed between January, 2014 and December, 2016.

RESULTS

Nineteen (47.5%) of the elderly patients and 144 (90.0%) of the younger patients underwent esophagectomy and 9 (22.5%) of the elderly patients and 131 (81.9%) of the younger patients received neoadjuvant chemotherapy. Ivor-Lewis or transhiatal esophagectomy was performed more frequently in the elderly group than in the younger group (P = 0.0096). The survival rate after esophagectomy was higher in the younger group than in the elderly group. The overall survival rate of the elderly patients who underwent esophagectomy was significantly higher than that in those who did not.

CONCLUSIONS

Esophagectomy is a practical choice for elderly patients with locally advanced ESCC, although reduced treatment intensity may impact long-term survival.

Human Epidermal Growth Factor Receptor 2-positive Primary Adenocarcinoma in the Cervical Oesophagus: A Case Report

BACKGROUND/AIM

Cervical oesophageal adenocarcinoma (COA) is extremely rare. We present a case of human epidermal growth factor receptor 2 (HER2)-positive COA that showed repeated recurrences despite multidisciplinary treatments.

CASE REPORT

A 49-year-old male was diagnosed with clinical stage IVA COA that originated from ectopic gastric mucosa. He initially underwent definitive chemoradiotherapy (CRT) (60.0 Gy/30 fractions, 5-fluorouracil, and cisplatin). Two months after CRT, the right supraclavicular lymph node (LN) reenlarged and salvage lymphadenectomy was performed. Immunohistochemical staining revealed a HER2-positive adenocarcinoma. Four months after lymphadenectomy, multiple metastases in the mediastinal LNs and lungs were detected, and S-1, oxaliplatin and trastuzumab were administered. Four months after chemotherapy, the patient presented with new liver metastasis. Further metastasis was prevented by Nivolumab treatment for four months.

CONCLUSION

HER2-positive COA may be more aggressive and may require further intensive treatments. This literature review may be helpful in determining treatment strategies for COA.

Prognostic Significance of Stratification Using Pathological Stage and Response to Neoadjuvant Chemotherapy for Esophageal Squamous Cell Carcinoma

PURPOSE

Risk stratification to select appropriate candidates for adjuvant therapy is required for esophageal cancer patients based on adjuvant therapy advancement including immunotherapy. The current study aims to develop a novel staging system using pathological stage (pStage) and response to neoadjuvant chemotherapy (NAC) for esophageal squamous cell carcinoma (ESCC).

METHODS

ESCC patients who received NAC and underwent transthoracic esophagectomy at two Japanese high-volume esophageal centers were retrospectively reviewed. The prognostic value of NAC response was evaluated within the same pStage, and a novel risk stratification to predict cancer-specific survival (CSS) was developed.

RESULTS

The HR (95% CI) of pathological responders in pStage 0-I, II, III, and IV was 0.29 (0.07-1.17), 0.37 (0.12-1.10), 0.37 (0.15-0.92), and 0.24 (0.06-0.98), respectively. Responders in pStage 0-II were classified to be in the same class and those in pStage III/IV in another group, because the 5-year CSS (5y-CSS) rate of responders in pStage 0-I, II, III, and IV was 94%, 92%, 76%, and 71%, respectively. Combining nonresponders in pStage 0-II as the same group, all patients were subdivided into five groups. Intriguingly, the 5y-CSS in pStage III-IV responders was 75%, almost identical to that of nonresponders in pStage 0-II (78%).

CONCLUSIONS

The histological response influenced the long-term outcomes of patients who underwent esophagectomy after NAC, even within groups stratified by pathologic stage. The current risk stratification system will contribute to selecting appropriate candidates for adjuvant therapy.

Efficacy of postoperative radiotherapy in esophageal squamous cell carcinoma patients with positive circumferential resection margin

BACKGROUND

The significance of postoperative radiotherapy for residual disease after esophageal cancer surgery remains controversial. The purpose of this study was to elucidate the efficacy of postoperative radiotherapy in esophageal squamous cell carcinoma (ESCC) patients with positive circumferential resection margin (CRM).

METHODS

We retrospectively analyzed data from 1190 patients who underwent esophagectomy for ESCC at our hospital from 2005 to 2018, of whom 61 (5.1%) patients were diagnosed with positive CRM of ESCC. Overall survival (OS), progression-specific survival (PSS), local progression-specific survival (LPSS), and clinicopathological factors were compared between patients with and without postoperative radiotherapy. The efficacy of additional radiotherapy on patient outcomes was evaluated.

RESULTS

Among the 61 patients analyzed, 29 (47.5%) underwent radiotherapy (RT group) and 32 (52.5%) did not (NRT group). In the RT group, 22 patients (75.9%) received radiotherapy and 7 patients (24.1%) received chemoradiotherapy. The RT group included younger patients, a greater number of upper-esophageal tumors, and a greater rate of R2 resections than the NRT group. The LPSS and PSS of the RT group were significantly better than those of the NRT group (P = 0.007, P < 0.001, respectively). In multivariate analysis, postoperative radiotherapy was an independent factor for LPSS [P < 0.001; hazard ratio (HR) 0.17; 95% confidence interval (CI) 0.06-0.46] and PSS (P < 0.001; HR 0.31; 95% CI 0.16-0.60).

