ABSTRACT
Introduction: Achalasia is a motility disorder of the esophagus characterized by impaired relaxation of the lower esophageal sphincter and loss of peristalsis in the distal esophagus. It is a rare condition with an annual incidence of 0.5-1.2 per 100,000 individuals. The etiology of primary achalasia is unknown, however secondary achalasia can be attributed to malignancy, infections or systemic diseases such as amyloidosis. An infrequent complication of achalasia is esophageal squamous cell carcinoma which has a prevalence of 26 in every 1,000 cases. We present a case of interval locoregionally advanced esophageal squamous cell carcinoma only 2 years after a normal upper endoscopy. Case Description/Methods: A 67-year-old female with known achalasia and previous pneumatic dilation in her 30s presented to our outpatient clinic in 2019 with complaints of worsening chronic dysphagia. EGD was performed which revealed a significantly dilated esophagus with candida esophagitis. Despite completing antifungal therapy, she continued to experience dysphagia to solids and liquids. Barium swallow demonstrated absent peristalsis with pooling of contrast within the esophagus. High-Resolution Manometry testing demonstrated absent peristalsis. She opted for surgical myotomy, however due to COVID restrictions, the procedure was delayed. Repeat EGD was performed in 2022 for pre-surgical evaluation and showed a large obstructing friable esophageal mass in the lower third of the esophagus. Pathology was consistent with invasive poorly differentiated squamous cell carcinoma. PET scan showed locoregional disease with FDG-avid esophageal and gastrohepatic node lesions. She was started on chemoradiation with Paclitaxel and Carboplatin (Figure). Discussion(s): The risk of esophageal squamous cell carcinoma in achalasia has significantly increased with incidence of approximately 1 in 300 patients. The presumed mechanism of malignancy in achalasia is poor emptying resulting in food stasis, bacterial overgrowth and inflammation leading to dysplasia and development of carcinoma. Given the relatively low incidence, there are currently no guidelines on routine endoscopic screening to assess for malignancy in patients with achalasia. Survival rates are poor as patients are often diagnosed at advanced stages. This case aims to illustrate the importance and need for interval screening in individuals with long standing achalasia to improve outcomes.
ABSTRACT
Introduction: Patients (pts) with metastatic cancers undergoing treatment are considered a high risk group for infection and potentially inferior outcome during the SarsCov2 pandemic. Currently no data have been published on the test rate, infection rate, efects on treatment and potential outcome. Here we present data from four prospective cohort studies (cancer registries) addressing these questions. Method(s): MYRIAM (multiple myeloma (MM), NCT03308474), OPAL (advanced breast cancer (ABC), NCT03417115), CARAT (advanced or metastatic renal cell carcinoma (mRCC), NCT03374267) and SAPHIR (gastric/oesophageal cancer (ESCC, GAC or GEJAC), NCT04290806) are prospective, observational, open, multicentre, interdisciplinary and intersectional clinical registries that collect data on all (sequential) treatments, patient and tumour characteristics, clinical and patient-reported outcomes in about 200 hospitals and ofce-based practices in Germany. Pts are recruited at start of treatment. In April 2nd 2020 data collection was updated regarding testing for SarsCov2, test results, efects on cancer treatment and outcome for all patients newly recruited, under observation or deceased afer March 1st 2020. Interim results as by June 17th have been summarised here and will be updated regarding further details with a data cut on August 31st 2020. Result(s): Until data cut for this snapshot analysis the question regarding testing had been answered for a total of 239 pts in the four projects (94 ABC, 72 MM, 46 RCC, 27 GAC/ESCC/GEJAC). Of these a total of 56 pts (23%) had been tested for a SarsCov2 infection and 5 patients (2% and 9% of those tested) had been tested positive. Further results on the test rate, severity of symptoms at diagnosis, course of disease and consequences on the cancer treatment will be analysed and presented with an updated data cut when about 500 pts are expected to have been documented. Conclusion(s): First data on SarsCov2 testing in patients with advanced cancers in Germany reveals that this high risk group had access to testing and that positive cases were identifed in routine care. While these first interim data have to be interpreted with caution, they proof that quick implementation of relevant new variables into existing cohort studies is feasibly and important to address urgent questions regarding the care of cancer patients.
ABSTRACT
A multimodality treatment conference with experts from across East Asia was held to establish a consensus for conversion therapy. An agreement was reached that conversion therapy was defined as surgery or chemoradiotherapy (CRT) aiming at cure after initial treatment for tumors that were initially unresectable due to adjacent organ invasion or distant metastasis.
