Han-Yu Deng

Neuroendocrine carcinoma of the esophagus: clinical characteristics and prognostic evaluation of 49 cases with surgical resection

BACKGROUND The clinicopathological features and optimum treatment of esophageal neuroendocrine carcinoma (NEC) are hardly known due to its rarity. Therefore, we conducted a retrospective study to analyze the clinical characteristics and prognosis of patients with surgically resected esophageal NEC. METHODS We collected clinicopathological data on consecutive limited disease stage esophageal NEC patients who underwent esophagectomy with regional lymphadenectomy in West China Hospital from January 2007 to December 2013. RESULTS A total of forty-nine patients were analyzed retrospectively. The mean age of the patients was 58.4±8.2 years with male predominance. Fifty-five percent of the esophageal NEC were located in the middle thoracic esophagus. Histologically, 28 (57.1%) patients were found to be small cell NECs. Fifty-one percent of the patients were found to have lymph node metastasis. According to the 2009 American Joint Committee on Cancer (AJCC) staging system for esophageal squamous cell carcinoma, 9 patients were at stage I, 21 patients stage II, and 19 patients stage III. Twenty-six patients (53.1%) received adjuvant therapy. After a median follow-up of 44.8 months [95% confidence interval (CI), 35.2-50.4 months], the median survival time of the patients was 22.4 months (95% CI, 14.0-30.8 months). The 1-year and 3-year survival rates for the whole cohort patients were 74.9% and 35.3%, respectively. In univariate analysis, TNM staging, lymph node metastasis and adjutant therapy significantly influenced survival time. In multivariate analysis, TNM staging was the only independent prognostic factor. CONCLUSIONS Esophageal NEC has a poor prognosis. The 2009 AJCC TNM staging system for esophageal squamous cell carcinoma may also fit for esophageal NEC. Surgery combined with adjuvant therapy may be a good option for treating limited disease stage esophageal NEC. Further prospective studies defining the optimum therapeutic regimen for esophageal NEC are needed.

Radiotherapy, lobectomy or sublobar resection? A meta-analysis of the choices for treating stage I non-small-cell lung cancer.

Whether stereotactic ablative radiotherapy (SABR) is comparable to surgery in treating stage I non-small-cell lung cancer (NSCLC) is unknown. Therefore, we conducted this meta-analysis to compare the efficacy of SABR with that of surgery in treating stage I NSCLC. A systematic literature search in PubMed, Embase, Cochrane Library databases and Google Scholar as well as the American Society of Clinical Oncology was conducted to identify relevant studies dated through 31 December 2015. Data including 3-year survival rate, overall survival (OS) and 3-year loco-regional control (LRC) rates were extracted and analysed. No complete randomized controlled trials but 12 cohort studies were included with a total of 13 598 patients. Meta-analysis showed a significantly lower 3-year survival rate (risk ratio = 0.78; 95% confidence interval [CI] = [0.68, 0.90]; P = 0.001) and shorter OS (hazard ratio =1.60; 95% CI = [1.24, 2.06]; P < 0.001) for patients treated with SABR compared with surgery. No difference in the 3-year LRC rate was observed between SABR and surgery (risk ratio = 0.95; 95% CI = [0.82, 1.09]; P = 0.453). Subgroup analysis was conducted on the basis of surgical procedures. In the subgroup analysis, SABR was found to yield significantly shorter OS than lobectomy (hazard ratio = 1.68; 95% CI = [1.09, 2.60]; P = 0.018), whereas SABR was comparable to sublobar resection in terms of 3-year survival rate, OS and 3-year LRC rate. Our meta-analysis found that lobectomy yielded better survival outcomes than SABR, whereas SABR yielded comparable rates when compared with sublobar resection. Lobectomy is still the preferred method for treating earlystage NSCLC. Well-designed and multicentred randomized controlled trials with large sample sizes, however, are needed to confirm and update our conclusions.