CONCLUSIONS

Postoperative radiotherapy contributed to the control of residual tumor and was significantly associated with better LPSS and PSS among patients with positive CRM after esophagectomy for ESCC.

Successful transition from open to minimally invasive approach in Ivor Lewis esophagectomy: a single-center experience in Japan

PURPOSE

This study evaluates surgical outcomes of Ivor Lewis esophagectomy (ILE) in our institution, with the transition from open ILE to hybrid or totally minimally invasive ILE (MI-ILE).

METHODS

Selected patients who underwent ILE for esophageal cancer between 2013 and 2020 were included. We retrospectively investigated the patients' background characteristics and the short-term surgical outcomes.

RESULTS

In this period, among a total of 858 esophagectomies, selected seventy-one patients (8.3%) underwent ILE, consisted of 17 cases with completely open procedures, 27 with hybrid MI-ILE, and 27 with total MI-ILE. The major indications for ILE were adenocarcinoma of the distal esophagus or esophagogastric junction (33.8%) and patients with prior treatment of head and neck cancer (31.0%). Among these approaches, there were no significant differences in the characteristics including age, body mass index (BMI), tumor location, preoperative therapy, and clinical TNM stage, except for histology. Compared to the completely open and hybrid groups, incidences of both total and severe complications in the total MI-ILE group were significantly lower (total 70.6 vs. 66.6 vs. 37.0%, p=0.036; severe 35.3 vs. 44.4 vs. 11.1%, p=0.023), and also, those of pneumonia (41.2 vs. 29.6 vs. 7.4%, p=0.026) and postoperative stricture (11.8 vs. 18.5 vs. 0%, p=0.001) were significantly fewer in the total MI-ILE group.

CONCLUSIONS

We have been able to achieve the transition from completely open to total MI-ILE with better short-term outcomes. Total MI-ILE with linear-stapled anastomosis can be a good alternative to open procedures for the selected patients with reducing the incidence of postoperative pneumonia and anastomotic stricture.

Significance of D-dimer-based screening for detecting pre-operative venous thromboembolism in patients with esophageal cancer after neoadjuvant chemotherapy

BACKGROUND

A limited number of studies have evaluated the risk of developing venous thromboembolism (VTE) during neoadjuvant chemotherapy (NAC) for esophageal cancer and the efficacy of a D-dimer (DD)-based VTE screening (DBS). In the present study, we aimed to clarify the changes in DD levels and the effectiveness of DBS.

METHODS

We included 234 patients who underwent esophagectomy between August 2017 and July 2019 and evaluated the changes in DD levels before and after NAC. We had introduced the DBS strategy in August 2018, in which we recommended ultrasound (US) of the leg or computed tomography (CT) with the deep vein thrombosis (DVT) protocol. We then evaluated the incidence of VTE detected by DBS compared with that in the clinical practice as a control.

RESULTS

The DD levels were significantly increased after NAC. After the introduction of DBS, the proportion of patients who underwent US and CT after NAC was significantly increased. VTE was more frequently detected in the DBS group than in the control group (16.7% vs. 3.0%, p < 0.02) among patients who underwent NAC. Pulmonary embolism (PE) during NAC was also more frequent in the DBS than in the control group (7.6% vs. 1.5%, p = 0.06). The DD levels after NAC were significantly higher in patients with VTE than in those without.

CONCLUSIONS

NAC for patients with esophageal cancer increases the risk of developing VTE. DBS is useful in identifying asymptomatic DVT and may contribute to improving patient safety.

Immunogenic characteristics of microsatellite instability-low esophagogastric junction adenocarcinoma based on clinicopathological, molecular, immunological and survival analyses

Microsatellite instability (MSI) is categorized by mutation frequency: high MSI (MSI-H), low MSI (MSI-L) and microsatellite stable (MSS). MSI-H tumors have a distinct immunogenic phenotype, with immunotherapies using checkpoint inhibitors already approved for the treatment of MSI-H gastroesophageal adenocarcinoma (GEA); this is not observed for MSI-L or MSS. Here, we tested the hypothesis that MSI-L tumors are also a distinct phenotype and potentially immunogenic. MSI-PCR assays (BAT25, BAT26, BAT40, D2S123, D5S346 and D17S250) were performed on 363 Epstein-Barr virus-negative, surgically resected esophagogastric junction (EGJ) adenocarcinoma samples. Tumors were characterized as MSI-H (≥2 markers), MSI-L (1 marker) or MSS (0 markers). CD8+ cell counts, PD-L1 and HER2 expression levels, TP53 mutations, epigenetic alterations and prognostic significance were also examined. All pathological and molecular experiments were conducted using serial, whole-tumor sections of chemo-naïve surgical specimens. MSI-H and MSI-L were assigned to 28 (7.7%) and 24 (6.6%) cases, respectively. Compared to MSS cases, MSI-L cases had significantly higher intratumoral CD8+ cell infiltration (P = .048) and favorable EGJ cancer-specific survival (multivariate hazard ratio = 0.35, 95% CI, 0.12-0.82; P = .012). MSI-L tumors were also significantly associated with TP53-truncating mutations as compared to MSI-H (P = .009) and MSS (P = .012) cases, and this trend was also observed in GEA data from The Cancer Genome Atlas (TCGA). Indel mutational burden among TCGA MSI-L tumors was significantly higher than that of MSS tumors (P = .016). These results suggest that MSI-L tumors may have a distinct tumor phenotype and be potentially immunogenic in EGJ adenocarcinoma.

