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Objective:To analyze the survival efficacy, prognostic factors and failure patterns of patients with esophageal squamous cell carcinoma (ESCC) underwent postoperative radiotherapy (PORT) using modified clinical target volume (CTV) based on postoperative high-frequency recurrence regions, so as to provide reference for the further optimization of CTV of PORT.Methods:The patients with ESCC underwent radical operation in Comprehensive Cancer Center of Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School from April 28, 2014 to November 29, 2018 were retrospectively analyzed. Patients with stage pT 3-4aN 0 or N +, who underwent PORT with modified CTV based on postoperative high-frequency recurrence regions, were included in the study. Kaplan-Meier method was used to calculate overall survival (OS) and locoregional recurrence free survival (LRFS) , adverse events of patients were evaluated, Cox proportional hazards model was used for univariate and multivariate survival analysis, and the failure patterns of patients after PORT were analyzed. Results:A total of 85 patients were included in this study, and the median follow-up time was 52.6 months. The median OS of the whole group was 74.1 months. The 1-year, 2-year and 3-year OS rates were 97.6%, 84.7% and 71.7% respectively. The median LRFS was not reached, and the 1-year, 2-year and 3-year LRFS rates were 92.9%, 78.6% and 71.5% respectively. The incidence of grade 3-4 adverse events was 17.6% (15/85) , mainly including lymphopenia, bone marrow suppression, gastrointestinal reaction and skin reaction. Univariate analysis of OS after PORT showed that the degree of differentiation (set G1+G1-2+G2 group as the control group, G2-3+G3 group HR=4.19, 95% CI: 1.91-9.17, P<0.001; NA+basal-like group HR=4.16, 95% CI: 1.29-13.44, P=0.017) and postoperative stage ( HR=2.19, 95% CI: 1.09-4.39, P=0.030) were the influencing factors of OS. Cox multivariate analysis showed that the degree of differentiation was an independent prognostic factor for OS after PORT (set G1+G1-2+G2 group as the control group, G2-3+G3 group HR=5.24, 95% CI: 2.30-11.93, P<0.001; NA+basal-like group HR=4.83, 95% CI: 1.33-17.62, P=0.017) . The first failure patterns analysis showed that 39 cases (45.9%) had recurrence, among which, 22 cases (25.9%) had locoregional recurrence with the median onset time of 15.2 months after operation, 19 cases (22.4%) had distant metastasis with the median onset time was 14.1 months after operation, and 2 cases (2.4%) were mixed failure mode. Among the locoregional recurrence, 16 cases (72.7%) recurred in the radiation field. Among all the local recurrence sites, the lymph node drainage regions in the supraclavicular, upper middle mediastinum and upper abdominal perigastric/celiac artery trunk areas were the most common sites. Among the distant metastatic organs, lung, bone and liver metastases were the most common. Conclusion:Patients of ESCC with high risk of recurrence after radical esophagectomy have long survival time and high safety after PORT with modified CTV according to the high-frequency recurrence regions. It is worthy of further confirmation by multicenter, large sample and prospective clinical trials.
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Objective To identify risk factors for postdischarge venous thromboembolism(VTE) following lung resection.Methods Patients undergoing anatomic resection for lung cancer were identified in our institution from 2005-2015.Patient demographic and clinical characteristics were evaluated for any association with post-discharge VTE.Predictors of post-discharge VTE were identified using multivariable analysis.Results VTE occurred in 1.6％ (117) of the 7 154 patients identified.43.6％ (51) VTE events occurred following hospital discharge.Undergoing pneumonectomy was associated with a threefold increased risk for post-discharge VTE compared with lobectomy(2.03％ vs.0.64％,P ＜ 0.01),as was open resection compared to minimally invasive resection(0.86％ vs.0.53％,P＜0.01).Prolonged operative time(＞75％) was also associated with increased risk for post-discharge VTE compared to shorter operative time.Multivariable analysis identified older age,obesity,pneumonectomy,and prolonged operative time as independent predictors for post-discharge VTE.Conclusion The risk for VTE extends after hospital discharge,few patients are managed with post-discharge prophylaxis.Post-discharge prophylaxis should be considered for those at high risk for VTE,particularly for older patients,those who are obese,and following extended or lengthy resections.
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Acute lung injury after thoracic surgery is the main cause of perioperative death.Acute lung injury is a complex pathophysiological process involving inflammation,characterized by non cardiogenic hypoxemia and acute exudation of the lungs in imaging.Intraoperative ventilation strategy is the most important factor of postoperative acute lung injury.The core of treatment for postoperative acute lung injury is symptomatic support,and prevention is still the most effective strategy for the management of acute lung injury.In this review,the diagnosis,pathogenesis,risk factors and treatment of post-thoracic acute lung injury are introduced,and the progress of prevention strategy and treatment are discussed and summarized.
