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The role of surgery in oligometastatic esophageal squamous cell carcinoma (ESCC) remains controversial. This study evaluated the oncological outcomes after esophagectomy in patients with ESCC with distant lymph node (LN) metastasis. Patients with ESCC and nodal metastasis treated with chemoradiotherapy or chemotherapy followed by esophagectomy between 2010 and 2020 were included. Overall survival (OS) and recurrence-free survival (RFS) were compared between patients with distant LN metastasis (dLN+) and exclusively regional LN metastasis (dLN–). The cohort comprised 69 dLN+ and 111 dLN– patients. Survival was significantly better in the dLN– group than in the dLN+ group (5-year OS, 51.9% vs. 25.5%, P  < 0.001; RFS, 47.2% vs. 18.1%, P  < 0.001). Stratified by the yp stage, 49 (44.1%) dLN– and 30 (43.5%) dLN+ patients achieved a pathological complete response (pCR). In the dLN– and dLN+ groups, the OS rates were significantly higher in the pCR group than in the non-pCR group (dLN–: 76.7% vs. 32.4%, P  < 0.001; dLN+: 39.6% vs. 14.2%; P  = 0.002). The dLN–/pCR group had the best OS, significantly outperforming the dLN−/non-pCR and dLN+/pCR groups. OS did not differ between the dLN−/non-pCR and dLN+/pCR groups. The dLN+/non-pCR group had the worst OS. The RFS analysis paralleled the OS findings. Patients with dLN+ disease had worse outcomes than their dLN– counterparts, irrespective of the pCR status. The survival rates were poor but comparable between the dLN+/pCR and dLN−/non-pCR groups. Adjuvant therapy may be required for dLN+ patients following systemic treatment and surgery, even after achieving pCR. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Tubeless uniportal video-assisted thoracic surgery (VATS), using a uniportal approach and non-intubated anaesthesia while avoiding postoperative chest drain insertion, for patients undergoing thoracoscopic surgery has been demonstrated to be feasible in selected cases. However, to date, the safety of the procedure has not been studied. METHODS We reviewed consecutive patients undergoing non-intubated uniportal VATS for pulmonary wedge resection at 2 medical centres between August 2016 and October 2019. The decision to avoid chest drain insertion was made in selected candidates. For those candidates in whom a tubeless procedure was performed, postoperative chest X-rays (CXRs) were taken on the day of the surgery [operation (OP) day], on postoperative day 1 and 1–2 weeks later. The factors associated with abnormal CXR findings were studied. RESULTS Among 135 attempts to avoid chest drain insertion, 13 (9.6%) patients ultimately required a postoperative chest drain. Among 122 patients in which a tubeless procedure was performed, 26 (21.3%) and 47 (38.5%) had abnormal CXR findings on OP day and postoperative day 1, respectively. Among them, 3 (2.5%) patients developed clinically significant abnormal CXRs and required intercostal drainage. Primary spontaneous pneumothorax was independently associated with a higher risk of postoperative abnormal CXRs. CONCLUSIONS Tubeless uniportal VATS for pulmonary wedge resection can be safely performed in selected patients. Most patients with postoperative abnormal CXRs presented subclinical symptoms that spontaneously resolved; only 2.5% of patients with postoperative abnormal CXRs required drainage. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES An optimal method for preoperative localization of small lung nodules is yet to be established, and there are few comparative studies in the literature. In the present study, we aimed to compare electromagnetic navigation-guided and computed tomography (CT)-guided methods of percutaneous transthoracic localization. METHODS The clinical, radiographic, surgical and pathological data of patients who underwent electromagnetic navigation-guided localization (EMNGL) and CT-guided localization (CTGL) before uniportal video-assisted thoracic surgery (VATS) were reviewed. Propensity score matching analysis was performed to compare the localization and surgical results. RESULTS After matching, 25 EMNGL and 50 CTGL patients were included in the analysis. In the CTGL group, pulmonary haemorrhage and pneumothorax were noted in 56% and 34% of patients, respectively, on postprocedural CT scans. Successful localization was achieved in 96% and 100% of patients in the EMNGL and CTGL groups, respectively (P  =   0.333). The median time in the operation room was significantly shorter in the CTGL group {142.5 [interquartile range (IQR) 123.8–175.0] vs 205.0 [IQR 177.5–290.0] min, P  <   0.001}. In contrast, EMNGL significantly decreased the total time [205.0 (IQR 177.5–290.0) vs 324.0 (IQR 228.3–374.0) min, P  =   0.002]. The median duration of chest drainage was 1 day shorter in the EMNGL group [2.0 (IQR 1.5–2.5) vs 3.0 (IQR 2.0–3.0), P  =   0.002]; the surgical complication rates were comparable between the 2 groups. CONCLUSIONS The localization and surgical results were similar between the EMNGL and CTGL groups. EMNGL is comparable to conventional CTGL with respect to preoperative localization of small lung nodules before uniportal VATS. [ABSTRACT FROM AUTHOR]