ABSTRACT
Introduction: The novel coronavirus firstly emerged in Wuhan, People's Republic of China, in December 2019. On March 11th, 2020 the World Health Organization (WHO) declared COVID-19 was spreading as a pandemic. In Argentina, the first outbreak of infection was identified on March 3rd, 2020. Since April 2020, the assistance activity changed progressively with the suspension of elective surgeries and giving priority to urgent cases and emergencies. The objective of the present study is to retrospectively analyze two groups of patients with metastatic spinal pathology surgery, before and after the diagnosis of the first SARS-CoV-19 case in Argentina. The hypothesis is that patients with metastatic spinal pathology present a more advanced neurological state (Frankel scale) at the time of surgery than before the pandemic, due to SARS-CoV-19. Material and Methods: The present is a retrospective observational study of surgically treated patients from January 1st, 2016 to May 15th, 2021 with a diagnosis of metastatic spinal pathology. Data collected: age, sex, comorbidities, neurological status (Frankel scale), Tomita and Tokuhashi scores, SINS score, ESCC scale, days of hospitalization, complications, type of discharge, mortality and unscheduled hospital readmission, number of spinal metastases and type of surgery. A comparative analysis between two groups which were treated surgically before and after the appearance of the first SARS-CoV 19 case in Argentina was performed in order to evaluate the impact of SARS-CoV-19 spreading in patients with surgery for metastatic spinal pathology Results: A total of 20 surgical procedures were analyzed, 9 patients in the Covid group and 11 patients in the no-Covid group. The analysis showed no statistically significant difference in: days of hospitalization, reoperation within 30 days, mortality within 30 days after surgery, mortality within 90 days after surgery, unscheduled hospital readmission at 90 days, SINS score, epidural spinal cord compression (ESCC) scale, Frankel scale preoperative and Frankel scale postoperative, and number of spinal metastases at diagnosis (p = 0399, p = 0.178, p = 0.353;p = 0.769, p = 0.881, p = 0.199). Significant differences were observed in unscheduled hospital readmissions at 30 days (p = 0.024). 55% of the patients in the Covid group were readmitted to the hospital within 30 days. One of the patients died related to covid within 90 postoperative days. Proportionally in time, more patients were surgically treated since the pandemic was confirmed in Argentina than before it. Conclusion: During the SARS-CoV-19 pandemic lockdown, more surgeries were performed for metastatic spinal pathology in our hospital in comparison to previous months. Our hypothesis was not proven, since no statistically significant differences were found in the groups regarding the preoperative Frankel scale. As a main limitation, the sample was small, with only 20 patients. Despite this, we believe that this one could be a preliminary investigation to carry out multicenter research and obtain results about spinal oncologic surgery in Argentina and Latin America during the pandemic lockdown.
ABSTRACT
Background and aim: Covid-19 has had a devastating global impact and resulted in over 4.4 million directly attributed deaths. The UK entered lockdown in March 2020, redistributing its medical workforce and resources. Early estimations suggested at least 4700 extra cancer deaths at 5 years if there was a 3-month delay to surgery. Delays to diagnosis and treatment for esophagogastric (EG) cancers can be particularly detrimental to survival. The aim of this study is to assess the impact of Covid-19 on new cancer referrals to a centralised UK EG cancer centre, including presentation, decision making and treatment. Methods: Patients with EG cancer referred to a tertiary, high-volume centre between March 2019 and March 2021 were reviewed. Patients were stratified into Pre-covid (March 2019-March 2020) and Covid (March 2020- 2021) cohorts. Number of new referrals, clinical stage, treatment decision, and time to treatment were compared for gastric adenocarcinoma (GA), esophagogastric-junction adenocarcinoma (EGJA), esophageal adenocarcinoma (EA) and esophageal SCC (ESCC). Results: There was an 11% reduction in new cancer referrals (485 vs 431). GA, EGJA and EA did not have significant change in treatment intent, although there was a significant increase in the decision for definitive nonsurgical treatment of EA (P = 0.046). GA and EA patients had a small, but significant increase in average clinical stage at presentation (P < 0.05). There was no increase in time to treatment for GA, EGJA and EA. A significantly higher proportion of ESCC patients were given curative intent treatment in the Covid-19 cohort (P = 0.0006) however, this was accompanied with an increased time to treatment (35.8 days vs 27.9 days P = 0.0198). Conclusion: This high-volume centre has seen a reduction in new cancer referrals since the first UK lockdown. This was associated with a small, but significant, increase in clinical stage of GA and EA at presentation. This may represent an early indication of excess esophagogastric cancer deaths due to the impact of Covid-19. This data also confirms initial results showing that oncological decisions were not compromised, although Covid-19 remains a dynamic challenge.
