Safety and Feasibility of Robot-Assisted Minimally Invasive Esophagectomy (RAMIE) with Three-Field Lymphadenectomy and Neoadjuvant Chemoradiotherapy in Patients with Resectable Esophageal Cancer and Cervical Lymph Node Metastasis

BACKGROUND

In the West, patients with cervical lymph node metastasis of resectable esophageal cancer at diagnosis are generally precluded from curative treatment. This study prospectively explored the safety and feasibility of neoadjuvant chemoradiotherapy followed by robot-assisted minimally invasive esophagectomy (RAMIE) with three-field lymphadenectomy for these patients.

METHODS

Between 2015 and 2021, patients with resectable thoracic esophageal cancer and cervical lymph node metastasis were recruited nationwide in the Netherlands. Patients without interval metastasis following neoadjuvant chemoradiotherapy and good physical condition underwent RAMIE with bilateral three-field lymphadenectomy. Safety was predefined as ≤50% Clavien-Dindo grade ≥3b postoperative complications.

RESULTS

Neoadjuvant chemoradiotherapy was administered to 29 patients (19 (66%) adenocarcinoma and 10 (34%) squamous cell carcinoma). After restaging, nine (31%) patients were excluded (interval metastasis, clinical deterioration, or withdrawn consent). RAMIE was performed in 20 patients (R0-rate 95%). A median of 42 [range 21-71] lymph nodes were resected of which 13 [range 2-35] were cervical. Only 1 (5%) patient had an unexpected contralateral cervical lymph node metastasis. Complications grade ≥3b occurred in 50%. Most frequent complications of any grade were recurrent laryngeal nerve palsy (45%) and pneumonia (40%). Overall survival at 1 year was 85% and quality of life at 6 months was comparable to esophageal cancer patients treated with curative intent.

CONCLUSIONS

RAMIE with three-field lymphadenectomy following neoadjuvant chemoradiotherapy for patients with resectable esophageal cancer presenting with cervical lymph node metastasis is feasible in a Western population. Because contralateral cervical metastasis is rare, a unilateral neck dissection would suffice in the majority of cases.

CLINICAL TRIAL

gov Identifier: NCT02426879. Dutch trial register Identifier: NTR 4552.

Analysis of metastases rates during follow-up after endoscopic resection of early "high-risk" esophageal adenocarcinoma

BACKGROUND AND AIMS

After endoscopic resection (ER) of early esophageal adenocarcinoma (EAC), the optimal management of patients with high-risk histologic features for lymph node metastases (ie, submucosal invasion, poor differentiation grade, or lymphovascular invasion) remains unclear. We aimed to evaluate outcomes of endoscopic follow-up after ER for high-risk EAC.

METHODS

For this retrospective cohort study, data were collected from all Dutch patients managed with endoscopic follow-up (endoscopy, EUS) after ER for high-risk EAC between 2008 and 2019. We distinguished 3 groups: intramucosal cancers with high-risk features, submucosal cancers with low-risk features, and submucosal cancers with high-risk features. The primary outcome was the annual risk for metastases during follow-up, stratified for baseline histology.

RESULTS

One hundred twenty patients met the selection criteria. Median follow-up was 29 months (interquartile range, 15-48). Metastases were observed in 5 of 25 (annual risk, 6.9%; 95% confidence interval [CI], 3.0-15) high-risk intramucosal cancers, 1 of 55 (annual risk, .7%; 95% CI, 0-4.0) low-risk submucosal cancers, and 3 of 40 (annual risk, 3.0%; 95% CI, 0-7.0) high-risk submucosal cancers.

CONCLUSIONS

Whereas the annual metastasis rate for high-risk submucosal EAC (3.0%) was somewhat lower than expected in comparison with previous reported percentages, the annual metastasis rate of 6.9% for high-risk intramucosal EAC is new and worrisome. This calls for further prospective studies and suggests that strict follow-up of this small subgroup is warranted until prospective data are available.

First case of Echinococcus vogeli infection imported to the Netherlands, January 2013

In January 2013 in the Netherlands, a man in his 50s from Suriname underwent hemihepatectomy because of a cystic liver mass, assumed to be a cystadenoma. Pathology revealed an echinococcal infection. PCR analysis of cyst material identified Echinococcus vogeli, causing polycystic hydatid disease. This echinococcus species is rarely diagnosed outside South America. The patient received adequate treatment, but this case emphasises the importance of awareness of this infection when treating patients with cystic tumours from endemic areas.