Selective En Masse Ligation of the Thoracic Duct to Prevent Chyle Leak After Esophagectomy

BACKGROUND Postoperative chylothorax remains an important cause of reoperation and prolonged hospital stay after esophagectomy for the treatment of esophageal carcinoma. Chylothorax is potentially life threatening and difficult to manage. The benefit of routine thoracic duct ligation is controversial. A promising alternative is to identify chyle leaks at the time of esophagectomy and perform the ligation selectively. We developed a novel technique to identify chyle leak at the time of esophagectomy and compared it with routine ligation of thoracic duct. METHODS This cohort study involved all of the qualified patients with resectable esophageal carcinoma treated between March 1, 2011, and December 31, 2015, by a single surgical team at West China Hospital. Patients receiving routine en masse ligation of the thoracic duct were assigned to group A, and patients receiving selective en masse ligation of the thoracic duct were assigned to group B. All patients in the selective ligation group received 120 mL olive oil orally before the operation. The end point included frequencies of chyle leak detected at the time of esophagectomy, postoperative chylothorax, and need for chylothorax-related reoperation. RESULTS The study enrolled 296 patients who fulfilled the study requirement: 55 in group A and 241 in group B. Patients in group A experienced significantly higher incidences of postoperative chylothorax and chylothorax-related reoperation than group B (9.1% vs 0% [p < 0.01] and 3.6% vs 0% [p < 0.01]). Incidence of detection of intraoperative chyle leak (chylothorax plus chylous ascites) was significantly higher in group B than in group A (9.5% vs 0%, p < 0.01). No intraoperative or postoperative complications related to preoperative oral olive oil administration or selective en masse ligation of the thoracic duct were observed. CONCLUSIONS Our method of selective en masse ligation of the thoracic duct during esophagectomy was feasible and safe and was associated with reduced rates of postoperative chylothorax.

Neoadjuvant chemoradiotherapy or chemotherapy? A comprehensive systematic review and meta-analysis of the options for neoadjuvant therapy for treating oesophageal cancer

Neoadjuvant therapy followed by surgery is a standard treatment for locally advanced oesophageal cancer. However, the roles of neoadjuvant chemoradiotherapy and chemotherapy in treating oesophageal cancer remain controversial. In this comprehensive meta-analysis, we examine the efficacy of adding radiotherapy to neoadjuvant chemotherapy for treating oesophageal cancer as reported in qualified randomized controlled trials (RCTs). We conducted a systematic literature search using PubMed, Embase, Cochrane Library databases, Google Scholar and the American Society of Clinical Oncology database to identify relevant studies up to 31 March 2016. Data including the pathological complete response rate, R0 resection rate and 3-year survival rate were extracted and analysed. Five qualified RCTs were included with a total of 709 patients. Meta-analysis showed that neoadjuvant chemoradiotherapy significantly increases the rates of pathological complete response and R0 resection in patients with oesophageal adenocarcinoma or squamous cell carcinoma (SCC). However, we found a significantly increased 3-year survival rate only in oesophageal SCC patients treated with neoadjuvant chemoradiotherapy compared with neoadjuvant chemotherapy (56.8 and 42.8%, respectively); relative risk (RR): 1.31 [95% confidence interval (CI) 1.10-1.58, P = 0.003]. In oesophageal adenocarcinoma patients, no significant survival benefit of neoadjuvant chemoradiotherapy was found compared with neoadjuvant chemotherapy alone (46.3 and 41.0%, respectively; RR: 1.13, 95% CI 0.88-1.45, P = 0.34). Our meta-analysis adds to the evidence showing that neoadjuvant chemoradiotherapy should be the standard preoperative treatment strategy for locally advanced oesophageal SCC. For oesophageal adenocarcinoma, neoadjuvant chemotherapy alone may be the best preoperative treatment strategy to avoid the risk of adverse effects of radiotherapy.

Long noncoding RNAs are novel potential prognostic biomarkers for esophageal squamous cell carcinoma: an overview.

Esophageal squamous cell carcinoma (ESCC) still has a poor prognosis. The prognostic biomarkers of ESCC are not yet well established. Long noncoding RNAs (lncRNAs) have recently been intensively investigated in various cancers including ESCC, and are found to be closely correlated to ESCC. Dysregulated expression of lncRNAs was widely observed in ESCC tumor tissue and was closely related to the tumorigenesis and progression of ESCC. More and more studies have found that lncRNAs were significantly correlated with the prognosis and diagnosis of patients with ESCC. Therefore, all those accumulating evidence indicated that lncRNAs could serve as a prognostic biomarker of ESCC. In this, we summarized the relation between lncRNAs and ESCC as well as the potential biomarker role of lncRNAs in ESCC, especially the prognostic value of lncRNAs. Our current review highlighted the need of further studies to explore the biomarker functions as well as therapeutic values of lncRNAs in ESCC.

Can lobe-specific lymph node dissection be an alternative to systematic lymph node dissection in treating early-stage non-small cell lung cancer: a comprehensive systematic review and meta-analysis?

