Hsien-Kun Chang

Salvage surgery after failed chemoradiotherapy in squamous cell carcinoma of the esophagus.

AIMS To investigate the survival benefit and preoperative risk factors for hospital mortality of salvage surgery in esophageal cancer patients who had locoregional residual/recurrent tumor after definitive chemoradiotherapy. METHODS We retrospectively reviewed the esophageal cancer patients who presented at our hospital from 1997 to 2004. Forty-seven patients who had squamous cell cancer and developed locoregional recurrent/persistent disease after primary definitive chemoradiotherapy were elected. Twenty-seven of them received salvage esophagectomy (group 1) and the other 20 underwent non-operative treatment only (group 2). In order to assess the surgery-related mobility and mortality in group 1, 191 patients who received neoadjuvant chemoradiotherapy followed by operation during the same time period were also enrolled (group 3). RESULTS The 5-year overall survival of group 1 patients was 25.4%. In contrast, all of the patients in the group 2 died within 16.7 months. The difference was statistically significant (p=0.0029). In comparison with group 3, group 1 patients had significantly more surgery-related complications and hospital mortality. In univariate analysis for preoperative risk factors, a low albumin or hemoglobulin level was associated with high hospital mortality in group 1 (p=0.004 and 0.003, respectively). After multivariate analysis, only the low albumin level remained borderline significance. As for disease specific survival after salvage surgery, R0 resection was the only independent prognosticator (p=0.049). CONCLUSION Salvage surgery provides survival benefit in esophageal cancer patients with locoregional persistent or recurrent disease after primary definitive chemoradiotherapy. Preoperative albumin and hemoglobulin levels are associated with hospital mortality and may aid in selecting suitable patient for salvage surgery.

High expression of phosphorylated 4E-binding protein 1 is an adverse prognostic factor in esophageal squamous cell carcinoma

Cell signaling pathways play important roles in oncogenesis. Among a large number of signaling regulators in different pathways, 4E-binding protein 1 (4E-BP1) was found to be a key factor, which converges several oncogenic signals, phosphorylates the molecules, and drives the downstream proliferative signals. Recent studies showed that high expression of phosphorylated 4E-BP-1 (p-4E-BP1) is associated with poor prognosis, tumor progression, or nodal metastasis in different human cancers, but its prognostic significance in esophageal cancer remains undefined. In this study, we investigated the expression levels of p-4E-BP1 with two different phosphorylation sites Thr37/46 and Thr70 by immunohistochemistry and their prognostic significance in 78 cases of surgically resected esophageal squamous cell carcinoma (SCC) for the first time. We found no correlation of p-4E-BP1 expression with age, gender, preoperative concurrent chemoradiotherapy, tumor grade, pT classification, pN, pM, or pStage. Multivariate Cox regression analysis showed that high expression of p-4E-BP-1 Thr37/46 was an independent adverse prognostic factor, with a hazard ratio of 1.73 (95% confidence interval = 1.03–2.90) and a p value of 0.038. Stratifying the patients with other prognostic factors, we found that the effect of p-4E-BP1 Thr37/46 on survival was significant only in patients with relatively early stage disease (pT1/pT2, pN0, or pStage I/II; p = 0.0047, 0.012, and 0.011, respectively). Our data suggest that assessment of p-4E-BP1 expression could identify a subpopulation of earlier stage esophageal SCC patients with poor prognosis. These patients could be possible candidates for future studies on more aggressive treatment or target therapy.

Impact of the number of lymph nodes sampled on outcome in ypT0N0 esophageal squamous cell carcinoma patients

Higher extent of lymph node dissection (LND) is beneficial in primarily resected esophageal cancer patients by providing accurate staging and better tumor control. Achieving pathological complete response (pCR) after chemoradiotherapy (CRT) also represents better outcome. We studied the controversial question whether higher LND could further improve survival after pCR.

Distant nodal metastases from intrathoracic esophageal squamous cell carcinoma: characteristics of long-term survivors after chemoradiotherapy.

Non‐regional lymph node metastasis in intrathoracic esophageal cancer is classified as M1 lesion with poor prognosis following surgery alone. We studied the controversial question of whether chemoradiotherapy (CRT) improves survival of these patients.

Characterization of residual tumours at the primary site in patients with a near pathological complete response after neoadjuvant chemoradiotherapy for oesophageal cancer.

A ‘surgery as needed’ strategy has been proposed for patients with oesophageal cancer who truly achieve a pathological complete response (pCR) following neoadjuvant chemoradiotherapy (nCRT). However, the ability to detect residual disease remains problematic. This study investigated the anatomical locations and pathological characteristics of residual cancer in patients with oesophageal squamous cell carcinoma (SCC) who achieved a near pCR following nCRT.

Palliative Metallic Stent Deployment for Advanced Esophageal Cancer with Airway Invasion

Background: To determine the clinical roles of metallic airway stents emplaced via rigid bronchoscopy in patients with malignant airway lesion caused by esophageal cancer. Method: Seventeen patients with malignant airway lesions caused by esophageal cancer were treated by placement of 23 expandable stents (19 airway, 4 esophagus). The clinical evaluations and assessments were completed in all patients. Result: The procedures were successful in 16 cases. Improvements in dyspnea were achieved in 88% of the patients (15 of 17 patients). The 30-day mortality rate was 18% (3 of 17 patients). The mean survival times were 85 days (5 to 262 days). Seven patients died due to hemoptysis and 9 died with pneumonia and respiratory failure. Conclusion: The placement of the expandable nitinol stent via rigid bronchoscopy is feasible and effective in achieving a patent airway, relieving dyspnea, and improving the quality of life.