The Design of and Rationale for the Effect of Perioperative Inhaled Tiotropium for Patients with Chronic Obstructive Pulmonary Disease in Esophageal Cancer Surgery (EPITOPE): an Open-Label, Randomized, Parallel-Group Study

INTRODUCTION

Pneumonia is one of the most frequently occurring complications after esophagectomy and is associated with increased operative mortality. Chronic obstructive pulmonary disease (COPD) is known to be a risk factor for pulmonary complications and operative mortality. However, in COPD patients preparing for esophagectomy, preventive measures against postoperative pneumonia have not yet been discovered. In this study, we evaluate the effect of perioperative inhaled tiotropium, a long-acting, antimuscarinic bronchodilator used in the management of COPD, on patients with COPD who undergo esophageal cancer surgery.

METHODS/DESIGN

This study investigates the effect of perioperative inhaled tiotropium on patients with COPD who undergo esophagectomy. It is an open-label, randomized controlled trial conducted in a single center (EPITOPE study). A total of 32 enrolled patients are randomly assigned in a 1:1 ratio to either conventional management or inhalation of tiotropium in addition to the conventional management. Patients included in the intervention group receive tiotropium Respimat 5 μg (two inhalations of 2.5 μg) for at least 2 weeks before the esophagectomy. Following the esophagectomy, tiotropium is re-delivered, starting as early as possible and continuing until the postoperative evaluation (between 30 and 44 days after the operation). The primary outcome is the incidence of pneumonia within 30 days after esophagectomy. Secondary outcomes are the incidence of cardiovascular complications within 30 days after esophagectomy, the incidence of any postoperative complications within 30 days after esophagectomy, pulmonary function (preintervention, preoperative, and postoperative), walking distance in the incremental shuttle walking test (preintervention, preoperative, and postoperative), the incidence of adverse events, and mortality within 30 days after esophagectomy.

DISCUSSION

The EPITOPE study is the first pilot study on the effects of perioperative inhaled tiotropium on patients with COPD undergoing esophagectomy. After completing this study, we will plan a multicenter RCT with the appropriate outcomes in the future.

Salvage esophagectomy for initially unresectable locally advanced T4 esophageal squamous cell carcinoma

BACKGROUND

Definitive chemoradiotherapy (dCRT) for esophageal squamous cell carcinoma (ESCC) is a potentially curative treatment modality, even for patients with unresectable T4 tumors. For patients who fail dCRT, salvage esophagectomy is known to be a high-risk procedure. However, the efficacy and safety of salvage surgery for these patients remain unclear.

METHODS

A total of 35 patients who underwent salvage esophagectomy after dCRT for initially unresectable locally advanced T4 ESCC were assessed, and both outcomes and prognostic factors after surgery were investigated.

RESULTS

Among the study population, R0 resection was achieved in 19 patients (54.3%). Postoperatively, 8 patients (22.9%) experienced Clavien-Dindo grade IIIb or higher complications, and 3 patients (8.6%) registered surgery-related mortality. Overall survival rates were 45.7%, 28.6%, and 5.7% at 1, 2, and 5 years, respectively. In Cox regression analysis, residual or relapsed tumor limited to T2 or less was an independent prognostic factor for better survival (P = 0.010). On the other hand, postoperative pneumonia and incomplete resection were negative prognostic factors (P < 0.001 and P = 0.019, respectively). Nodal involvement and extent of lymph node dissection did not impact patient survival.

CONCLUSIONS

Although salvage esophagectomy for initially unresectable T4 ESCC is considered a high-risk surgery with poor prognosis, long-term survival may be achieved in patients with ≤ T2 residual tumors. In addition, R0 resection and postoperative pneumonia prevention are crucial to improve patient survival.

Recent progress in multidisciplinary treatment for patients with esophageal cancer

Esophageal cancer is one of the most aggressive gastrointestinal cancers. This review focuses on eight topics within the multidisciplinary approach for esophageal cancer. As esophagectomy is highly invasive and likely to impair quality of life, the development of less invasive strategies is expected. Endoscopic resection (ER) of early esophageal cancer is a less invasive treatment for early esophageal cancer. A recent phase II trial revealed that combined ER and chemoradiotherapy (CRT) is efficacious as an esophagus-preserving treatment for cT1bN0 squamous cell carcinoma (SCC). Esophagectomy and definitive CRT are equally effective for patients with clinical stage I SCC in terms of long-term outcome. For locally advanced resectable cancers, multidisciplinary treatment strategies have been established through several clinical trials of neoadjuvant or perioperative treatment. Minimally invasive esophagectomy may improve the outcomes of patients and CRT is a curative-intent alternative to esophagectomy. CRT with 50.4 Gy radiotherapy combined with salvage surgery is a promising option to preserve the esophagus. Induction chemotherapy followed by esophagectomy may improve the outcomes of patients with locally advanced unresectable tumors. Immune checkpoint inhibitors are effective for esophageal cancer, and their introduction to clinical practice is awaited.

