Tamar B. Nobel

Anastomotic Complications After Esophagectomy: Frequency, Prevention, and Management

Abstract This chapter examines the etiology, diagnostic techniques, and treatment approaches of anastomotic complications after esophagectomy. An understanding of these much feared events may help mitigate the impact of the associated negative clinical sequelae. Anastomotic leak has a wide variation in presentation, from an incidental radiologic finding to a catastrophic septic event. Patients should be adequately resuscitated, and further management is dependent upon the location of the leak and clinical presentation. Mild cases may be observed or managed with local drainage. The most severe cases are conduit necrosis. In suspected cases, direct visualization of the conduit is necessary, and subsequent resection must be performed if the diagnosis is confirmed. Anastomotic leak is a frequent cause of anastomotic stricture; however, later presentation must raise suspicion for tumor recurrence. In benign cases, endoscopic dilation is often sufficient. Leaks are also a frequent cause of conduit airway fistulas. Such events are rare but are life threatening and must rapidly be identified. In such cases, a trial of conservative treatment may be pursued with subsequent endoscopic therapy and, ultimately, surgical resection if this is not successful.

Neutrophil to Lymphocyte Ratio as Predictor of Treatment Response in Esophageal Squamous Cell Cancer

BACKGROUNDnThe aim of this study was to assess the difference (Δ) in neutrophil to lymphocyte ratio (NLR), before and after chemoradiotherapy, as a predictor of treatment response and a prognostic factor for recurrence and disease-free survival in patients with esophageal squamous cell cancer treated with chemoradiotherapy with or without surgery.nnnMETHODSnPatients with locally advanced esophageal squamous cell cancer treated with chemoradiation with and without surgery who had a complete blood count before and after chemoradiotherapy were included. Pretreatment and posttreatment NLR were calculated by dividing the absolute neutrophil count by the absolute lymphocyte count. The ΔNLR was defined as posttreatment minus pretreatment NLR. Characteristics were evaluated for association with ΔNLR using the Wilcoxon signed rank test or the Kruskal-Wallis test. Risk of recurrence and disease-free survival were evaluated using Grays and the log rank tests, respectively.nnnRESULTSnWe included 217 patients. Of them, 133 patients (61.3%) received only chemoradiotherapy and 84 (38.7%) underwent surgery after chemoradiotherapy. Among the surgical patients, 43% with pathologic complete response showed significantly lower median ΔNLR than patients with residual disease (-0.03 versus 1.04, pxa0= 0.004). High ΔNLR was a negative predictor of treatment response (odds ratio 0.77, 95% confidence interval: 0.62 to 0.9, pxa0= 0.004). A significant association between high ΔNLR and increased risk of recurrence was also identified.nnnCONCLUSIONSnThe ΔNLR was inversely related to pathologic complete response and associated with risk ofxa0recurrence. This simple test, in concert with other clinical tools, can help identify patients with pathologic complete response.

Predictors of Nodal Metastases for Clinical T2N0 Esophageal Adenocarcinoma

BACKGROUNDnInduction therapy has not been proven to be beneficial for patients with clinical T2N0 esophageal adenocarcinoma. Surgery alone is associated with disappointing survival for patients found to have nodal disease on final pathologic examination. The aim of this study was to identify factors that predict pathologic nodal involvement in patients with endoscopic ultrasound (EUS)-proven T2N0 esophageal adenocarcinoma.nnnMETHODSnWe retrospectively reviewed patients with EUS-staged T2N0 (uT2N0) esophageal adenocarcinoma treated with surgery alone. Final pathologic staging was compared with clinical staging. Demographic and clinicopathologic variables were evaluated as putative risk factors for nodal metastases. Logistic regression models were used to identify factors associated with nodal involvement. Kaplan-Meier analysis was performed to compare overall and recurrence-free survival between patients with (N+) and without (N-) nodal disease.nnnRESULTSnWe identified 80 patients with uT2N0 esophageal adenocarcinoma treated with surgery alone. Clinical staging with EUS was inaccurate for 73 patients (91%). Twenty-eight patients (35%) had pathologic N+ disease at resection. Five-year overall survival was 67% for N- patients and 41% for N+ patients (pxa0= 0.006). Recurrence-free survival was 65% for N- patients and 32% for N+ patients (pxa0= 0.0043). Univariable analysis identified vascular invasion and neural invasion as risk factors for nodal metastasis. Multivariable analysis identified vascular invasion asxa0an independent predictor of pathologic nodal involvement.nnnCONCLUSIONSnEUS is inaccurate for staging of T2N0 esophageal adenocarcinoma and often fails to identifyxa0nodal involvement. Identification of vascular invasion on preoperative biopsy should be explored as a prognostic marker to select patients for induction therapy.

