Low-Dose Radiation Yields Lower Rates of Pathologic Response in Esophageal Cancer Patients.

BACKGROUND: Although neoadjuvant chemoradiation (nCRT) followed by surgery is standard treatment for locally advanced esophageal or gastroesophageal junction (E/GEJ) cancer, the optimal radiation dose is still under debate. OBJECTIVE: The aim of this study was to assess the impact of different preoperative radiation doses (41.4 Gy, 45 Gy or 50.4 Gy) on pathologic response and survival in E/GEJ cancer patients. METHODS: All consecutive patients with E/GEJ tumors, treated with curative intent between January 2009 and December 2016 in two referral centers were divided into three groups (41.4 Gy, 45 Gy and 50.4 Gy) according to the dose of preoperative radiotherapy. Pathologic complete response (pCR) rates, postoperative morbidity, overall survival (OS) and disease-free survival (DFS) were compared among the three groups, with separate analyses for adenocarcinoma (AC) and squamous cell carcinoma (SCC). RESULTS: From the 326 patients analyzed, 48 were included in the 41.4 Gy group (14.7%), 171 in the 45 Gy group (52.5%) and 107 in the 50.4 Gy group (32.8%). Postoperative complication rates were comparable (p = 0.399). A pCR was observed in 15%, 30%, and 34% of patients in the 41.4 Gy, 45 Gy and 50.4 Gy groups, respectively (p = 0.047). A 50.4 Gy dose was independently associated with pCR (odds ratio 2.78, 95% confidence interval 1.10-7.99) in multivariate analysis. Within AC patients, pCR was observed in 6.2% of patients in the 41.4 Gy group, 29.2% of patients in the 45 Gy group, and 22.7% of patients in the 50.4 Gy group (p = 0.035). No OS or DFS differences were observed. CONCLUSIONS: A pCR was less common after a preoperative radiation dose of 41.4 Gy in AC patients. Radiation dose had no impact on postoperative morbidity, long-term survival, and recurrence.

Incidence and Risk Factors for Diaphragmatic Herniation Following Esophagectomy for Cancer.

OBJECTIVE: To evaluate the incidence and risk factors of diaphragmatic herniation following esophagectomy for cancer (DHEC), and assess the results of surgical repair. SUMMARY BACKGROUND DATA: The current incidence of DHEC is discussed with conflicting data regarding its treatment and natural course. METHODS: Monocentric retrospective cohort study (2009-2018). From 902 patients, 719 patients with a complete follow-up of CT scans after transthoracic esophagectomy for cancer were reexamined to identify the occurrence of a DHEC. The incidence of DHEC was estimated using Kalbfleisch and Prentice method and risk factors of DHEC were studied using the Fine and Gray competitive risk regression model by treating death as a competing event. Survival was analyzed. RESULTS: Five-year DHEC incidence was 10.3% [95% CI, 7.8%-13.2%] (n = 59), asymptomatic in 54.2% of cases. In the multivariable analysis, the risk factors for DHEC were: presence of hiatal hernia on preoperative CT scan (HR = 1.72 [1.01-2.94], P = 0.046), previous hiatus surgery (HR = 3.68 [1.61-8.45], P = 0.002), gastroesophageal junction tumor location (HR = 3.51 [1.91-6.45], P < 0.001), neoadjuvant chemoradiotherapy (HR = 4.27 [1.70-10.76], P < 0.001), and minimally invasive abdominal phase (HR = 2.98 [1.60-5.55], P < 0.001). A cure for DHEC was achieved in 55.9%. The postoperative mortality rate was nil, the overall morbidity rate was 12.1%, and the DHEC recurrence rate was 30.3%. Occurrence of DHEC was significantly associated with a lower hazard rate of death in a time-varying Cox's regression analysis (HR = 0.43[0.23-0.81], P = 0.010). CONCLUSIONS: The 5-year incidence of DHEC is 10.3% and is associated with a favorable prognosis. Surgical repair of symptomatic or progressive DHEC is associated with an acceptable morbidity. However, the optimal surgical repair technique remains to be determined in view of the large number of recurrences.

Early postoperative decrease of albumin is an independent predictor of major complications after oncological esophagectomy: A multicenter study.

BACKGROUND AND OBJECTIVES: Serum albumin perioperative decrease (∆Alb) may reflect the magnitude of the physiological stress induced by surgery. Studies highlighted its value to predict adverse postoperative outcomes, but data in esophageal surgery are scant. This study aimed to investigate the role of ∆Alb to predict major complications after esophagectomy for cancer. METHODS: Multicenter retrospective study conducted in five high-volume centers, including consecutive patients undergoing an esophagectomy for cancer between 2006 and 2017. Patients were randomly assigned to a training (n = 696) and a validation (n = 350) cohort. Albumin decrease was calculated on postoperative day 1 and defined as ΔAlb. The primary endpoint was major complications according to Clavien classification. RESULTS: In the training cohort, esophagectomy induced a rapid drop of albumin. Cut-off of ΔAlb was established at 11 g/L and allowed to distinguish patients with adverse outcomes. On multivariable analysis, ΔAlb was identified as an independent predictor of major complications (OR, 1.06; 95% CI, 1.01-1.11; p = .014). Higher BMI and laparoscopy were associated with lower ΔAlb. Analysis of the validation cohort provided consistent findings. CONCLUSIONS: ΔAlb appeared as a promising biomarker after oncological esophagectomy, allowing prediction of potential adverse outcomes.