First case of Echinococcus vogeli infection imported to the Netherlands, January 2013

In January 2013 in the Netherlands, a man in his 50s from Suriname underwent hemihepatectomy because of a cystic liver mass, assumed to be a cystadenoma. Pathology revealed an echinococcal infection. PCR analysis of cyst material identified Echinococcus vogeli, causing polycystic hydatid disease. This echinococcus species is rarely diagnosed outside South America. The patient received adequate treatment, but this case emphasises the importance of awareness of this infection when treating patients with cystic tumours from endemic areas.

Post-mortem findings and causes of death of harbour porpoises (Phocoena phocoena) stranded from 1990 to 2000 along the coastlines of Belgium and Northern France

Between the years 1990 and 2000, an attempt was made to determine the causes of death of 55 harbour porpoises stranded along the Belgian and northern French coasts. From 1990 to 1996, only five carcasses were collected as against seven in 1997, eight in 1998, 27 in 1999 and eight in 2000. The sex ratio was normal and most of the animals were juvenile. The most common findings were emaciation, severe parasitosis and pneumonia. A few cases of fishing net entanglement were observed. The main microscopical lesions were acute pneumonia, massive lung oedema, enteritis, hepatitis and gastritis. Encephalitis was observed in six cases. No evidence of morbillivirus infection was detected. Pneumonia was associated with bacteria or parasites, or both. The causes of death and the lesions were similar to those previously reported in other countries bordering the North Sea. The cause of the increased numbers of carcasses in 1999 was unclear but did not include viral epizootics or net entanglement. A temporary increase in the porpoise population in the southern North Sea may have been responsible.

Pathological investigations on guillemots (Uria aalge) stranded on the Belgian coast during the winter of 1993-94

Pathological investigations were carried out on 67 guillemots (Uria aalge) washed up on the Belgian coast between November 1993 and March 1994. Emaciation and acute haemorrhagic gastroenteropathy were observed in more than 70 per cent of the birds. There was no statistical relationship between the level of oil contamination and the severity of the lesions. Differences in bodyweight were accounted for by age, sex, emaciation, and acute haemorrhagic gastroenteropathy. The birds had a severe weight deficit but the concentrations of pollutants were below acutely toxic levels.

Postmortem investigations on winter stranded sperm whales from the coasts of Belgium and The Netherlands

During winter 1994-95, four and three sperm whales (Physeter macrocephalus) were stranded along the Belgian and the Dutch coasts, respectively. Necropsies and tissue samplings were collected 24 hrs post mortem. Lesions on several whales included round and linear skin scars, ventral skin abrasions, acute skin ulcers, acute ulcerative stomatitides, acute to chronic external otitides, and passive visceral congestion. In addition, these sperm whales appeared to be debilitated with severe weight deficit, had blubber thickness reduction, the absence of abdominal fat, and the intestinal tracts were almost empty. Three categories of lesions and their possible relation with the stranding were evaluated. Cutaneous scars observed on the seven whales appeared to have no relation with the stranding. The poor body condition and acute integument ulcerative lesions were present before the stranding. Ventral skin abrasions and visceral passive congestion were caused by the strandings. Absence of food in the alimentary tracts, evidence of weight loss and blubber thickness reduction were compatible with an extended presence of the sperm whales in the North Sea, where adequate food is not available. This might lead to progressive weakness, predisposing the animals to secondary pathogens such as viral diseases. Finally, the coastal configuration of the southern North Sea makes it a trap for sperm whales which have entered the area during their wanderings.

Observations on the helminths of harbour porpoises (Phocoena phocoena) and common guillemots (Uria aalge) from the Belgian and German coasts

Between February 1990 and July 1991, 18 harbour porpoises (Phocoena phocoena) and 248 common guillemots (Uria aalge), found dead along the Belgian and German coasts, were examined for their burden of helminths. A total of three species were found in the guillemots (one cestode, one nematode and one pentastomid), and six species in the porpoises (one trematode, one cestode and four nematodes). Among the guillemots the burden of helminths was not statistically different between juvenile and adult birds. The deaths of the birds were apparently not related to the parasite infections. In contrast, the adult porpoises were more heavily parasitised than the juveniles, except for one young porpoise stranded on the Belgian coast. In the porpoises, four species of parasites had a pathological effect and Torynurus convolutus was responsible for the death of one animal from the Belgian coast and three from the German coast.