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Esophagectomy has long been considered the standard of care for early-stage (≤ T2N0) esophageal cancer. Minimally invasive esophagectomy (MIE), using a combined laparoscopic and thoracoscopic approach, was first performed in the 1990s and showed significant improvements over open approaches. Refinement of MIE arrived in the form of robotic-assisted minimally invasive esophagectomy (RAMIE) in 2004. MIE is a challenging procedure for which consensus on optimal technique is still elusive. Although nonrobotic MIE confers significant advantages over open approaches, MIE remains associated with stubbornly high rates of complications, including pneumonia, aspiration, arrhythmia, anastomotic leakage, surgical site infection, and vocal cord palsy. RAMIE was envisioned to improve operative-associated morbidity while achieving equivalent or superior oncologic outcomes to nonrobotic MIE. However, owing to RAMIE's significant upfront costs, steep learning curve, and other requirements, adoption remains less than widespread and convincing evidence supporting its use from well-designed studies is lacking. In this review, we compare operative, oncologic, and quality-of-life outcomes between open esophagectomy, nonrobotic MIE, and RAMIE. Although RAMIE remains a relatively new and underexplored modality, several studies in the literature show that it is feasible and results in similar outcomes to other MIE approaches. Moreover, RAMIE has been associated with favorable patient satisfaction and quality of life.
RESUMEN
BACKGROUND: More than one-half of patients treated with esophagectomy for esophageal cancer experience recurrence. Oligometastasis, a proposed intermediate state of isolated local or solid organ recurrence that occurs before widespread systemic disease, is a potential target for aggressive local intervention. This study investigated presentation and prognosis among solid organ recurrence sites. METHODS: Patients with isolated solid organ recurrence at the liver, lung, or brain who underwent R0 esophagectomy from 1995 to 2016 were identified. Clinicopathologic characteristics and outcomes were compared among sites of recurrence. Overall survival was quantified using the Kaplan-Meier approach and Cox proportional hazards models. RESULTS: In total, 104 patients were included (site: brain, 37; lung, 27; liver, 40). Eighty percent of liver, 51% of brain, and 44% of lung oligometastases occurred in the first 12 months after esophagectomy. Despite the limited use of aggressive therapy, patients with lung oligometastasis had significantly longer median overall survival (2.41 years; 95% confidence interval [CI], 1.58 to 3.31) than did patients with brain (0.95 years; 95% CI, 0.62 to 1.49) or liver (0.95 years; 95% CI, 0.82 to 1.41) oligometastasis (P < .001). This difference remained after patient and tumor characteristics were adjusted for (brain: hazard ratio, 4.48; 95% CI, 2.24 to 8.99; liver: hazard ratio, 2.94; 95% CI, 1.48 to 5.82). CONCLUSIONS: Presentations and prognoses differ by site of esophageal cancer recurrence. Lung oligometastases are associated with a more indolent course, and patients with these lesions may benefit from more aggressive treatment to improve their more favorable outcomes further. These differences by site of recurrence advocate for moving beyond a standardized palliative approach to all esophageal cancer recurrences.
Asunto(s)
Adenocarcinoma/secundario , Neoplasias Encefálicas/secundario , Neoplasias Esofágicas/cirugía , Esofagectomía/efectos adversos , Neoplasias Hepáticas/secundario , Neoplasias Pulmonares/secundario , Estadificación de Neoplasias , Adenocarcinoma/diagnóstico , Adenocarcinoma/cirugía , Anciano , Neoplasias Encefálicas/diagnóstico , Neoplasias Encefálicas/mortalidad , Supervivencia sin Enfermedad , Neoplasias Esofágicas/diagnóstico , Femenino , Humanos , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/etiología , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/mortalidad , Masculino , Persona de Mediana Edad , Metástasis de la Neoplasia , Recurrencia Local de Neoplasia , Pronóstico , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Induction 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. METHODS: We 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. RESULTS: We 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 (p = 0.006). Recurrence-free survival was 65% for N- patients and 32% for N+ patients (p = 0.0043). Univariable analysis identified vascular invasion and neural invasion as risk factors for nodal metastasis. Multivariable analysis identified vascular invasion as an independent predictor of pathologic nodal involvement. CONCLUSIONS: EUS is inaccurate for staging of T2N0 esophageal adenocarcinoma and often fails to identify nodal involvement. Identification of vascular invasion on preoperative biopsy should be explored as a prognostic marker to select patients for induction therapy.
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Adenocarcinoma/patología , Adenocarcinoma/cirugía , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Esofagectomía/métodos , Ganglios Linfáticos/patología , Adenocarcinoma/diagnóstico por imagen , Adenocarcinoma/mortalidad , Anciano , Instituciones Oncológicas , Estudios de Cohortes , Supervivencia sin Enfermedad , Endosonografía/métodos , Neoplasias Esofágicas/diagnóstico por imagen , Neoplasias Esofágicas/mortalidad , Esofagectomía/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Ganglios Linfáticos/cirugía , Metástasis Linfática , Masculino , Persona de Mediana Edad , Análisis Multivariante , Invasividad Neoplásica/patología , Estadificación de Neoplasias , Valor Predictivo de las Pruebas , Pronóstico , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Medición de Riesgo , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUNDS AND AIMS: As 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. METHODS: Combining 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. RESULTS: In 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 ≥ 6 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 (p < 0.001). Compliance with QIs was better for EUS reports: 71% of OSH reports and 72% of MSK reports were good quality. CONCLUSIONS: Detailed 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.
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Documentación/normas , Endoscopía Gastrointestinal , Endosonografía , Neoplasias Esofágicas/diagnóstico por imagen , Adhesión a Directriz/estadística & datos numéricos , Registros Médicos/normas , Anciano , Neoplasias Esofágicas/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Indicadores de Calidad de la Atención de SaludRESUMEN
BACKGROUND: In the USA, a quarter of elderly patients do not receive any treatment for regional gastric cancer, which results in poorer outcomes. We sought to identify factors associated with undertreatment of regional gastric cancer in this population, as well as to assess overall survival in the undertreated population. METHODS: Elderly patients (aged ≥ 65 years) diagnosed with regional gastric cancer between 2001 and 2009 were identified from the Surveillance Epidemiology and End Results (SEER)-Medicare linked databases. Treatment was defined as receiving any medical or surgical therapy for gastric cancer. Logistic regression analysis was used to identify factors associated with failure to receive treatment. Overall survival was analyzed using the Kaplan-Meier method and Cox proportional hazard model. RESULTS: Of 5972 patients with regional gastric cancer, 1586 (26.5%) received no treatment. Median age was 78 years; 56.1% of patients were men. On multivariable analysis, the factors strongly associated with lack of therapy were age ≥ 80 years, black race, lower education level, and diagnosis before 2007. As expected, patients who received therapy had better overall survival (log-rank test, p < 0.001). Specifically, median survival and 5-year survival were 16.5 months and 20.5% for treated patients, compared with 9.1 months and 19.0% for untreated patients. CONCLUSIONS: Elderly patients with gastric cancer have better overall 5-year survival after receiving treatment for their cancer. Disparities in the use of treatment for curable cancers are associated with older age, black race, lower educational level, and diagnosis before 2007.