Prognosis of radiotherapy for esophageal cancer in elderly patients exceeding seventy-five years old

BACKGROUND Esophageal cancer(EC)often occurs in the elderly,with approximately 33%of patients aged≥75 years at the time of diagnosis.AIM To evaluate the prognostic factors for radiotherapy(RT)in elderly patients with unresectable EC.METHODS We retrospectively analyzed the clinical characteristics,toxic reactions,and survival information of EC patients aged≥75 years who underwent intensity-modulated RT at Lu’an Hospital of Anhui Medical University between January 2016 and September 2023.Kaplan-Meier analysis was used to draw the overall survival(OS)curves,and Cox regression analysis was employed to evaluate the influence of various clinical factors on the prognosis.RESULTS A total of 139 patients were enrolled.The median follow-up time was 52.0 months.The median OS was 20.0 months.The 1-year,2-year,3-year,and 5-year OS rates were 69.8%,38.7%,28.2%,and 17.5%,respectively.Univariate analysis showed that age,radiation dose,and chemotherapy had no significant impact on prognosis.Multivariate analysis indicated that clinical stage[Ⅲ-Ⅳa vsⅠ-Ⅱ,hazard ratio(HR)=2.421,95%confidence interval(CI):1.242-4.718,P=0.009;IVb vsⅠ-Ⅱ,HR=4.222,95%CI:1.888-9.438,P<0.001),Charlson comorbidity index(CCI)(0 vs≥1,HR=1.539,95%CI:1.015-2.332,P=0.042),and nutritional risk screening 2002(NRS2002)(<3 vs≥3,HR=2.491,95%CI:1.601-3.875,P<0.001)were independent prognostic factors for OS.CONCLUSION Our results suggest that CCI and NRS2002 were independent prognostic factors of OS for unresectable elderly EC patients undergoing RT.For elderly patients with EC,full attention should be given to biological age-related indicators,such as comorbidities and nutrition,when formulating treatment protocols.These factors should be considered in future clinical practice.

Esophageal cancer screening,early detection and treatment:Current insights and future directions

Esophageal cancer ranks among the most prevalent malignant tumors globally,primarily due to its highly aggressive nature and poor survival rates.According to the 2020 global cancer statistics,there were approximately 604000 new cases of esophageal cancer,resulting in 544000 deaths.The 5-year survival rate hovers around a mere 15%-25%.Notably,distinct variations exist in the risk factors associated with the two primary histological types,influencing their worldwide incidence and distribution.Squamous cell carcinoma displays a high incidence in specific regions,such as certain areas in China,where it meets the cost-effect-iveness criteria for widespread endoscopy-based early diagnosis within the local population.Conversely,adenocarcinoma(EAC)represents the most common histological subtype of esophageal cancer in Europe and the United States.The role of early diagnosis in cases of EAC originating from Barrett's esophagus(BE)remains a subject of controversy.The effectiveness of early detection for EAC,particularly those arising from BE,continues to be a debated topic.The variations in how early-stage esophageal carcinoma is treated in different regions are largely due to the differing rates of early-stage cancer diagnoses.In areas with higher incidences,such as China and Japan,early diagnosis is more common,which has led to the advancement of endoscopic methods as definitive treatments.These techniques have demonstrated remarkable efficacy with minimal complications while preserving esophageal functionality.Early screening,prompt diagnosis,and timely treatment are key strategies that can significantly lower both the occurrence and death rates associated with esophageal cancer.