Esophagectomy for Esophageal Cancer in a Patient with Left Pulmonary Artery Sling

BACKGROUND

In esophageal squamous cell cancer (ESCC) patients, the dissection of the lymph nodes around the recurrent laryngeal nerve (RLN) is essential for curative esophagectomy.1,2 Left pulmonary artery sling (LPAS) is a rare congenital anomaly, in which anomalous left pulmonary artery arises from the right pulmonary artery and reach the left pulmonary hilum.3-5 Because LPAS crosses between esophagus and trachea and the hemodynamics of LPAS could collapse when retracting the trachea anteriorly for left RLN node dissection, esophagectomy for patients with LPAS is technically challenging. In this video, we applied the cervicothoracoscopic approach in a patient with LPAS, in which we performed bilateral RLN node dissection from cervical operation field before thoracoscopic surgery.6,7 METHODS: A 44-year-old woman was diagnosed with stage II ESCC. Following neoadjuvant chemotherapy, we planned to perform a three-stage esophagectomy. Preoperative-enhanced computed tomography revealed LPAS. During the cervical procedure, we identified the RLN, dissected the lymph nodes around the nerve, and mobilized the cervical esophagus. After the cervical procedures, we performed thoracoscopic surgery through the right thoracic cavity with the patient in a prone position.

RESULTS

We achieved curative esophagectomy without any intraoperative adverse events. Total operation time was 419 min, with an estimated blood loss of 40 ml. There were no postsurgical complications, including RLN palsy.

CONCLUSIONS

The presence of LPAS in esophageal cancer surgery makes it difficult to dissect the left RLN nodes. We could safely perform curative esophagectomy for an ESCC patient with LPAS using the cervicothoracoscopic approach.

Steam induced by the activation of energy devices under a wet condition may cause thermal injury

BACKGROUND

During esophagectomy for esophageal cancer, meticulous attention is needed to prevent thermal injury to the vital organs, such as the recurrent laryngeal nerve (RLN) and tracheobronchus. In order to clarify the novel mechanism behind thermal injury induced by energy devices, we investigated the temperature of steam with the use of two different devices under wet and dry conditions.

METHODS

An ultrasonic device (Sonicision™) and a vessel sealing device (Ligasure™) were studied. We evaluated the temperature at the tip of the devices and the steam when the devices were activated under different grasping ranges, under four different combinations of device and muscle, and under four different wet/dry conditions (dry-dry, dry-wet, wet-dry, and wet-wet).

RESULTS

Although the maximum temperature of the devices was significantly higher with Sonicision™ than with Ligasure™, the maximum temperature of the steam was significantly higher with Ligasure™ than with Sonicision™ in almost all situations. At 1 mm away from Sonicision™, the critical temperature more than 60 °C was observed only when used with one-third grasping range under the wet-dry or the wet-wet conditions. In case of Ligasure™, high-temperature steam was observed when used with one-third grasping under the wet-dry or the wet-wet condition and two-third grasping under the dry-wet, the wet-dry, or the wet-wet condition. Under the wet condition, the emission of steam from the non-grasping part of Ligasure™ caused a spike in temperature that exceeded the critical temperature.

CONCLUSION

We demonstrated that the use of energy devices under a wet condition generates steam from the non-grasping part of the devices. The temperatures of steam from Ligasure™ were significantly higher than that from Sonicision™. To prevent thermal injury to the vital organs, a very attentive and meticulous surgical technique is imperative considering the characteristics of each device.

Ivor-Lewis esophagectomy for patients with squamous cell carcinoma of the thoracic esophagus with a history of total pharyngolaryngectomy

BACKGROUND

Synchronous or metachronous esophageal, and head and neck cancers are often observed, and we occasionally encounter esophageal cancer cases with a past history of total pharyngolaryngectomy (TPL) for head and neck cancers. Total esophagectomy after TPL may impair blood supply to the trachea and may cause tracheal necrosis. Meanwhile, Ivor-Lewis esophagectomy can prevent the above-mentioned risks, but there is a concern about an anastomosis with the remnant upper esophagus that lost blood supply after two surgical procedures. The surgical outcomes of Ivor-Lewis esophagectomy after TPL remain unclear. Therefore, we investigated the surgical outcomes.

METHODS

This study included patients who underwent Ivor-Lewis esophagectomy for esophageal cancer with a history of TPL at our institution between 2005 and 2017. We retrospectively investigated the patients' background characteristics and short-term surgical outcomes.

RESULTS

Twelve consecutive patients (8 men and 4 women) were included in this study. The median period between TPL and esophagectomy was 32 months (range 2-185 months). All patients underwent esophagectomy via right open thoracotomy and reconstruction using a gastric tube with intrathoracic anastomosis. Although the esophagogastric anastomosis was made on the remnant upper esophagus, which had already lost blood supply from the inferior thyroid artery, there was no case of anastomotic leakage or esophageal necrosis, and hospital mortality was not observed.

CONCLUSION

Ivor-Lewis esophagectomy for patients with a history of TPL is a safe procedure, which can prevent severe complications including anastomotic leakage or tracheal necrosis.

Significance of Intramural Metastasis in Patients with Esophageal Squamous Cell Carcinoma: An Indicator of Aggressive Cancer Behavior

BACKGROUND

Intramural metastasis (IM) is occasionally noted in patients with esophageal squamous cell carcinoma (ESCC). However, few recent studies have investigated the clinicopathological characteristics of IM and its survival impact. The present study aimed to clarify the clinicopathological and prognostic significance of IM in patients with ESCC.

