Jean Pierre Triboulet

The number of metastatic lymph nodes and the ratio between metastatic and examined lymph nodes are independent prognostic factors in esophageal cancer regardless of neoadjuvant chemoradiation or lymphadenectomy extent.

Objective:To investigate whether the number of lymph nodes metastasis (LNMs) and the ratio between metastatic and examined lymph nodes (LNs) are better prognostic factors when compared with traditional staging systems in patients with esophageal carcinoma. Summary Background Data:The accuracy of the 6th UICC/TNM classification is suboptimal, especially when not taking into account neoadjuvant therapy and lymphadenectomy extent. Methods:For 536 patients who underwent curative en bloc esophagectomy, in whom 51.5% (n = 276) received neoadjuvant chemoradiation, LNMs were classified according to the 6th UICC/TNM classification and systems based on the number (≤4 and >4) or the ratio (≤0.2 and >0.2) of LNMs. Survival of the respective stages, predictors of survival, and influence of both chemoradiation and number of examined LNs were studied. Results:After a median follow-up of 50 months, the 5-year survival rates were 47% for the entire population, significantly poorer for patients with >4 LNMs (8% vs. 53%, P < 0.001) or a ratio of LNMs >0.2 (22% vs. 54%, P < 0.001). After adjustment for confounding variables, a number of LNMs >4 and a ratio of LNMs >0.2 were the only predictors of poor prognosis. The prognostic role of both the number and the ratio of LNMs was maintained whether patients received neoadjuvant chemoradiation or not. Moreover, LN ratio is shown to be more accurate for inadequately staged patients (<15 examined LNs), whereas the number of LNMs is pertinent for adequately staged patients (≥15 examined LNs). Conclusion:Staging systems for esophageal cancer that use the number (≤4 or >4) and the ratio (≤0.2 or >0.2) of LNMs have greater prognostic importance than the current staging systems because of the good stratification of the groups and their clinical utility, taking into account neoadjuvant therapy and lymphadenectomy extent.

Oesophagogastric junction adenocarcinoma: which therapeutic approach?

Gastric and oesophageal cancers are among the leading causes of cancer-related death worldwide. By contrast with the decreasing prevalence of gastric cancer, incidence and prevalence of oesophagogastric junction adenocarcinoma (OGJA) are rising rapidly in developed countries. We provide an update about treatment strategies for resectable OGJA. Here we review findings from the latest randomised trials and meta-analyses, and propose guidelines regarding endoscopic, surgical, and perioperative treatments. Through a team approach, members from all diagnostic and therapeutic disciplines, such as gastroenterologists, surgeons, oncologists, radiologists, and radiotherapists, can effectively administer a range of treatment modalities.

Esophageal Carcinoma: Prognostic Differences between Squamous Cell Carcinoma And Adenocarcinoma

Whether squamous cell carcinoma (SCC) and adenocarcinoma (ADC) of the esophagus differ in their natural history and treatment outcome remains controversial. The aim of the study was to identify the similarities and differences between SCC and ADC in terms of their clinical and histologic presentations and the oncologic results. Curative esophagectomy was attempted in 742 consecutive patients between January 1982 and January 2002. Neoadjuvant radiochemotherapy was proposed for patients with locally advanced tumors. Demographic parameters, histomorphologic tumor characteristics, treatment strategies, postoperative mortality and morbidity rates, recurrence, and long-term prognosis were recorded retrospectively.The SCC and ADC groups were composed of 624 and 118 patients, respectively. ADC occurrence increased significantly during the study period. Compared to the SCC group, patients in the ADC group were significantly older and had a lower incidence of respiratory and otolaryngologic histories; they also had more advanced tumors and a higher percentage of invaded lymph nodes, shorter time until resumption of feeding, shorter hospital stay, a higher diffuse recurrence rate, and a lower incidence of tobacco-related second primary tumors. Five-year survival rates after R0 resection were 46% and 45% in the SCC and ADC groups, respectively (p = 0.804). There was a significant survival advantage for ADC patients with pT1, pN0, or stage I tumors (p < 0.050) and different independent prognostic factors than those with SCCs. In conclusion, the clinical, histologic, and oncologic differences between SCC and ADC justify a differentiated therapeutic concept for these two tumor entities and distinct consideration in clinical reports.

Effects of hybrid minimally invasive oesophagectomy on major postoperative pulmonary complications

Morbidity after oesophageal cancer surgery remains high, mainly due to major postoperative pulmonary complications (MPPCs). The aim of this study was to test the hypothesis that hybrid minimally invasive oesophagectomy (HMIO) decreases the 30‐day MPPC rate without compromising oncological outcomes.

Extent of oesophageal resection for adenocarcinoma of the oesophagogastric junction.