Efficacy and safety of endoscopic submucosal dissection for early gastric cancer and precancerous lesions in elderly patients

BACKGROUND With advancements in the development of endoscopic technologies,the endo-scopic submucosal dissection(ESD)has been one of the gold-standard therapies for early gastric cancer.AIM To investigate the efficacy and safety ESD in the treatment of early gastric cancer and precancerous lesions in the elderly patients.METHODS Seventy-eight elderly patients with early gastric cancer and precancerous lesions admitted to the Third Affiliated Hospital of Qiqihar Medical University were se-lected and classified into two groups according to the different surgical therapies they received between January 2021 and June 2022.Among them,39 patients treated with ESD were included in an experimental group,and 39 patients treated with endoscopic mucosal resection(EMR)were included in a control group.We compared the basic intraoperative conditions,postoperative short-term recovery,long-term recovery effects and functional status of gastric mucosa between the two groups;the basic intraoperative conditions included lesion resection,intra-operative bleeding and operation time;the postoperative short-term recovery assessment indexes were length of hospital stay and incidence of surgical complic-ations;and the long-term recovery assessment indexes were the recurrence rate at 1 year postoperatively and the survival situation at 1 year and 3 years postoper-atively;and we compared the preoperative and predischarge serum pepsinogen I(PG I)and PG II levels and PG I/PG II ratio in the two groups before surgery and discharge.RESULTS The curative resection rate and the rate of en bloc resection were higher in the experimental group than in the control group.The intraoperative bleeding volume was higher in the experimental group than in the control group.The operation time was longer in the experimental group than that in the control group,and the rate for base residual focus was lower in the experimental group than that of the control group,and the differences were all statistically significant(all P<0.05).The length of hospital stay was longer in the experi-mental group than in the control group,and the incidence of surgical complications,1-year postoperative recu-rrence rate and 3-year postoperative survival rate were lower in the experimental group than in the control group,and the differences were statistically significant(all P<0.05).However,the difference in the 1-year postoperative survival rate was not statistically significant between the two groups(P>0.05).Before discharge,PG I and PG I/PG II ratio were elevated in both groups compared with the preoperative period,and the above indexes were higher in the experimental group than those in the control group,and the differences were statistically significant(both P<0.05).Moreover,before discharge,PG II level was lower in both groups compared with the preoperative period,and the level was lower in the experimental group than in the control group,and the differences were all statistically significant(all P<0.05).CONCLUSION Compared with EMR,ESD surgery is more thorough.It reduces the rate of base residual focus,recurrence rate,surgical complications,and promotes the recovery of gastric cells and glandular function.It is safe and suitable for clinical application.

Early diagnosis of esophageal cancer:How to put“early detection”into effect?

This editorial comments on the article by Qu et al in a recent edition of World Journal of Gastrointestinal Oncology,focusing on the importance of early diagnosis in managing esophageal cancer and strategies for achieving“early detection”.The five-year age-standardized net survival for esophageal cancer patients falls short of expectations.Early detection and accurate diagnosis are critical strategies for improving the treatment outcomes of esophageal cancer.While advancements in endoscopic technology have been significant,there seems to be an excessive emphasis on the latest high-end endoscopic devices and various endoscopic resection techniques.Therefore,it is imperative to redirect focus towards proactive early detection strategies for esophageal cancer,investigate the most cost-effective screening methods suitable for different regions,and persistently explore practical solutions to improve the five-year survival rate of patients with esophageal cancer.

Effect of postoperative early enteral nutrition support on anti-tumor immune response and inflammatory response process in the elderly patients with esophageal cancer

Objective: To explore the effect of postoperative early enteral nutrition support on anti-tumor immune response and inflammatory response process in the elderly patients with esophageal cancer. Methods: A total of 110 cases of elderly patients with esophageal cancer who underwent radical operation in this hospital between January 2015 and December 2017 were divided into the parenteral nutrition group (n=57) who received parenteral nutrition support and the enteral nutrition group (n=53) who received enteral nutrition support according to the postoperative nutrition intervention methods. The differences in anti-tumor immune response and inflammatory response degree were compared between the two groups of patients immediately after the patients returned to the ward (T0), 48h after nutritional support (T1) and 72h after nutritional support (T2). Results: At T0, there was no statistically significant difference in the contents of Th1/Th2 immune response and Th17/Treg immune response indexes as well as inflammatory mediators in serum between the two groups of patients. At T1 and T2, serum Th1 cytokines IFN-γ and IL-12 contents of enteral nutrition group were higher than those of parenteral nutrition group whereas Th2 cytokines IL-4 and IL-13 contents were lower than those of parenteral nutrition group;serum contents of Th17 cytokines IL-6 and IL-17 as well as Treg cytokines TGF-β and IL-10 were lower than those of parenteral nutrition group;serum inflammatory mediators hs-CRP, PGE and HMGB1 contents were lower than those of parenteral nutrition group. Conclusion: Postoperative early enteral nutrition support can effectively regulate the Th1/Th2 and Th17/Treg immune response balance and inhibit the systemic inflammatory response in elderly patients with esophageal cancer.