METHODS

We retrospectively examined 918 consecutive patients who underwent curative intent esophagectomy for ESCC. IM was defined as a pathologically confirmed metastatic lesion, which was clearly separate from the primary tumor and located within the esophageal or gastric wall. The clinicopathological characteristics and survival impact of IM were evaluated. A propensity score-matched analysis was performed to further elucidate the prognostic impact of IM.

RESULTS

Among 918 patients, 46 (5.0%) had IM. Advanced tumors were significantly more frequent in patients with IM than in those without IM. The curative resection rate was lower in patients with IM (P = 0.001). Overall survival (OS) and disease-specific survival (DSS) were worse in patients with IM (both P < 0.001). In multivariate Cox proportional hazard analysis, IM presence was an independent poor prognostic indicator for OS and DSS (both P < 0.001). After propensity score matching, advanced tumors according to pathological N stage and lymphatic invasion were more frequent in patients with IM (P = 0.015 and 0.004, respectively). Additionally, OS and DSS were different between patients with and those without IM (both P = 0.002).

CONCLUSIONS

IM from ESCC is a local indicator of lymphatic invasion and advanced cancer, as well as an independent factor for poor prognosis.

The usefulness of three-dimensional video-assisted thoracoscopic esophagectomy in esophageal cancer patients

BACKGROUND

The three-dimensional video-assisted (3D-VA) system is known to provide depth perception and the precise measurement of anatomical spaces, unlike the two-dimensional video-assisted (2D-VA) system. However, the advantages of the 3D-VA system in thoracoscopic esophagectomy remains unclear.

METHODS

We retrospectively analyzed data from 104 patients who underwent thoracoscopic esophagectomy for esophageal cancer from 2016 to 2017. We performed thoracic esophagectomy using either the 2D-VA or 3D-VA system during this period. Whenever the 3D-VA system was available in our surgical center, we performed 3D-VA thoracoscopic esophagectomy. Perioperative parameters, including operation times, blood loss, the number of dissected lymph nodes, postoperative complications, and the duration of postoperative hospital stays, were compared between the 2D-VA and 3D-VA system groups.

RESULTS

There were 51 and 53 patients in the 2D-VA and 3D-VA system groups, respectively. Preoperative parameters, including age, sex, tumor location, clinical stage and the distribution of preoperative treatment, were not significantly different between the groups. Although intraoperative blood loss did not differ between the two groups, operation times were significantly shorter in the 3D-VA system group than the 2D-VA system group (P = 0.023). The number of dissected mediastinal lymph nodes was similar in both groups. The incidences of postoperative complications, including pneumonia, recurrent nerve palsy, anastomotic leakages and chylothorax, were similar between the groups. The duration of postoperative hospital stays was also comparable between the groups.

CONCLUSIONS

An introduction of 3D-VA endoscopy into minimally invasive esophagectomies may contribute to the shortening of the duration of thoracoscopic procedures.

Clinical Importance of Sputum in the Respiratory Tract as a Predictive Marker of Postoperative Morbidity After Esophagectomy for Esophageal Cancer

BACKGROUND

Respiratory morbidity is common after esophagectomy and can be a major cause of surgery-related mortality. Thus, it is important to identify novel predictors that can preoperatively estimate the incidence of postoperative respiratory morbidity. Asymptomatic sputum in the respiratory tract is sometimes observed on preoperative computed tomography (CT). This study aimed to determine the clinical importance of sputum in the respiratory tract as a predictor of postoperative morbidity after esophagectomy for esophageal cancer.

PATIENTS AND METHODS

The study included 609 consecutive patients who underwent three-incisional esophagectomy for esophageal cancer between April 2005 and November 2018.

RESULTS

Among the patients, 76 (12.5%) had sputum in the respiratory tract on preoperative CT. This finding was significantly associated with older age, more extreme smoking habit, worse performance status, lower forced expiratory volume 1%, and more frequent pulmonary comorbidities. Additionally, the incidence of postoperative pneumonia was higher in these patients than in those without sputum (16 vs 8%, p = 0.028). Sputum in the main bronchus was associated with higher frequencies of morbidity of Clavien-Dindo classification (CDc) ≥ II (p = 0.019), severe morbidity of CDc ≥ IIIb (p = 0.058), pneumonia (p = 0.10), and pulmonary morbidity (p = 0.19) compared with the finding of sputum in the trachea alone. On multivariate analysis, sputum in the respiratory tract was an independent risk factor (hazard ratio, 2.07; 95% confidence interval, 1.019-4.207; p = 0.044) for postoperative pneumonia.

CONCLUSIONS

Sputum in the respiratory tract is a novel predictor of postesophagectomy pneumonia. Patients with sputum in the more distal respiratory tract might have high risk of postoperative morbidities.

Recent Incidence Trend of Surgically Resected Esophagogastric Junction Adenocarcinoma and Microsatellite Instability Status in Japanese Patients

BACKGROUND

The incidence trend of esophagogastric junction (EGJ) adenocarcinoma in Japan has not been sufficiently investigated. Little is known about the microsatellite instability (MSI) status of this tumor.

