[Clinical value of routine contrast esophagram in the diagnosis of anastomotic leakage for three-incision esophagectomy with cervical anastomosis]

Objective: To examine the clinical value of routine contrast esophagram (RCE) for the diagnosis of anastomotic leakage (AL) after three-incision esophagectomy with cervical anastomosis. Methods: Clinical data of 1 022 patients with esophageal cancer who underwent McKeown three-incision esophagectomy with cervical anastomosis from January 2015 to December 2019 at Department of Minimally Invasive Esophageal Surgery, Tianjin Medical University Cancer Hospital and Institute were analyzed retrospectively. There were 876 males and 146 females, aging(M(IQR)) 48(16) years (range: 36 to 84 years). There were 253 patients (24.8%) with neoadjuvant therapy, and 817 patients (79.9%) with minimally invasive esophagectomy. According to the diagnosis and treatment habits of the attending surgeons, 333 patients were included in the RCE group, and RCE was performed on the 7^th day postoperative, while 689 patients were included in the non-RCE group, and RCE was performed when the patients had suspicious symptoms. Taking clinical symptoms, RCE, CT, endoscopy and other methods as reference to the diagnosis of AL, the sensitivity and specificity were used to analyze and evaluate the efficacy of RCE for the diagnosis of AL. The data were compared by U test or χ² test between groups. Results: The incidence rate of AL after three-incision esophagectomy was 7.34% (75/1 022), including 30 cases in the RCE group and 45 cases in the non-RCE group (9.0%(30/333) vs. 6.5%(45/689), χ²=2.027, P=0.155). The diagnostic time of AL was 9(5) days postoperative (range: 4 to 30 days). Among them, 23 cases showed cervical leakages, 50 cases showed intro-thoracic leakages, and 2 cases both cervical and intro-thoracic leakages. The diagnostic time of patients with intro-thoracic leakages was longer than that of cervical leakages (10(4) days vs. 6(3) days, Z=-2.517, P=0.012). Among the 333 patients in the RCE group, 16 cases of RCE indicated leakages including 11 cases of true positive and 5 cases determined to be false positive, while 317 cases indicated no abnormalities including 19 cases developed leakages. The sensitivity and specificity of RCE to detect AL were 36.7%(11/30) and 98.3%(298/333), respectively. The Youden-index was 0.35, and the diagnostic accuracy was 92.8%(309/333). The positive and negative predictive value were 11/16 and 94.0%(298/317), respectively. Conclusions: Routine contrast esophagram after three-incision esophagectomy with cervical anastomosis has low sensitivity and high specificity in the diagnosis of AL. The diagnostic time of AL is the 9^th day after surgery. It is necessary to prolong the observation time clinically, and combine RCE with CT, endoscopy and other inspection methods for diagnosis.

[Current status and prognosis of immune checkpoint inhibitors for esophageal cancer]

Programmed cell death protein 1 (PD-1/CD279) and cytotoxic T Lymphocyte Antigen-4 (CTLA-4) are important immune checkpoints, through the role of the corresponding ligands and inhibit T cell activation and production of cytokines, in maintaining the body's vital role in peripheral tolerance. The use of anti-CTLA-4/PD-1 /PD-L1 monoclonal antibodies to block the tumor signaling pathway has shown excellent anti-tumor efficacy in a variety of solid tumors, and it is expected that immunotherapy will be available for the treatment of 60% advanced tumors in the next decade. Esophageal cancer is one of the major causes of cancer-related deaths worldwide, and its 5-year survival rate is generally low. Currently, radiotherapy, chemotherapy, and surgery are the standard treatments for esophageal cancer, and there is no effective treatment scheme for patients with esophageal cancer who fail to respond to standard treatment. Due to the diversity of somatic cell gene mutations and the generation of neo-antigens in esophageal cancer, immunotherapy has become a feasible treatment scheme to improve the prognosis of esophageal cancer. In this situation, the application of immunotherapy for esophageal cancer or more specific immune checkpoint inhibitors has gradually become the focus of the treatment of esophageal cancer. Nowadays, the research of immune checkpoint inhibitors, such as ipilimumab, tremelimumab, pembrolizumab, nivolumab and avelumab on esophageal cancer is proceeding at an amazing speed. The phase Ⅰ b clinical study of immunotherapy for esophageal cancer, which previously attracted great interest, has been replaced by the phase Ⅲ clinical study, and the results of the relevant studies also show a good prospect for the application of immune checkpoint inhibitors for esophageal cancer. However, the prediction of therapeutic effect and the selection of the best candidates still need to be further studied.

[Association between chronicity of HBV infection and host immunity]

The prognosis of hepatitis B virus (HBV) infection is determined by innate immunity, adaptive immunity, and a variety of regulatory factors in the host. Controversy still exists over the role of innate immunity in the progression of HBV infection. Adaptive immunity, especially the immune response mediated by CD8+ T cells, plays an important role in HBV clearance. However, in patients with chronic infection, such CD8+ T cells are often exhausted and associated with various regulatory factors including programmed cell death 1 and T-cell immunoglobulin mucin-3. This article elaborates on the association of chronicity of HBV infection with host immune system and various regulating factors.