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Objective To investigate the prognostic factors of postoperative single metastasis in patients with esophageal cancer after treatment.Methods The clinical data of patients with single lesion metastasis from 2002 to 2016 were analyzed retrospectively.Demographic and clinicopathologic data were reviewed.Predictors of PRS after definitive therapy for isolated EC recurrence were determined by the multivariable Cox proportional hazards model.Results Of the 1 016 curative esophagectomies,383 patients(37.7％) experienced recurrences(median followup 53 months).114 (11.2％) received definitive treatment of isolated EC recurrence(63 were treated surgically with or without chemotherapy-radiotherapy[CTRT] and 51 received definitive CTRT alone).Median time to recurrence(TTR) was 18 months.The 1-year and 3-year PRSs were 78.9％ and 38.6％ (median survival 28 months).On multivariable analysis;TTR was the only significant independent predictor for survival after recurrence (HR =0.982,95 ％ CI:0.95-1.03,P =0.036).No pronounced difference was found in disease-free survival or in PRS between recurrent patients treated with operation with or without CTRT and patients who received definitive CTRT.Conclusion A select subgroup of patients with isolated EC recurrence can be treated with curative intent.TTR was the best predictor for PRS.
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<p><b>OBJECTIVE</b>To explore the impact of the gastric tube diameter on quality of life of esophagus cancer patients after Ivor-Lewis esophagectomy.</p><p><b>METHODS</b>Clinical and follow-up data of 188 esophageal cancer patients who underwent Ivor-Lewis esophagectomy at Department of Cardio-Thoracic Surgery, Drum Tower Clinical Medicine College, Nanjing Medical University from January 2015 to June 2016 were retrospectively analyzed. Inclusion criteria included age <75 years old, good foundation health situation, no distant metastasis, complete follow-up data for one-year after surgery, and middle-lower esophageal squamous cell carcinoma (ESCC). According to the diameter of gastric tube formed during operation, 92 patients were assigned to narrow gastric tube group (NGT group, ≥2 cm to <4 cm), which were further divided into narrower group (≥2 cm to <3 cm, n=44) and medium narrow group (≥3 cm to <4 cm, n=48); 96 patients were assigned to wide gastric tube group(WGT group, ≥4 cm), which were further divided into medium wide group(≥4 cm to <5 cm, n=50) and wider group(≥5 cm, n=46). Postoperative patients were followed up by telephone or outpatient service for one year and then re-hospitalized to receive associated examinations, including lung function test, esophageal pressure measurement, 24-hour esophageal dynamic pH monitoring (total number of pH<4, number of pH<4 lasting more than 5 minutes, maximum duration of pH<4 and time percentage of pH<4) and dilatation measurement of gastric tube (the diameter measured by CT minus the diameter measured in surgery). During follow-up, postoperative quality of life(QoL) was assessed by questionnaire. These contents were compared and plotted as a chart.</p><p><b>RESULTS</b>There were no statistically significant differences between NGT group and WGT group regard to preoperative baseline information, postoperative pathology and postoperative complications (residual gastric leakage, anastomotic leakage, anastomotic stenosis, pulmonary complications, atrial fibrillation and chylothorax) (all P>0.05). Compared with WGT group, the NGT group had better postoperative lung function, including percentage of vital capacity [(76.4±6.8)% vs. (73.2±7.7)%, t=2.168, P=0.033], percentage of maximal voluntary ventilation [(72.7±6.4)% vs. (69.3±6.8)%, t=2.409, P=0.018] and percentage of forced expiratory volume in the first second [(69.2±5.0)% vs. (66.7±6.2)%, t=2.033, P=0.045], higher plane pressure of anastomotic stoma [(5.4±3.1) mmHg vs. (4.2±2.4) mmHg, t=2.083, P=0.038], greater dilatation of gastric tube [(1.0±0.4) cm vs. (0.5±0.3) cm, t=5.888, P=0.000], milder gastroesophageal reflux according to the indices of 24-hour esophageal dynamic pH monitoring, including the total number of pH<4 (228.3±65.3 vs. 280.8±103.9, t=-2.920,P=0.004), the number of pH<4 lasting more than 5 minutes (19.9±8.5 vs. 30.6±15.6, t=-4.127,P=0.000), the maximum duration of pH<4[(32.5±9.4) minutes vs. (37.9±13.6) minutes, t=-2.232,P=0.028] and the time percentage of pH<4 [(23.4±10.2)% vs. (28.4±10.6)%, t=-2.303, P=0.024]. However, no significant difference was found in the scores of postoperative QoL between the two groups(P=0.051). According to the pairwise comparisons among the four subgroups, narrower group showed better performance on postoperative lung function, plane pressure of anastomotic stoma, the dilatation of gastric tube, indices of 24-hour esophageal dynamic pH monitoring and scores of postoperative QoL as compared to wider group (all P<0.05). There were no statistically significant differences among medium narrow group, medium wide group and wider group. Line charts showed that the larger of the gastric tube diameter, the worse of the postoperative lung function, the more severe of gastroesophageal reflux and the smaller degree of gastric tube dilatation.