SUMMARY

Previously published studies analyzing the trend of EGJ adenocarcinoma in Japan were reviewed. And a trend of surgically resected cases (Siewert type I-III) utilizing a retrospective multicenter cohort of 379 patients from 4 academic institutions in Japan investigated. Although an increasing trend in the last 2 reports was considered controversial, our cohort demonstrated a growing number of EGJ adenocarcinoma cases between 2006 and 2013. This trend was evident, especially in Siewert type I cases. In the previous 16 studies that performed MSI testing, MSI-high tumors ranged 0-8.3%, though there were no fixed microsatellite markers on EGJ adenocarcinoma. In a recent comprehensive genetic analysis by The Cancer Genome Atlas, MSI testing using the following 7 markers, BAT25, BAT26, BAT40, D2S123, D5S346, D17S250 and TGFR-II showed a favorable correlation with hypermutated tumors. We performed MSI testing using 6 of those markers, except TGFR-II, on 206 cases from one institution, and detected 15 cases (7.3%) with MSI-high. The prevalence of MSI-high was 0% in Siewert type I, 7.6% in type II, and 16.7% in type III. Key message: The number of surgically resected EGJ adenocarcinoma cases gradually increased, and MSI-high was infrequent in Siewert type I-II tumors in our Japanese cohort. Considering MSI-high as a predictive biomarker for emerging immune checkpoint inhibitors, MSI status is becoming more beneficial in EGJ adenocarcinoma.

Preservation of physiological passage through the remnant stomach prevents postoperative malnutrition after proximal gastrectomy with double tract reconstruction

PURPOSE

Double tract reconstruction (DT) after proximal gastrectomy (PG) is considered beneficial for postoperative nutrition status by preserving the physiological passage of food. We conducted this study to assess postoperative nutrition status based on food passage after this operation.

METHODS

The subjects of this retrospective study were 63 patients who underwent PG with DT. The patients were divided into two groups according to whether they had postoperative malnutrition (PM) 1 year postoperatively (PM group) or not (non-PM group). PM was defined by both weight loss > 10% and a low body mass index of < 20 or < 22 kg/m² for patients younger and older than 70 years, respectively. We then evaluated the predictors of PM.

RESULTS

There were 33 patients in the PM group. These patients were predominantly female (p < 0.01) and lacked physiological passage through the remnant stomach (PRS) on postoperative fluoroscopy (defined as non-PRS, p = 0.03). Multivariate logistic regression analysis revealed that female gender and non-PRS status were independent predictors of PM (odds ratio [95% CI]; 7.42 [1.33-41.4]; p = 0.02, 6.77 [1.01-45.4]; p = 0.04, respectively).

CONCLUSION

Preservation of the physiological passage of food through the remnant stomach prevents PM after PG with DT.

Lateral thermal spread induced by energy devices: a porcine model to evaluate the influence on the recurrent laryngeal nerve

BACKGROUND

Recurrent laryngeal nerve (RLN) paralysis is a frequently observed complication after esophagectomy, and thermal injury is considered to be one of the causes. The difference in the lateral thermal spread associated with the grasping range of various energy devices remains unknown.

METHODS

Ultrasonic devices (Harmonic® HD1000i and Sonicision™) and a vessel-sealing device (Ligasure™) were studied. We evaluated the temperature of these devices, the activation time required, and the thermal spread on porcine muscle when the devices were used with different grasping ranges (thermal spread study). In addition, we evaluated the influence of thermal spread by short grasping use of the energy devices on the viability of RLN in a live porcine model (NIM study).

RESULTS

In the thermal spread study, the temperature of the ultrasonic devices lowered as grasping range increased, whereas the highest temperature of Ligasure was observed when used with two-thirds grasping. The activation time of ultrasonic devices became longer as grasping range increased, whereas the grasping range did not influence the activation time of Ligasure. Thermal spreads 1 mm from the energy devices were unaffected by the grasping ranges. Although the temperature of the Ligasure was lower than that of the ultrasonic devices, thermal spread by Ligasure was significantly greater than that induced by the ultrasonic devices. In the NIM study, the activation of the Sonicision with one-third grasping range did not cause EMG changes at distances of up to 1 mm from the RLN, whereas applying Ligasure with a one-third grasping range 1 mm away from the RLN led to a critical result.

CONCLUSIONS

The grasping range did not influence the thermal spread induced by the energy devices. Ultrasonic devices may be safer in terms of lateral thermal spread to the RLN than Ligasure.

MSI-low is an intermediate type between MSI-high and MSS in esophagogastric junction adenocarcinoma

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Background: High level of microsatellite instability (MSI-high) is an actionable molecular status in oncology, informing tumor response to immune checkpoint inhibitor. However, little is known about MSI-low. The aim of this study is to unveil the characteristics of MSI-low tumor in esophagogastric junction (EGJ) adenocarcinoma. Methods: Using 372 cases with chemo-naive EGJ adenocarcinoma tissue, MSI testing and Epstein Barr Virus (EBV)-DNA detection were performed by DNA fragment analysis (BAT25, BAT26, BAT40, D2S123, D5S346, and D17S250) and real-time PCR, respectively. MSI-high was defined as having two or more unstable markers, MSI-low as one, and microsatellite stable (MSS) as none. MSI status was compared with clinicopathological and molecular status including epigenetic alteration in MLH-1, LINE-1, and CpG methylator phenotype (CIMP), TP53 status (sequencing and immunohistological expression), Ki-67 index, intra-/peri-tumoral lymphocyte counts (CD8+ or FOXP3+), combined positive score (CPS) of PD-L1 expression. Results: MSI-low was detected in 29, MSI-high in 28, and EBV (+) in 9 cases. Three cases with MSI-low showed EBV (+), but MSI-high and EBV (+) were mutually exclusive. In 363 EBV (-) cases, MSI-low was associated with younger age (MSI-high 71.7 ± 11.3, MSI-low 61.3 ± 12.5, and MSS, 65.0 ± 12.3 years old, P = 0.003). Notably, MSI-low exhibited an intermediate type between MSI-high and MSS, in terms of no. of lymph node metastasis, and tumor immune microenvironment [no. of intra-/peri-tumoral CD8+ cells, no. of intra-/peri-tumoral FOXP3+ cells, and CPS of PD-L1 (all P among the 3 groups < 0.05)]. In contrast to MSI-high tumors, MSI-low tumor was not associated with epigenetic alteration in any of MLH-1, LINE-1, or CIMP status. In survival analysis, 3-year disease-specific survival rate of MSI-low was better than that of MSS tumors, and similar to MSI-high (92.2% for MSI-low, 92.2% for MSI-high, and 69.6% for MSI-low). This trend was also observed in time to recurrence (P = 0.01). Conclusions: MSI-low cases exhibited an intermediate immune microenvironment between MSI-high and MSS, and favorable outcome. Our results may implicate MSI-low as a predictive biomarker for immune checkpoint inhibitor.