Background Whether lobe-specific lymph node dissection (L-SLND) could serve as an alternative to systematic lymph node dissection (SLND) in treating early-stage non-small cell lung cancer (NSCLC) remains unclear. Therefore, we conducted this comprehensive meta-analysis to compare the effect of L-SLND with that of SLND in treating early-stage NSCLC. Methods A systematic literature search in PubMed and Embase was conducted to identify relevant studies up to 30 November 2017. Data including 5-year overall survival (OS) and disease-free survival (DFS) rates, recurrence rates, and morbidity rate were extracted and analysed. Results A total of six studies [one randomized controlled trial (RCT) and five retrospective cohort studies] consisting of 2,037 patients with early-stage NSCLC were included for analysis. Meta-analysis showed that there was no significant difference of 5-year OS [81.7% and 79.5%, respectively; risk ratio (RR) =1.021; 95% confidence interval (CI), 0.977-1.068; P=0.352] and DFS (76.4% and 69.9%, respectively; RR =1.061; 95% CI, 0.999-1.128; P=0.054) between patients treated with L-SLND and those with SLND. Moreover, there was also no significant difference of total recurrence rates (24.3% and 25.8%, respectively; RR =0.892; 95% CI, 0.759-1.048; P=0.166) and loco-regional recurrence rates (7.9% and 9.3%, respectively; RR =0.851; 95% CI, 0.623-1.162; P=0.310) between patients treated with L-SLND and those with SLND. However, patients treated with L-SLND yielded a significant lower morbidity rate than those treated with SLND (10.2% and 13.5%, respectively; RR =0.681; 95% CI, =0.521-0.888; P=0.005). Conclusions L-SLND yielded a significantly lower risk of morbidity compared to SLND without compromising long-term oncologic outcomes based on available studies with relatively poor quality. L-SLND may serve as an alternative to SLND in treating early-stage NSCLC. Further well-conducted RCTs, however, are badly needed to confirm and update our conclusions.

Novel biologic factors correlated to visceral pleural invasion in early-stage non-small cell lung cancer less than 3 cm

Background Visceral pleural invasion (VPI) in early-stage non-small cell lung cancer (NSCLC) is traditionally believed as the result of too much close distance between cancerous lesion and the visceral pleura, but whether there are any other biologic factors correlated to VPI beyond our instinctive thoughts remains unclear. Therefore, we conducted this study to investigate potential factors correlated to VPI comprehensively. Methods Both clinical and pathological characteristics of patients undergoing surgery for NSCLC with a size of ≤3 cm were retrospectively analysed. Results A total of 403 patients were included for analysis. Patients with VPI had older age than those without (61.1 vs. 56.1 years; P<0.001). The mean size of NSCLCs with VPI was larger than those without (2.1 vs. 1.6 cm; P<0.001). Moreover, NSCLCs with VPI were located closer to visceral pleura (0.8 vs. 1.3 cm; P<0.001) and showed larger rates of pleural indentation (86.8% vs. 45.6%; P<0.001) and spiculation (59.7% vs. 34.7%; P<0.001) than those without. Pathologically, NSCLCs with VPI tended more likely to be adenocarcinomas (96.9% vs. 92.7%; P=0.097), and was more likely to be poorly differentiated (38.0% vs. 15.3%; P<0.001), to have cancer embolus (6.2% vs. 0.7%; P=0.001) and lymph node metastasis (29.5% vs. 10.2%; P<0.001) than those without. Besides shorter distance to visceral pleura [odds ratio (OR)=2.169, 95% CI: 1.221-3.855; P=0.008], older age [OR =2.119, 95% confidence interval (CI): 1.255-3.503; P=0.005], pleural indentation (OR =3.679, 95% CI: 1.888-7.169; P<0.001), adenocarcinoma (OR =4.741, 95% CI: 1.383-16.255; P=0.013), and poor tumor differentiation (OR =11.816, 95% CI: 4.470-31.234; P<0.001) were also found to be closely correlated to VPI in early-stage NSCLC. Conclusions Besides shorter distance to visceral pleura and pleural indentation, elderly, adenocarcinoma, and poor tumor differentiation were novel biologic factors correlated to VPI in early-stage NSCLC, which may explain why VPI was an unfavorable prognostic factor for early-stage NSCLC.