Prediction of lymph node metastasis in early esophageal cancer

BACKGROUND Given the poor prognosis of patients with lymph node metastasis,estimating the lymph node status in patients with early esophageal cancer is crucial.Indicators that could be used to predict lymph node metastasis in early esophageal cancer have been reported in many recent studies,but no recent studies have included a review of this subject.AIM To review indicators predicting lymph node metastasis in early esophageal squamous cell carcinoma(ESCC)and early esophageal adenocarcinoma(EAC).METHODS We searched PubMed with“[early esophageal cancer(Title/Abstract)]and[lymph node(Title/Abstract)]”or“[early esophageal carcinoma(Title/Abstract)]and[lymph node(Title/Abstract)]”or“[superficial esophageal cancer(Title/Abstract)]and[lymph node(Title/Abstract)].”A total of 29 studies were eligible for analysis.RESULTS Preoperative imaging(size),serum markers(microRNA-218),postoperative pathology and immunohistochemical analysis(depth of invasion,tumor size,differentiation grade,lymphovascular invasion,neural invasion,expression of PIM-1<30%)were predictive factors for lymph node metastasis in both early ESCC and EAC.Serum markers(thymidine kinase 1≥3.38 pmol/L;cytokeratin 19 fragment antigen 21-1>3.30 ng/mL;stathmin-1)and postoperative pathology and immunohistochemical analysis(overexpression of cortactin,mixed-lineage leukaemia 2,and stanniocalcin-1)were predictive for lymph node metastasis in early ESCC.Transcription of CD69,myeloid differentiation protein 88 and toll-like receptor 4 and low expression of olfactomedin 4 were predictive of lymph node metastasis in early EAC.A total of 6 comprehensive models for early ESCC,including logistic regression model,nomogram,and artificial neural network(ANN),were reviewed.The areas under the receiver operating characteristic curve of these models reached 0.789-0.938,and the ANN performed best.As all these models relied on postoperative pathology,further models focusing on serum markers,imaging and immunohistochemical indicators are still needed.CONCLUSION Various factors were predictive of lymph node metastasis in early esophageal cancer,and present comprehensive models predicting lymph node metastasis in early ESCC mainly relied on postoperative pathology.Further studies focusing on serum markers,imaging and immunohistochemical indicators are still in need.

Effects of Total Intravenous Anesthesia and Static Aspiration Combined General Anesthesia on Postoperative Cognitive Function and Psychological State of Elderly Patients with Esophageal Cancer

Objective: To compare the effects of total intravenous anesthesia and static aspiration combined general anesthesia on postoperative cognitive function and psychological state of elderly esophageal cancer patients. Methods: From July 2020 to April 2021, 180 elderly patients who underwent radical esophageal cancer surgery in our hospital were randomly divided into 90 cases in the control group and 90 in the observation group. The control group used static aspiration compound general anesthesia, and the patients in the observation group used intravenous anesthesia to compare the cognitive function and psychological state of the two groups of patients. Results: There was no statistical difference in the cognitive function score of patients in the observation group 30 minutes before anesthesia, 1 h and 24 hours after anesthesia compared with that in the control group, P > 0.05;there was no statistical difference between the Hamilton Anxiety Scale (HAMA) scores 30 minutes before and 24 hours after anesthesia in the observation group compared with the control group, P > 0.05;the cognitive function score of patients in the observation group of 4 h after surgery and 12 h after operation was significantly higher than that of the control group;the HAMA scores of patients in the observation group of 1 h, 4 h and 12 h after surgery were significantly lower than that of the control group, P Conclusion: The application of total intravenous anesthesia in elderly patients with esophageal cancer surgery can reduce the impact of anesthesia on their cognitive function and psychological state, which is worth popularizing and applying in clinical practice.