Supraclavicular and celiac metastases in squamous cell carcinoma of the middle thoracic esophagus

PURPOSE

Squamous cell carcinoma of the middle thoracic esophagus (SCC-ME) often metastasizes to the neck, mediastinum, and abdomen. This study aims to assess the prognostic impact of supraclavicular (SC) and celiac (CE) lymph node (LN) metastases in patients with SCC-ME.

METHODS

We examined 210 patients who underwent curative esophagectomy with three-field LN dissection for SCC-ME. The clinicopathological features and survival outcomes of patients with and without SC and/or CE metastases were compared to assess the prognostic significance of SC and/or CE metastases.

RESULTS

We observed metastases to SC and CE in 25 (11.9%) and 20 (9.5%) patients, respectively. Seven patients (3.3%) had both SC and CE metastases. Although the survival of patients with SC and/or CE metastases was worse compared with those without, that of patients with SC metastases but without CE metastases was comparable with that of patients with CE metastases but without SC metastases; the 5 year overall survival rates were 35.6% and 46.2%, respectively. However, survival of patients with both SC and CE metastases was the worst among all groups, and all patients with both SC and CE metastases experienced disease recurrence.

CONCLUSIONS

The prognosis of patients with both SC and CE metastases was extremely poor. In contrast, patients with metastasis to either one of these sites could be candidates for surgery as the main modality in a multidisciplinary strategy.

Recent progress in perioperative management of patients undergoing esophagectomy for esophageal cancer

Esophagectomy remains the mainstay of curative intent treatment for esophageal cancer. Oncologic esophagectomy is a highly invasive surgery and both morbidity and mortality rates still remain high. Recently, it has been revealed that multidisciplinary perioperative management can decrease the postoperative complications after esophagectomy. In this review, we summarized the recent progress in each component of multidisciplinary perioperative care bundle, including oral hygiene, cessation of smoking and alcohol, respiratory training, measurement of physical fitness, swallowing evaluation and rehabilitation, nutritional support, pain control and management of delirium. The accumulation of evidence and the popularization of knowledge will increase safety of esophagectomy and thus improve the outcome of patients with esophageal cancer.

PLOD2 as a potential regulator of peritoneal dissemination in gastric cancer

Peritoneal dissemination is the most common metastatic pattern in advanced gastric cancer (GC) and has a very poor prognosis. However, its molecular mechanism has not been elucidated. Our study investigated genes associated with peritoneal dissemination of GC. We performed combined expression analysis of metastatic GC cell lines and identified Procollagen-lysine, 2-oxoglutarate 5-dioxygenase2 (PLOD2) as a potential regulator of peritoneal dissemination. PLOD2 is regulated by hypoxia-inducible factor-1 (HIF-1) and mediates extracellular matrix remodeling, alignment, and mechanical properties. We analyzed PLOD2 expression immunohistochemically in 179 clinical samples, and found high PLOD2 expression to be significantly associated with peritoneal dissemination, leading to poor prognosis. In an in vivo-collected metastatic cell line, downregulation of PLOD2 by siRNA reduced invasiveness and migration. Hypoxia upregulated PLOD2 mediated by HIF-1, and promoted invasiveness and migration. After exposure to hypoxia, a cell line transfected with siPLOD2 exhibited significantly suppressed invasiveness and migration, despite high HIF-1 expression. These findings indicate that PLOD2 is a regulator of, and candidate therapeutic target for peritoneal dissemination of GC. Although peritoneal dissemination of GC has a very poor prognosis, its molecular mechanism has not been elucidated. We identified PLOD2 regulated by HIF-1 as a potential regulator of peritoneal dissemination of GC. Finally, we showed that PLOD2 promotes cell invasiveness and migration in GC under hypoxia and lead to peritoneal dissemination of GC.

Primary colonic well-differentiated / dedifferentiated liposarcoma of the ascending colon: a case report

BACKGROUND

Primary colonic and dedifferentiated liposarcomas are both remarkably rare. This work describes a case of primary colonic well-differentiated/dedifferentiated liposarcoma and reviews the clinical characteristics and current therapies for liposarcoma tumors.