Background Esophageal cancer is an aggressive malignancy with high incidence of lymph node metastasis and recurrence rate even after neoadjuvant treatment and radical resection. Previous study has shown that modified en bloc esophagectomy (mEBE) improves survival for esophageal squamous cell carcinoma (ESCC) after neoadjuvant chemoradiotherapy (nCRT). In this study, we aim to investigate the pattern of lymph node recurrence after nCRT+mEBE. Methods The data of patients who received nCRT followed by curative surgical resection for ESCC were retrospectively reviewed. The mEBE includes 'mesophagus' dissection and bilateral recurrent laryngeal nerve node dissection, whereas conventional esophagectomy (CE) only requires periesophageal tissues dissection that were close to the esophagus. The pattern of recurrence, especially lymph node recurrence (cervical, upper mediastinum, infra-carina, and abdominal), were compared between CE and mEBE, with stratification according to pathological stage (ypT0N0 or not.) Results A total of 221 (CE, n = 181; mEBE, n = 40) patients were included. Mediastinal lymph node recurrence was noted in 16.0% and 7.5% of patients after CE and mEBE, respectively (p = 0.166). In ypT0N0 patients who received CE, 6.0% had upper mediastinum recurrence, whereas no mediastinal recurrence was noted after mEBE (p = 0.329). In non-ypT0N0 stage patients who received CE, 15.3% and 8.2% had upper mediastinum and infra-carina recurrences, compared to 12.0% and 0% after mEBE (p = 0.283). There cervical/abdominal recurrences were noted in 6.6%/7.2% and 15.0%/5.0% after CE and mEBE, respectively (p = 0.080/0.618). Conclusion Although there was no significant difference in lymph node recurrence pattern between mEBE and CE, we observed that (1) 6% of ypT0N0 patients developed mediastinal lymph node recurrence after CE, implying the possibility of understaging after CE; (2) no patients developed infra-carina lymph node recurrence after mEBE, suggesting the necessity of mesoesophagus dissection, and (3) high incidence of cervical lymph node recurrence even after mEBE, indicating that cervical dissection should be considered in selected patients. [ABSTRACT FROM AUTHOR]

View large Download slide View large Download slide OBJECTIVES The 8th edition American Joint Committee on Cancer Tumour-Nodes-Metastasis (TNM) staging system distinguishes between the clinical (c), pathological (p) and post-neoadjuvant pathological (yp) stage groups. However, the ability to discriminate between ypStage II and ypStage III is poor. We aim to identify prognostic factors in patients with ypStage II/III oesophageal squamous cell carcinoma. METHODS The data of 150 patients with ypStage II/III oesophageal squamous cell carcinoma from 2 medical centres were retrospectively reviewed. The neoadjuvant treatments included chemotherapy with cisplatin and 5-fluorouracil, administered concurrently with external beam radiation. The determination of perineural invasion (PNI) was based on pathological reports. Survival curves were compared using the log-rank test, and multivariable survival analysis was performed with a Cox regression model. RESULTS The 3-year/5-year overall survival rate/median survival in ypStages II, IIIa and IIIb were 35.3%/26.9%/21.9 [95% confidence interval (CI) 14.9–28.8] months, 33.8%/22.5%/22.4 (95% CI 20.1–24.7) months and 21.7%/14.0%/14.4 (95% CI 11.1–17.7) months, respectively (P  =   0.07). The 3-year/5-year overall survival rate/median survival was 36.7%/26.4%/22.8 (95% CI 19.2–26.5) months in the absence of PNI and 6.9%/3.4%/9.1 (95% CI 8.9–9.4) months in the presence of PNI (P  <   0.001). In the multivariable survival analysis, tumour location in the upper third of the thoracic oesophagus [hazard ratio (HR) 1.692, 95% CI 1.087–2.635; P  =   0.020] and positive PNI (HR 3.316, 95% CI 2.005–4.905; P  <   0.001) remained as independent prognostic factors. CONCLUSIONS The existence of PNI after neoadjuvant treatment is closely associated with poor prognosis and could be incorporated into the TNM staging system for better discrimination between patients with ypStage II/III oesophageal squamous cell carcinoma. [ABSTRACT FROM AUTHOR]

