M.F.J. Seesing

Management of resectable esophageal and gastric (mixed adeno)neuroendocrine carcinoma: A nationwide cohort study.

INTRODUCTION The aim of this study is to provide insight in accuracy of diagnosing, current treatment and survival in patients with resectable esophageal and gastric neuroendocrine- and mixed adenoneuroendocrine carcinomas (NEC, MANEC). METHODS All patients with esophageal or gastric (MA)NEC, who underwent surgical resection between 2006 and 2016, were identified from the Dutch national registry for histo- and cytopathology (PALGA). Patients with a neuroendocrine tumor lower than grade 3 were excluded. Data on patients, treatment and outcomes were retrieved from the patient records. Diagnosis by endoscopic biopsy was compared with diagnosis by resection specimen. Kaplan Meier survival analysis was performed. RESULTS A total of 49 patients were identified in 25 hospitals, including 21 patients with esophageal (MA)NEC and 26 patients with gastric (MA)NEC on resection specimen. Biopsy diagnosis of (MA)NEC was correct in 23/27 patients. However, 20/47 patients with definitive diagnosis of (MA)NEC, were misdiagnosed on biopsy. Neoadjuvant therapy was administered in 13 (62%) esophageal (MA)NECs and 12 (46%) gastric (MA)NECs. Survival curves were similar with and without neoadjuvant therapy. One (4.8%) esophageal (MA)NEC and 4 (15%) gastric (MA)NECs died within 90 days postoperatively. For esophageal (MA)NEC the median overall survival (OS) after surgery was 37 months and 1-, 3- and 5-year OS were 71%, 50% and 35%, respectively. For gastric (MA)NEC, the median OS was 23 months and 1-, 3- and 5-year OS were 62%, 50% and 39%, respectively. CONCLUSION Localized esophageal and gastric (MA)NEC are often misdiagnosed on endoscopic biopsies. After resection, long-term survival was achieved in respectively 35% and 39% of patients.

Defining pneumonia after esophagectomy for cancer: validation of the Uniform Pneumonia Score in a high volume center in North America

Surgery is a central component of multimodality therapy for esophageal and gastroesophageal junction cancer. Pneumonia is a common sequela of esophagectomy, leading to an increase in intensive care unit stay, hospital stay, readmission rates, and postoperative mortality. Developing strategies to reduce pneumonia after esophagectomy is hampered by the absence of a standardized methodology for defining pneumonia. This study aims to validate the Uniform Pneumonia Score (UPS) in a high volume center in the USA. The UPS was developed to define pneumonia after esophagectomy for cancer and is based on the assessment of temperature (°C), leukocyte count (×109/L), and pulmonary radiography. The UPS has been validated utilizing a prospective, Institutional Review Board approved database of esophageal cancer patients treated in a high volume esophagectomy center in the USA between 2010 and 2015. One hundred ninety-three consecutive patients were included and 21 (10.9%) were treated for pneumonia. The UPS was able to predict treatment for suspected pneumonia with a good sensitivity (85.7%, confidence interval (CI): 63.7%-96.7%), specificity (97.1%, CI: 93.4%-99.1%), positive predictive value (78.3%, CI: 59.9%-89.7%), and negative predictive value (98.2%, CI: 95.1%-99.4%). The diagnostic accuracy was 95.9%, CI: 92.0%-98.2%. The UPS demonstrated to be a reliable scoring system to define pneumonia after esophagectomy for cancer. Global application of this model will standardize the definition of pneumonia after esophagectomy. This will improve outcome reporting and comparisons of complications between individual institutions, clinical trials, and national audits.

The predictive value of new-onset atrial fibrillation on postoperative morbidity after esophagectomy

New-onset atrial fibrillation (AF) is frequently observed following esophagectomy and may predict other complications. The aim of the current study was to determine the association between, and the possible predictive value of, new-onset AF and infectious complications following esophagectomy. Consecutive patients who underwent elective esophagectomy with curative intent for esophageal cancer between 2004 and 2016 in the University Medical Center Utrecht were included from a prospective database. The date of diagnosis of the complications included in the current analysis was retrospectively collected from the computerized medical record. The association between new-onset AF and infectious complications was studied in univariable and multivariable logistic regression analyses. A total of 455 patients were included. In 93 (20.4%) patients new-onset AF was encountered after esophagectomy. There were no significant differences in patient and treatment-related characteristics between the patients with and without AF. In 9 (9.7%) patients, AF was the only adverse event following surgery. In multivariable analyses, AF was significantly associated with infectious complications in general (OR 3.00, 95% CI: 1.73-5.21). More specifically, AF was associated with pulmonary complications (OR 2.06, 95% CI: 1.29-3.30), pneumonia (OR 2.41, 95% CI: 1.48-3.91) and anastomotic leakage (OR 3.00, 95% CI: 1.80-4.99). In patients who underwent esophagectomy, new-onset AF was highly associated with infectious complications. AF may serve as an early clinical warning sign for anastomotic leakage. Therefore, further evaluation of patients who develop new-onset AF after esophagectomy is warranted.