Comparison of involved-field intensity-modulated radiotherapy combined with S-1 vs radiotherapy alone for elderly patients with esophageal cancer

BACKGROUND It is estimated that about 30%of esophageal cancer(EC)patients are over 70 years old.Therefore,there is less evidence on the diagnosis and management of elderly EC patients.It is important to explore how elderly EC patients benefit from radical radiochemotherapy regimens,including the target area of radiotherapy(RT),radiation dose and fraction,and choice of chemotherapy drugs.AIM To compare the efficacy of involved-field intensity-modulated RT(IF-IMRT)combined with S-1 vs RT alone in the treatment of elderly EC patients in terms of safety,short-term response,and survival.METHODS Thirty-four EC patients aged>70 years were prospectively enrolled between December 2017 and December 2019.Based on the random number table,they were divided into an IF-IMRT+S-1 group and an IF-IMRT alone group,with 17 patients in each group.All patients were treated with IF-IMRT at a dose of 50.4-56 Gy in 28-30 fractions(1.8-2 Gy/fraction,5 fractions/wk).Oral S-1 was administered concomitantly in the IF-IMRT+S-1 group for 14 consecutive days,and a second cycle was started 7 d after drug withdrawal.After RT,4 cycles of S-1 treatment were offered as the consolidation chemotherapy.The safety,short-term response,and survival were observed after the treatment.RESULTS As of April 2022,these 34 patients had been followed up for 15.2-32.5 mo,with a median follow-up period of 24.5 mo.Complete efficacy indicators were obtained from all the patients.The objective response rate was 88.2%vs 76.5%,respectively,in the IF-IMRT+S-1 group and the RT alone group,where as the disease control rate was 100%vs 82.4%,respectively.The incidence of adverse events including grade 1-2 fatigue,granulocytopenia,thrombocytopenia,anemia,radiation esophagitis,radiation-induced skin injury,and radiation-induced lung injury was not significantly different between these two groups,so was the incidence of the grade 3 radiation esophagitis(0%vs 5.7%).The rate of progressive disease(PD)was 52.9%(n=9)in the IF-IMRT+S-1 group and 64.7%(n=11)in the RT alone group.The median progression-free survival(PFS)was 23.4 mo vs 16.3 mo,and the 2-year PFS rate was 42%vs 41.2%.The median overall survival(OS)was 27.0 mo vs 23.0 mo,and the 2-year OS rate was 58.8%vs 47.1%.Multivariate analysis showed that age was a significant prognostic factor(P=0.0019);patients aged<75 years had a significant survival advantage over patients aged≥75 years.The locations of EC also affected the prognosis.In the IFIMRT+S-1 group,the number of chemotherapy cycles was a significant prognostic factor(P=0.0125),and the risk of PD was significantly lower in EC patients who had received 6 cycles of chemotherapy than those who had received 2-5 cycles of chemotherapy.CONCLUSION Compared with IF-IMRT alone,IF-IMRT+S-1 shows the benefits of preventing PD and prolonging survival without increasing adverse reactions.Therefore,this concurrent radiochemotherapy deserves clinical application.