ABSTRACT
BACKGROUND: During the coronavirus disease 2019 (COVID19) pandemic, pedicle flaps (instead of free flaps) were recommended for reconstruction following wide resection for patients with head and neck cancer, in order to reduce the use of medical resources. Currently, there are no established treatment guidelines for patients with head and neck cancer with synchronous esophageal cancer. CASE REPORT: We present a 68-year-old male with cT4aN2cM0 oral floor and synchronous cT1bN1M0 esophageal cancers who had defective reconstruction following oral tumor resection before esophagectomy during the pandemic. At the initial surgery, the oral resected defect was reconstructed using supraclavicular artery flap. The subsequent esophagectomy was reconstructed by gastric tube reconstruction. Both postoperative courses were successful, without the need for postoperative ventilator use. The days from initial or second surgery to discharge were 14 or 16 days, respectively. CONCLUSION: This case had achieved negative surgical margins and recovered oral intake with tracheostomy decannulation. Further case accruement using supraclavicular artery flap is required for patients with head and neck cancer and synchronous esophageal cancer.
Subject(s)
COVID-19 , Head and Neck Neoplasms , Plastic Surgery Procedures , Aged , Arteries , Esophagectomy , Humans , Male , Pandemics , SARS-CoV-2ABSTRACT
BACKGROUND: The outbreak of the coronavirus disease 2019 (COVID-19) pandemic imposed limitations for elective surgery, impacting the associated hospital standards worldwide. As certain treatment windows must be adhered to in oncological surgery, the limited intensive care unit (ICU) capacity had to be critically distributed in order to do justice to both acutely ill and oncology patients. This manuscript summarizes the impact of COVID-19 on the management of oncological surgery of the upper gastrointestinal tract and particularly esophageal surgery in German medical centers. MATERIAL AND METHODS: A survey of German centers for esophageal surgery was performed on the impact of COVID-19 on operative management for esophageal surgery during the first lockdown. After inspection, assessment, critical analysis and interpretation, the results were compared to the international literature. RESULTS AND DISCUSSION: Initial recommendations of international societies warned for caution and restraint regarding interventions of the upper gastrointestinal tract that were not absolutely necessary. Oncological surgery should be performed under strict restrictions, especially only after negative testing for COVID-19 and only with sufficiently available personal protective equipment for the personnel. Furthermore, minimally invasive procedures were preferably not recommended. In diseases with alternative treatment options, such as definitive chemoradiotherapy of esophageal squamous cell carcinoma, these should be given priority when possible. In the further development of the pandemic, it was shown that due to a high standardization of preoperative management, postoperative results comparable to pre-pandemic times could be achieved particularly with respect to the diagnostics of infections.
Subject(s)
COVID-19 , Esophageal Neoplasms , Esophageal Squamous Cell Carcinoma , Upper Gastrointestinal Tract , COVID-19 Testing , Communicable Disease Control , Esophageal Neoplasms/surgery , Humans , SARS-CoV-2ABSTRACT
OBJECTIVE: To evaluate the efficacy and safety of neoadjuvant chemotherapy with albumin-bound paclitaxel plus cisplatin and capecitabine for locally advanced esophageal squamous cell carcinoma (ESCC). METHODS: The data of thirty-one patients with locally advanced ESCC (cT1-2N+M0, cT3-4aNanyM0) received preoperative chemotherapy with albumin-bound paclitaxel plus cisplatin and capecitabine (referred as APCC regimen) were retrospectively analysed. The primary endpoint was pathological complete response (pCR) rate. RESULTS: The median number of chemotherapy cycles with APCC regimen every 3 weeks were 4 (range: 1-6), which was completed by 23 patients. The clinical efficacy of 30 patients was evaluated and all showed reduction of tumours in varying degrees. Five patients received radiotherapy following chemotherapy. Four patients could not receive surgery due to COVID-19 pandemic. Of the 24 patients who underwent surgery, 3 received radiotherapy following chemotherapy, the resection rate of R0 was 95.8%, 9 cases (37.5%) showed pCR and 16 cases (66.7%) showed major pathological response (MPR). Postoperative pathology of 15 cases (62.5%) were stage I (ypT0-2N0M0). Of the 21 patients who underwent surgery after neoadjuvant chemotherapy alone, 8 (38.1%) had pCR and 15 (71.4%) had MPR. The most common grade 3/4 adverse events of chemotherapy included neutropenia (35.5%) and leukopenia (9.7%). Grade 2 postoperative complications occurred in 3 (12.5%) patients. CONCLUSION: The preliminary results of this study suggest that preoperative chemotherapy with the triplet regimen of albumin-bound paclitaxel, cisplatin and capecitabine for patients with locally advanced ESCC revealed significant tumour downstage and encouraging pCR rate, with well-tolerable toxicities. The role of this regimen warrants further investigation.