Background Both lymphovascular invasion, which is characterized by penetration of tumor cells into the peritumoural vascular or lymphatic network, and perineural invasion, which is characterized by involvement of tumor cells surrounding nerve fibers, are considered as an important step for tumor spreading, and are known poor prognostic factors in esophageal cancer. However, the information of these histological features is unavailable until pathological examination of surgical resected specimens. We aim to predict the presence or absence of these factors by positron emission tomography images during staging workup. Methods The positron emission tomography images before treatment and pathological reports of 278 patients who underwent esophagectomy for squamous cell carcinoma were collected. Stepwise convolutional neural network was constructed to distinguish patient with either lymphovascular invasion or perineural invasion from those without. Results Randomly selected 248 patients were included in the testing set. Stepwise approach was used in training our custom neural network. The performance of fine-tuned neural network was tested in another independent 30 patients. The accuracy rate of predicting the presence or absence of either lymphovascular invasion or perineural invasion was 66.7% (20 of 30 were accurate). Conclusion Using pre-treatment positron emission tomography images alone to predict the presence of absence of poor prognostic histological factors, i.e. lymphovascular invasion or perineural invasion, with deep convolutional neural network is possible. The technique of deep learning may identify patients with poor prognosis and enable personalized medicine in esophageal cancer. Disclosure All authors have declared no conflicts of interest. [ABSTRACT FROM AUTHOR]

OBJECTIVES Previous studies have shown that patients who undergo oesophageal cancer surgery in high-volume hospitals have lower postoperative mortality rates. However, the impact of hospital volume on long-term survival is controversial. METHODS We identified 2151 patients who were diagnosed with oesophageal cancer between 2008 and 2011 from a national population-based cancer registry in Taiwan. High-volume hospitals were defined as those performing more than 86 oesophagectomies during that period (22 cases/year). Patients were stratified by whether they received preoperative chemoradiation. Cox regression analyses were used to determine the survival impact of hospital volume. RESULTS The 3-year overall survival rates after oesophagectomies were 44.9% in high-volume hospitals, compared with 40.2% in low-volume hospitals (P = 0.002). For patients who received preoperative chemoradiation (n = 850), the 1- and 3-year overall survival rates were 74.7 and 36.8%, respectively, in high-volume hospitals, compared with 73.5 and 42.6%, respectively, in low-volume hospitals (P = 0.333). For patients who did not receive preoperative chemoradiation (n = 1301), the 1- and 3-year overall survival rates were 78.1 and 50.0%, respectively, in high-volume hospitals, compared with 67.9 and 38.8%, respectively, in low-volume hospitals (P < 0.001). Multivariate analysis showed that hospital volume, resection margin, cT, pT and pN stages are significant independent prognostic factors. CONCLUSIONS Overall survival rate of patients who undergo oesophagectomies without preoperative chemoradiation at high-volume hospitals is significantly higher than at low-volume hospitals. However, there was no significant correlation between hospital volume and long-term outcome in patients who received preoperative chemoradiation. [ABSTRACT FROM AUTHOR]

Photographs from a computed tomography showing an aorto-oesophageal fistula with persistent contrast extravasation from the aorta of a 52-year old male patient with oesophageal cancer are presented.