The influence of neoadjuvant chemotherapy on immunity function in elderly patients with the stages of Ⅱ and Ⅲ esophageal cancer

Objective: We aimed to study the influence of neoadjuvant chemotherapy on immunity function in elderly patients with the stages of II and III esophageal cancer. Methods: Thirty-seven elderly patients (age ranged from 60 to 75 years) with the stages of II and III esophageal cancer underwent 2 cycles chemotherapy preoperatively with single-drug regimen (docetaxel, 35 mg/m2 once a week, on days 1, 8 and 15, at interval of 2 weeks for one cycle). Surgery were performed three weeks later. Blood samples were drawn separately on the day of admission, 1 day before operation, 7 day and 1 month after operation, and we conducted the Flow Cytometry to detect the levels of CD3+, CD4+, CD8+,CD4+/CD8+ and NK cells. Results: There were no significant differences in the levels of CD3+, CD4+, CD8+, CD4+/CD8+ and NK cells between before and after chemotherapy (P > 0.05). On day 7 after operation, the levels of CD3+, CD4+, CD4+/CD8+ and NK cells were degraded and CD8+ increased significantly (P < 0.05). One month after operation, the levels of CD3, CD4+, CD4+/CD8 and NK cells were higher than normal, and CD8 was depressed significantly (P < 0.05). Conclusion: Neoadjuvant chemotherapy has no significant impact on cellular immune function in elderly patients with the stages of II and III esophageal cancer, it is an effective and safe treatment.

Clinical Applications of Successive Spot Radiographs in Esophagography for Diagnosing the Early Esophageal Cancer

Objective:To introduce primary experience of clinical applications of successive spot radiographs in esophagography for the diagnosis of early esophageal cancer(EEC). Methods: Six patients with EEC were examined and diagnosed by a digital X-ray machine.According to the routine double contrast study of esophagus,the patient gulped a barium suspension in the upright position when the successive films were taken by 2 frames per second lasting for about 10 seconds.Various phases were obtained including barium-filled views,mucosal relief views and double contrast views. Results: Functional changes and abnormal mucosal folds of esophagus were present on successive spot radiographs of esophagography in patients with EEC and those patients with EEC were confirmed by endoscopic and pathologic findings.Four patients had mild loss of distensibility,2 patients had spasmodic contraction and 1 patient had barium retention.Thickened or interrupted folds were found in all cases.Little niches were detected in 5 of 6 patients. Conclusion: Evidence presented in barium studies of esophagus is more comprehensive and intact for the diagnosis of EEC when successive spot radiographs are employed.Functional changes of esophagus are more evident with this approach.

Early esophagus cancer segmentation from gastrointestinal endoscopic images based on U-Net++model

Automatic segmentation of early esophagus cancer(EEC)in gastrointestinal endoscopy(GIE)images is a critical and challenging task in clinical settings,which relies primarily on labor-intensive and time-consuming routines.EEC has often been diagnosed at the late stage since early signs of cancer are not obvious,resulting in low survival rates.This work proposes a deep learning approach based on the U-Net++method to segment EEC in GIE images.A total of 2690 GIE images collected from 617 patients at the Digestive Endoscopy Center,West China Hospital of Sichuan University,China,have been utilized.The experimental result shows that our proposed method achieved promising results.Furthermore,the comparison has been made between the proposed and other U-Net-related methods using the same dataset.The mean and standard deviation(SD)of the dice similarity coefficient(DSC),intersection over union(IoU),precision(Pre),and recall(Rec)achieved by the proposed framework were DSC(%)=94.62±0.02,IoU(%)=90.99±0.04,Pre(%)=94.61±0.04,and Rec(%)=95.00±0.02,respectively,outperforming the others.The proposed method has the potential to be applied in EEC automatic diagnoses.

Magnetic anchor technique assisted endoscopic submucosal dissection for early esophageal cancer