The influence of heparin on coagulation function of patients undergoing video-assisted major thoracic surgery

Background Venous thromboembolism (VTE) remains a common complication after major thoracic surgery, especially resection of lung or esophagus cancer. This trial aims to explore the influence of preoperative usage of heparin on coagulation function of patients treated with video-assisted major thoracic surgery. Methods This prospective randomized control trial collected 91 patients who are diagnosed with lung or esophagus cancer intending to accept video-assisted neoplasm resection from June 2016 to May 2017 in West China Hospital, Sichuan University. After admission to hospital, the patients received heparin sodium (unfractionated heparin) 5,000 U twice a day before operation. The change of blood platelet count (PLT), prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), fibrinogen (FIB), international normalized ratio (INR) was collected and analyzed at the points of admission to hospital and post-operation. Results The mean value of all coagulation parameters (PLT, PT, APTT, TT, INR, FIB) were in normal range both before and after operation. Postoperative PLT and FIB were not significantly different from preoperative PLT and FIB respectively (P>0.05). Preoperative PT, APTT, and INR increased significantly compared to pre-operation respectively (P<0.05). Postoperative TT significantly decreased when compared to preoperative TT (P<0.05). Preoperative and postoperative abnormal rate of PT or APTT or TT or INR (number of abnormal cases/all cases) was not different significantly respectively (P>0.05). Postoperative mean drainage was 240 mL/d, mean time of hospital stay was 7.50 days, drainage tube was maintained for 4.22 days on average. Conclusions All patients underwent video-assisted major thoracic surgery with preoperative use of heparin, there were significant differences in coagulation function after operation. However, mean values of all coagulation parameters stayed normal range clinically. In a word, the method showed no influence on coagulation function clinically.

A two-step surgical approach combining sternotomy and subsequent thoracotomy for locally advanced lung cancers requiring both right upper lung resection and superior vena cava reconstruction

Background Locally advanced lung cancers involving both right upper lung lobe and superior vena cava (SVC) requiring both lung resection and SVC reconstruction are generally deemed unresectable. However, previous evidence has proved that such patients could benefit from surgery if radical resection is achieved. Generally, a hemi-clamshell approach is adopted to complete such resection. However, it has the limitation of insufficient exposure of posterior mediastinum. Therefore, we introduced a two-step surgical approach combining sternotomy and thoracotomy for such lung cancers. Methods A two-step surgical approach combining median sternotomy and subsequent posterolateral thoracotomy, via which radical lobectomy with systematic lymphadenectomy and SVC reconstruction could be successfully achieved, was described. Results We have performed such surgery via the two-step surgical approach combining median sternotomy and subsequent posterolateral thoracotomy in five patients from January 2017 to March 2018. All those patients achieved radical resection of the lung cancer with lobectomy and systematic lymphadenectomy and SVC reconstruction with artificial blood vessels, and had an uneventful postoperative recovery without any major complications. Conclusions Our initial experience proved that this two-step surgical approach combining median sternotomy and subsequent posterolateral thoracotomy was safe and feasible for locally advanced lung cancers requiring both lung resection and SVC reconstruction.

Cancerous esophageal stenosis before treatment was significantly correlated to poor prognosis of patients with esophageal cancer: a meta-analysis

Background Cancerous esophageal stenosis encountered during endoscopic ultrasonography before treatment was observed in about 30% of esophageal cancer patients. Since the pT stage in TNM classification measures only the depth of infiltration but not the growth to esophagus, it is interesting to know whether tumor growth into the esophagus (and eventual stenosis) is of added value in prognostic assessment. However, the impact of esophageal stenosis on survival of esophageal cancer patient remains unclear. Therefore, we conducted a meta-analysis focusing on current topic for the first time. Methods A systematic literature search in PubMed and EMBASE was conducted to identify relevant studies up to 14 March 2018. Data of 5-year overall survival (OS) was extracted and analysed. Results A total of five cohort studies consisting of 1,282 patients (278 patients with cancerous esophageal stenosis before treatment and 1,004 patients without) with esophageal cancer treated with surgery, chemoradiotherapy, or palliative therapy were included for analysis. Meta-analysis showed that patients with esophageal stenosis had significantly lower 5-year OS [22.3% and 33.0%, respectively; risk ratio (RR) =1.21; 95% CI, 1.11-1.32; P<0.001; I2=27.1%] than those without. No heterogeneity or publication bias was observed during analysis. Conclusions Patients with cancerous esophageal stenosis identified by endoscopy before treatment had significantly poorer survival than those without. High-quality studies with appropriate adjustments for confounding factor are needed to confirm the findings.