Restaging After Neoadjuvant Therapy

Neoadjuvant therapy has been demonstrated to improve overall (OS) and disease-free survival (DFS) in patients undergoing surgical resection for locally advanced esophageal cancer. Restaging after treatment has an important role in therapeutic decision-making and determining patient prognosis. Available methodologies most often utilize a combination of endoscopy and imaging in characterization of treatment response. While endoscopic ultrasound (EUS) is routinely used in initial staging, resultant inflammation and fibrosis after treatment challenges the utility of this modality in restaging. Endoscopic biopsy similarly has a limited benefit in the assessment of treatment response. Change in metabolic response on 18-fluorodeoxyglucose-positron emission tomography/computed tomography (FDG- PET/CT) on pre- and post-treatment imaging has been demonstrated may help predict tumor regression, and consequently, patient survival. Adoption of an approach utilizing FDG-PET response to adjust neoadjuvant chemotherapy has been observed to result in an increase in the rate of pathologic complete response (pCR) and progression-free survival. Current diagnostic tools enable differentiation between responders versus nonresponders to neoadjuvant therapy; however, they remain limited in their ability to identify therapeutic response.

Outcomes of Radiation-Associated Esophageal Squamous Cell Carcinoma: The MSKCC Experience

ObjectiveEsophageal squamous cell carcinoma (ESCC-R) is a rarely encountered sequela of chest radiation. Treatment is limited by toxicity with reirradiation and complex surgical dissection in a previously radiated field. The clinical presentation, prognosis, and treatment selection of ESCC-R remain undefined.MethodsA retrospective review of patients with esophageal squamous cell carcinoma at a single institution between 2000 and 2017 was performed to identify patients with previous radiation therapy (≥u20095xa0years delay). Clinicopathologic characteristics, treatment, and outcomes of ESCC-R (nu2009=u200969) patients were compared to patients with primary esophageal squamous cell carcinoma (ESCC) (nu2009=u2009827). Overall survival (OS) and cumulative incidence of recurrence (CIR) were compared using log-rank and Gray’s tests, respectively.ResultsMedian time from radiation to ESCC-R was 18.2xa0years. The majority of ESCC-R patients werexa0female and presented with earlier disease and decreased behavioral risk factors. ESCC-R treated with surgery alone had worse OS than ESCC (5-year 15 vs 33%; pu2009=u20090.045). Patients with ESCC-R who received neoadjuvant treatment had higher risk of postoperative in-house mortality (16.7 vs 4.2%; pu2009=u20090.032). Patients with ESCC-R treated with surgery alone and definitive chemoradiation had higher recurrence risk than those with neoadjuvantu2009+u2009surgery (5-year recurrence 55 and 45 vs 15%; pu2009=u20090.101).ConclusionNeoadjuvant chemotherapy or chemoradiation should be used whenever possible for ESCC-R as it is associated with lower risk of recurrence. The improved survival benefits of aggressive treatment must be weighed against the higher associated postoperative risks.

Quality of Endoscopy Reports for Esophageal Cancer Patients: Where Do We Stand?

Backgrounds and AimsAs treatment for esophageal cancer often involves a multidisciplinary approach, the initial endoscopic report is essential for communication between providers. Several guidelines have been established to standardize endoscopic reporting. This study evaluates the compliance of esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS) reporting with the current national guidelines.MethodsCombining the National Comprehensive Cancer Network and Society of Thoracic Surgeons guidelines, 11 quality indicators (QIs) for EGD and 8 for EUS were identified. We evaluated initial EGD and EUS reports from our institution (Memorial Sloan Kettering [MSK]) and outside hospitals (OSHs) and calculated individual and overall quality measure scores. Scores between locations were compared using the Wilcoxon signed-rank test and McNemar’s test for paired data.ResultsIn total, 115 initial EGD reports and 105 EUS reports were reviewed for patients who underwent surgery for esophageal cancer between 2014 and 2016. The median number of QIs reported for the initial EGD was 4 (IQR, 3–6)—only 34% of reports qualified as “good quality” (those with ≥u20096 QIs). None of the reports included all QIs. For patients who underwent EGD at both MSK and an OSH, 32% of reports from OSHs were good quality, compared with 68% from MSK (pu2009<u20090.001). Compliance with QIs was better for EUS reports: 71% of OSH reports and 72% of MSK reports were good quality.ConclusionsDetailed information on the initial endoscopic assessment is essential in today’s age of multidisciplinary care. Identification and adoption of QIs for endoscopic reporting is warranted to ensure the provision of appropriate treatment.

Testing the waters of adjuvant chemotherapy after esophagectomy

Esophageal cancer continues to be associated with a high mortality rate despite significant advances in the therapeutic treatment over the past 15 years; in patients with resectable tumors, a 15–25% rate of 5-year overall survival (OS) has been reported (1). Multimodality therapy has been demonstrated to be beneficial in improving survival for patients with locally advanced disease. Options include chemotherapy and radiation, either alone or in combination, administered before or after esophagectomy. When considering the utility of adjuvant chemotherapy (aCT) in esophageal cancer, it is important to understand current areas of debate pertaining to multimodality therapy.