BACKGROUND Esophageal cancer has high incidence globally and is often diagnosed at an advanced stage.With the widespread application of endoscopic technologies,the need for early detection and diagnosis of esophageal cancer has gradually been realized.Endoscopic submucosal dissection(ESD)has become the standard of care for managing early tumors of the esophagus,stomach,and colon.However,due to the steep learning curve,difficult operation,and technically demanding nature of the procedure,ESD has currently been committed to the development of various assistive technologies.AIM To explore the feasibility and applicability of magnetic anchor technique(MAT)-assisted ESD for early esophageal cancer.METHODS Isolated pig esophagi were used as the experimental model,and the magnetic anchor device was designed by us.The esophagi used were divided into two groups,namely the operational and control groups,and 10 endoscopists completed the procedure.The two groups were evaluated for the following aspects:The total operative time,perforation rate,rate of whole mucosal resection,diameter of the peering mucosa,and scores of endoscopists’feelings with the procedure,including the convenience,mucosal surface exposure degree,and tissue tension.In addition,in the operational group,the soft tissue clip and the target magnet(TM)were connected by a thin wire through a small hole at the tail end of the TM.Under gastroscopic guidance,the soft tissue clip was clamped to the edge of the lesioned mucosa,which was marked in advance.By changing the position of the anchor magnet(AM)outside the esophagus,the pulling force and pulling direction of the TM could be changed,thus exposing the mucosal peeling surface and assisting the ESD.RESULTS Herein,each of the two groups comprised 10 isolated esophageal putative mucosal lesions.The diameter of the peering mucosa did not significantly differ between the two groups(2.13±0.06 vs 2.15±0.06,P=0.882).The total operative time was shorter in the operational group than in the control group(17.04±0.22 min vs 21.94±0.23 min,P<0.001).During the entire experiment,the TM remained firmly connected with the soft tissue clip and did not affect the opening,closing,and release of the soft tissue clip.The interaction between the TM and AM could provide sufficient tissue tension and completely expose the mucosa,which greatly assists the surgeon with the operation.There was no avulsion of the mucosa,and mucosal lesions were intact when peeled.Therefore,the scores of endoscopists’feelings were higher in the operational group than in the control group in terms of the convenience(9.22±0.19 vs 8.34±0.15,P=0.002),mucosal surface exposure degree(9.11±0.15 vs 8.25±0.12,P<0.001),and tissue tension(9.35±0.13 vs 8.02±0.17,P<0.001).The two groups did not significantly differ in the perforation rate and rate of whole mucosal resection.CONCLUSION We found MAT-assisted ESD safe and feasible for early esophageal cancer.It could greatly improve the endoscopic operation experience and showed good clinical application prospects.

Endoscopic ultrasound staging for early esophageal cancer: Are we denying patients neoadjuvant chemo-radiation?

AIM To evaluate the accuracy of endoscopic ultrasound(EUS) in early esophageal cancer(EC) performed in a highvolume tertiary cancer center. METHODS A retrospective review of patients undergoing esophagectomy was performed and patients with c T1 N0 and c T2 N0 esophageal cancer by EUS were evaluated. Patient demographics, tumor characteristics, and treatment were reviewed. EUS staging was compared to surgical pathology to determine accuracy of EUS. Descriptive statistics was used to describe the cohort. Student's t test and Fisher's exact test or χ~2 test was used to compare variables. Logistic regression analysis was used to determine if clinical variables such as tumor location and tumor histology were associated with EUS accuracy.RESULTS Between 2000 and 2015, 139 patients with clinical stage Ⅰ or Ⅱ?A esophageal cancer undergoing esophagectomy were identified. There were 25(18%) female and 114(82%) male patients. The tumor location included the middle third of the esophagus in 11(8%) and lower third and gastroesophageal junction in 128(92%) patients. Ninety-three percent of patients had adenocarcinoma. Preoperative EUS matched the final surgical pathology in 73/139 patients for a concordance rate of 53%. Twenty-nine patients(21%) were under-staged by EUS; of those, 19(14%) had unrecognized nodal disease. Positron emission tomography(PET) was used in addition to EUS for clinical staging in 62/139 patients. Occult nodal disease was only found in 4 of 62 patients(6%) in whom both EUS and PET were negative for nodal involvement. CONCLUSION EUS is less accurate in early EC and endoscopic mucosal resection might be useful in certain settings. The addition of PET to EUS improves staging accuracy.