AIMS The optimal extent of oesophageal resection and surgical approach in patients treated for adenocarcinomas of the oesophagogastric junction (OGJ) are still uncertain. We report the correlations between resection margin involvement and outcome. METHODS Patients with positive proximal resection margin (PPRM) and those with negative proximal resection margin (NPRM) were compared. RESULTS Of 94 patients with macroscopically complete resection, eight were PPRM. There was no difference between the two groups in postoperative mortality or morbidity rates, in anastomotic leakage or in recurrence rates. The median survival in the PPRM group was 11.1 months compared with 36.3 months in the NPRM group (P=0.02). No infiltration was observed in patients whose proximal margin exceeded 7 cm. The extended transthoracic approach was the only prognostic factor for tumours type II (P=0.03, RR=1.4, 95% CI: 1.1-1.8). CONCLUSION Histologic infiltration of oesophageal resection margin influences 5-year survival rate. In adenocarcinomas of the OGJ that can be treated curatively, a transection with a 8 cm oesophagectomy above the tumour in fresh specimen should be performed, and by thoracoabdominal approach for tumours type I and II.

Value of endoscopic ultrasonography as a predictor of long-term survival in oesophageal carcinoma

Endoscopic ultrasonography (EUS) is considered to be the best locoregional staging technique for cancer of the oesophagus. This study evaluated the relationship between preoperative EUS findings, completeness of surgical resection and survival.

Impact of preoperative radiochemotherapy on postoperative course and survival in patients with locally advanced squamous cell oesophageal carcinoma.

The aim of this study was to determine the effect of neoadjuvant radiochemotherapy (RCT) on postoperative complications and survival after surgery for locally advanced oesophageal squamous cell carcinoma.

[Digestive oncology: surgical practices].

Membres du groupe de travail (par ordre alphabétique) : Blay JY (Oncologue Lyon), Brouquet A (Chirurgien Boulogne), Chatelain D (Anatomopathologiste Amiens), Comy M (Chirurgien La Roche sur Yon), Delpero JR (Chirurgien Marseille), Denet C (Chirurgien Paris), Elias D (Chirurgien Villejuif), Fléjou JF (Anatomopathologiste Paris), Fourquier P (Chirurgien Nantes), Fuks D (Chirurgien Amiens), Glehen O (Chirurgien Lyon), Karoui M (Chirurgien Paris), Kohneh-Shahri N (Chirurgien Villejuif), Lesurtel M (Chirurgien Clichy), Mariette C (Chirurgien Lille), Mauvais F (Chirurgien Beauvais), Nicolet J (Chirurgien Meaux), Perniceni Th (Chirurgien Paris), Piessen G (Chirurgien Lille), Regimbeau JM (Chirurgien Amiens), Rouanet Ph (Chirurgien Montpellier), Sauvanet A (Chirurgien Clichy), Schmitt G (Chirurgien Reims), Vons C (Chirurgien Bondy).

Transcriptional regulation of human mucin MUC4 by bile acids in oesophageal cancer cells is promoter-dependent and involves activation of the phosphatidylinositol 3-kinase signalling pathway

Abnormal gastro-oesophageal reflux and bile acids have been linked to the presence of Barretts oesophageal premalignant lesion associated with an increase in mucin-producing goblet cells and MUC4 mucin gene overexpression. However, the molecular mechanisms underlying the regulation of MUC4 by bile acids are unknown. Since total bile is a complex mixture, we undertook to identify which bile acids are responsible for MUC4 up-regulation by using a wide panel of bile acids and their conjugates. MUC4 apomucin expression was studied by immunohistochemistry both in patient biopsies and OE33 oesophageal cancer cell line. MUC4 mRNA levels and promoter regulation were studied by reverse transcriptase-PCR and transient transfection assays respectively. We show that among the bile acids tested, taurocholic, taurodeoxycholic, taurochenodeoxycholic and glycocholic acids and sodium glycocholate are strong activators of MUC4 expression and that this regulation occurs at the transcriptional level. By using specific pharmacological inhibitors of mitogen-activated protein kinase, phosphatidylinositol 3-kinase, protein kinase A and protein kinase C, we demonstrate that bile acid-mediated up-regulation of MUC4 is promoter-specific and mainly involves activation of phosphatidylinositol 3-kinase. This new mechanism of regulation of MUC4 mucin gene points out an important role for bile acids as key molecules in targeting MUC4 overexpression in early stages of oesophageal carcinogenesis.

Reconstruction after gastrectomy: which technique is best?

Several reconstruction techniques are possible after gastrectomy. The best reconstruction is one, that maintains satisfactory nutritional status and quality of life while keeping postoperative morbidity as low as possible. The aim of this study was to describe the different reconstruction techniques that can be proposed after distal and total gastrectomy, heeding to the French guidelines on the use of mechanical sutures in these indications. We then conducted a review of randomized trials dealing with reconstruction techniques after distal and total gastrectomy. After distal gastrectomy, Roux-en-Y reconstruction seems superior to Billroth I and Billroth II reconstructions in terms of functional outcomes and long-term endoscopic results and should be chosen in patients with benign disease or superficial tumors. Otherwise, Billroth II should be preferred over Billroth I reconstruction because of lower postoperative morbidity and better oncologic margins. After total gastrectomy, Roux-en-Y reconstruction remains the easiest solution, with satisfactory functional results. Addition of a pouch reservoir after Roux-en-Y reconstruction seems to improve short-term functional outcome after total gastrectomy with better potential for nutritional intake. In the long-term, quality of life seems better mainly in patients with small-resected tumors associated with a good prognosis.