CASE PRESENTATION

A 52-year-old woman was referred to our hospital with a submucosal tumor of the ascending colon. Clinical analysis by ultrasound colonoscopy and computed tomography revealed a partially ossified tumor with irregular edges continuous with the muscular layer. High F-18 deoxyglucose uptake was detected by positron emission tomography. Radical resection with lymph node dissection was performed, yielding a tumor specimen approximately 6.5 × 4.0 × 3.2 cm. Neoplastic spindle cell proliferation was found from submucosa to subserosa. Well-differentiated adipose tissue surrounded the tumor, but contained atypical nuclei with condensed chromosomes. Immunohistochemical staining was positive for p16, CDK4, and MDM2 expression. Based on these findings, a diagnosis of well-differentiated/dedifferentiated liposarcoma was given. Dedifferentiated liposarcomas are more aggressive than their well-differentiated, low-grade counterparts. While local recurrence can occur with both tumor types, dedifferentiated liposarcomas are more prone to developing distant metastases. The patient received no postoperative therapy, and no recurrences have been observed 12 months after surgery.

CONCLUSIONS

Here we report an extremely rare case of well-differentiated/dedifferentiated liposarcoma of the ascending colon. The dedifferentiated component was high-grade liposarcoma and well-differentiated liposarcoma was detected around the main tumor.

Abstract 4407: Glucose transporter 1 is associated with proliferation and prognosis on esophageal squamous cell carcinoma

Purpose: Cancer cells exhibit altered glucose metabolism, termed glycolysis which is described by the increased uptake of glucose and the conversion of glucose to lactate in cancer cells under adequate oxygen tension. Alternating glucose transporters (GLUTs) expression was detected in the cancer specific metabolism to adapt to the rapid growth and tumor microenvironment in diverse malignant tumors. In this study, GLUTs profiling of ESCC patients, the relation between proliferation and GLUT1 expression using siRNA for GLUT1 were analyzed. Furthermore, the prognostic features according to GLUT1 expression was evaluated on esophageal squamous cell carcinoma (ESCC) patients.

Methods: The ratio of the 11 GLUTs (GLUT1- GLUT14) expression between tumor and normal tissue (T/N) were analyzed in silico (GDS3838). GLUT1 expression was down-regulated using 3 siRNAs in vitro. Immunohistochemical staining of GLUT1 was performed using paraffin sections of tissues obtained from 145 resectable ESCC patients without preoperative treatment.

Results: Expression of GLUT1 (T/N 2.44; 95% confidence interval (CI): 1.78-3.34, P&lt;0.001), GLUT3 (T/N 1.96; 95%CI: 1.23-3.13, P=0.01) and GLUT6 (T/N 1.31; 95%CI: 1.12-1.54, P&lt;0.001) increased in tumor tissue compared with normal tissue. TE-1 and TE-8 cells were treated with 3 siRNAs for GLUT1 and control siRNA for 72 hours in vitro. The proliferation of TE-1 and TE-8 cells after siRNAs for GLUT1 compared with control siRNA decreased 72.9-84.5% and 44.8-53.3%, respectively. GLUT1 expression was evaluated with 145 ESCC patients. Glut1 positivity was observed in 41 patients (28.2%) and associated with depth of invasion (odds ratio (OR)=2.984; 95%CI: 1.208-7.371, P=0.018) and vascular invasion (OR=2.771; 95% CI: 1.118-6.871, P=0.028) in multivariate analysis. GLUT1 positivity was a significant disadvantage to both relapse-free survival (hazard ratio (HR)=2.021; 95%CI: 1.100-3.712; P=0.023) and esophageal cancer-specific survival (HR=2.223; 95%CI: 1.121-4.411; P=0.022) in univariate Cox hazard analysis.

Conclusions: GLUTs expression was altered in ESCC patients and GLUT1 expression was most up-regulated among the 11 GLUTs. Growth assay with siRNAs for GLUT1 revealed that GLUT1 played a curial role of ESCC cells proliferation. High expression of GLUT1 was associated with depth of invasion and poor prognosis of ESCC patients. These findings provide evidence of the significance of GLUT1 expression as a biomarker and GLUT1 may be therapeutic target in ESCC patient.

Citation Format: Hiroshi Sawayama, Masaaki Iwatsuki, Naoya Yoshida, Yoshifumi Baba, Yasuo Sakamoto, Koichi Kinoshita, Kenichi Nakamura, Daisuke Kuroda, Eto Tsugio, Tasuku Toihata, Tomoyuki Uchihara, Eri Oda, Taisuke Yagi, Mayuko Ohuchi, Takatugu Ishimoto, Hideo Baba. Glucose transporter 1 is associated with proliferation and prognosis on esophageal squamous cell carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4407. doi:10.1158/1538-7445.AM2017-4407

Intraoperative gastrojejunoscopy-assisted fistulojejunostomy for postoperative pancreatic fistula

Postoperative pancreatic fistula is a known complication after pancreaticojejunostomy. When an anastomosis collapses completely, two-stage reconstruction is necessary. Herein, we describe the case of a 70-year-old woman who underwent subtotal stomach-preserving pancreaticoduodenectomy with pancreaticojejunostomy after she had developed a severe postoperative pancreatic fistula. The pancreaticojejunostomy was divided, and an external pancreatic drainage tube was placed. Four months later, fistulojejunostomy between the pancreas and the stump of the jejunum was performed successfully using intraoperative gastrojejunoscopy.