</p><p><b>CONCLUSION</b>Narrow gastric tube with a diameter of 2-4 cm can improve the postoperative QoL of esophagus cancer patients after Ivor-Lewis esophagectomy without increasing the risk of postoperative complications.</p>
Subject(s)
Aged , Humans , Middle Aged , Enteral Nutrition , Esophageal Neoplasms , General Surgery , Esophagectomy , Postoperative Complications , Quality of Life , Retrospective StudiesABSTRACT
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common hereditary cerebral small vessel disease.NOTCH3 missense mutation causes its coded cysteine occurring odd change and then affects the conformation and function of protein of NOTCH3.The abnormal NOTCH3 protein has vascular smooth muscle toxicity and finally deposits in the cerebral small blood vessels and causes the disease.Usually,CADASIL can be suspected by its typical clinical manifestations and neuroimaging findings.Its diagnosis needs genetic testing or skin biopsy to find the outer granular osmiophilic deposits of small vascular smooth muscle cells or immunohistochemical NOTCH3-ECD staining positive.For nearly two decades,the studies on genetics,pathogenesis,clinical manifestations,and diagnostic techniques of CADASIL have made great progress,however,many important questions have not been fully clarified and have new discoveries,such as the NOTCH3 gene mutation pattern and loci,and the relationship between gene phenotype and clinical phenotype,optimization of diagnosis process,depth study of pathogenic mechanism,exploration of new discoveries,new therapeutic targets and concepts.This article reviews the genetic characteristics,pathogenesis,and clinical diagnosis and treatment technology of CADASIL.
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<p><b>BACKGROUND</b>To maximize the preservation of functional pulmonary parenchyma, extend the indication of lung cancer operation and improve the life quality of patients with central lung cancer, reconstruction of carina, bronchoplasty and arterioplasty are widely used with good efficacy. The aim of this study is to summarize the clinical results of reconstruction of carina, bronchoplasty and arterioplasty in the treatment of 79 patients with central lung cancer.</p><p><b>METHODS</b>From June, 1988 to June, 2005, reconstruction of carina, bronchoplasty and arterioplasty were carried out in 79 patients with central lung cancer. The ope- rations included single sleeve lobectomy in 58 cases, double sleeve lobectomy in 15 cases, carinal resection and reconstruction in 6 cases.</p><p><b>RESULTS</b>There was no operative death in this series. Seven patients had operative complications and the operative complication rate was 8.86% (7/79). The 1-, 3-, 5- and 10-year survival rates were 78.5%, 59.5%, 35.4% and 17.7% respectively.</p><p><b>CONCLUSIONS</b>Reconstruction of carina, bronchoplasty and arterioplasty can significantly protect pulmonary function, improve the prognosis and increase the curative rate and long term survival in patients with central lung cancer.</p>
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Objective To summarize the clinical results of combined procedure of resections and constructions of bronchus,great vessels and heart in the treatment of 79 patients with central lung cancer.Methods From Jun,1988 to Jun,2005,the combined procedure of resections and constructions of bronchus,great vessels and heart were carried out in 74 patients with central lung cancer.The operations included ring of bronchus or sleeve lobectomy in 57 cases,double sleeve lobectomy in 15 cases,carinal resection and reconstruction in 4 cases.Results There was no operative deaths and 7(8.86 %) patients had operative complications.The survival rates of 12,36,60 months and 10 years were 78.5%,59.5%,35.4% and 17.7% respectively.Conclusion With the treatment of sleeve lobectomy or combined with resection and reconstruction of pulmonary artery,great vessels or heart,the pulmonary function can be protected significantly,and the cure rate and the long term survival rate can be improved in patients with central lung cancer.