Juha Kauppi

Locally advanced esophageal adenocarcinoma: Response to neoadjuvant chemotherapy and survival predicted by [18F]FDG-PET/CT

Abstract Background. [18F]fluorodeoxyglycose-Positron Emission Tomography/Computer Tomography ([18F]FDG-PET/CT) is commonly used in staging of locally advanced esophageal cancer. Its predictive value for response to neoadjuvant therapy and survival after multimodality therapy is controversial. Methods. Sixty-six consecutive patients with locally advanced adenocarcinoma of the esophagus or esophagogastric junction underwent surgery after neoadjuvant chemotherapy. Staging was done prospectively with [18F]FDG-PET/CT, before and after completion of neoadjuvant therapy. Pre- and post-therapy maximal standardized uptake values for the primary tumor (SUV1 and SUV2) were determined, and their relative change (SUV∆%) calculated. Percentage change in SUV1 was compared with histopathologic response (HPR, complete or subtotal histologic remission), disease-free- (DFS) and overall survival (OS). Results. Resection with negative margins was achieved in 60 patients. HPR rate was 14 of 66 (21.2%). Median follow-up was 16 months (range 4–72). For all patients, OS probability at three years was 59% and DFS 50%. In receiver operating characteristics (ROC) analysis, HPR was optimally predicted by a > 67% change in baseline maximal SUV (sensitivity 79% and specificity 75%). In univariate survival analysis (Cox regression proportional hazards), HPR associated with improved DFS (HR 0.208, p = 0.033) but not OS (HR 0.030, p = 0.101), SUV % > 67% associated with improved OS (HR 0.249, p = 0.027) and DFS (HR 0.383, p = 0.040). In a multivariate model (adjusted by age, sex, and ASA score), neither HPR nor SUV∆% > 67% was predictive of improved OS and DFS. However, SUV∆% as a continuous variable was an independent predictor of OS (HR 0.966, p < 0.0001) or DFS (HR 0.973, p < 0.0001). Conclusion. Our results support previous results showing that [18F]FDG-PET/CT can distinguish a group of patients with worse prognosis after neoadjuvant chemotherapy in adenocarcinoma of the esophagus or esophagogastric junction. This information could offer a new independent preoperative marker of prognosis.

Boerhaave’s Syndrome: Lessons Learned from 83 Cases Over Three Decades

The authors describe their experience in the treatment of 83 Boerhaave patients. During the last few years the mortality of the disease has decreased. A successful treatment requires good treatment resources and experienced team work. The tailored open primary repair technique with fundic reinforcement, developed by the authors, is described in detail. This technique has decreased the amount of postoperative fistulation and esophageal resection. The mortality after stenting was 20%.

Defining Benchmarks for Transthoracic Esophagectomy: A Multicenter Analysis of Total Minimally Invasive Esophagectomy in Low Risk Patients

Objective: To define “best possible” outcomes in total minimally invasive transthoracic esophagectomy (ttMIE). Background: TtMIE, performed by experts in patients with low comorbidity, may serve as a benchmark procedure for esophagectomy. Patients and Methods: From a cohort of 1057 ttMIE, performed over a 5-year period in 13 high-volume centers for esophageal surgery, we selected a study group of 334 patients (31.6%) that fulfilled criteria of low comorbidity (American Society of Anesthesiologists score ⩽2, WHO/ECOG score ⩽1, age ⩽65 years, body mass index 19–29 kg/m2). Endpoints included postoperative morbidity measured by the Clavien-Dindo classification and the comprehensive complication index. Benchmark values were defined as the 75th percentile of the median outcome parameters of the participating centers to represent best achievable results. Results: Benchmark patients were predominantly male (82.9%) with a median age of 58 years (53–62). High intrathoracic (Ivor Lewis) and cervical esophagogastrostomy (McKeown) were performed in 188 (56.3%) and 146 (43.7%) patients, respectively. Median (IQR) ICU and hospital stay was 0 (0–2) and 12 (9–18) days, respectively. 56.0% of patients developed at least 1 complication, and 26.9% experienced major morbidity (≥grade III), mostly related to pulmonary complications (25.7%), anastomotic leakage (15.9%), and cardiac events (13.5%). Benchmark values at 30 days after hospital discharge were ⩽55.7% and ⩽30.8% for overall and major complications, ⩽18.0% for readmission, ⩽3.1% for positive resection margins, and ≥23 for lymph node yield. Benchmarks at 30 and 90 days were ⩽1.0% and ⩽4.6% for mortality, and ⩽40.8 and ⩽42.8 for the comprehensive complication index, respectively. Conclusion: This outcome analysis of patients with low comorbidity undergoing ttMIE may serve as a reference to evaluate surgical performance in major esophageal resection.