Artificial intelligence technique in detection of early esophageal cancer

Due to the rapid progression and poor prognosis of esophageal cancer(EC),the early detection and diagnosis of early EC are of great value for the prognosis improvement of patients.However,the endoscopic detection of early EC,especially Barrett's dysplasia or squamous epithelial dysplasia,is difficult.Therefore,the requirement for more efficient methods of detection and characterization of early EC has led to intensive research in the field of artificial intelligence(AI).Deep learning(DL)has brought about breakthroughs in processing images,videos,and other aspects,whereas convolutional neural networks(CNNs)have shone lights on detection of endoscopic images and videos.Many studies on CNNs in endoscopic analysis of early EC demonstrate excellent performance including sensitivity and specificity and progress gradually from in vitro image analysis for classification to real-time detection of early esophageal neoplasia.When AI technique comes to the pathological diagnosis,borderline lesions that are difficult to determine may become easier than before.In gene diagnosis,due to the lack of tissue specificity of gene diagnostic markers,they can only be used as supplementary measures at present.In predicting the risk of cancer,there is still a lack of prospective clinical research to confirm the accuracy of the risk stratification model.

Outcomes of curative esophageal cancer surgery in elderly:A metaanalysis

BACKGROUND An increasing number of older patients is undergoing curative,surgical treatment of esophageal cancer.Previous meta-analyses have shown that older patients suffered from more postoperative morbidity and mortality compared to younger patients,which may lead to patient selection based on age.However,only studies including patients that underwent open esophagectomy were included.Therefore,it remains unknown whether there is an association between age and outcome in patients undergoing minimally invasive esophagectomy.AIM To perform a systematic review on age and postoperative outcome in esophageal cancer patients undergoing esophagectomy.METHODS Studies comparing older with younger patients with primary esophageal cancer undergoing curative esophagectomy were included.Meta-analysis of studies using a 75-year age threshold are presented in the manuscript,studies using other age thresholds in the Supplementary material.MEDLINE,Embase and the Cochrane Library were searched for articles published between 1995 and 2020.Risk of bias was assessed with the Newcastle-Ottawa Scale.Primary outcomes were anastomotic leak,pulmonary and cardiac complications,delirium,30-and 90-d,and in-hospital mortality.Secondary outcomes included pneumonia and 5-year overall survival.RESULTS Seven studies(4847 patients)using an age threshold of 75 years were included for meta-analysis with 755 older and 4092 younger patients.Older patients(9.05%)had higher rates of 90-d mortality compared with younger patients(3.92%),(confidence interval=1.10-5.56).In addition,older patients(9.45%)had higher rates of in-hospital mortality compared with younger patients(3.68%),(confidence interval=1.01-5.91).In the subgroup of 2 studies with minimally invasive esophagectomy,older and younger patients had comparable 30-d,90-d and in-hospital mortality rates.CONCLUSION Older patients undergoing curative esophagectomy for esophageal cancer have a higher postoperative mortality risk.Minimally invasive esophagectomy may be important for minimizing mortality in older patients.

Feasibility of same-day discharge following endoscopic submucosal dissection for esophageal or gastric early cancer

BACKGROUND Endoscopic submucosal dissection(ESD)is an established technique for the treatment of early gastrointestinal neoplasia.Generally,multi-day(M-D)admission is required for patients undergoing ESD due to potential complications.AIM To evaluate the feasibility of a same-day(S-D)discharge strategy for ESD of the esophagus or stomach.METHODS The data of patients who underwent esophageal or gastric ESD were retrospectively collected from January 2018 to December 2021 at Peking University Cancer Hospital.The propensity score matching(PSM)method was applied to balance the unevenly distributed patient baseline characteristics between the S-D and M-D groups.Intraoperative and postoperative parameters were compared between the matched groups.RESULTS Among the 479 patients reviewed,470 patients,including 91 in the S-D group and 379 in the M-D group,fulfilled the inclusion and exclusion criteria.Following PSM,78 patients in each group were paired using the 1:1 nearest available score match algorithm.No significant difference was found between groups with respect to intraoperative and postprocedural major adverse events(AEs).Tumor size,complete resection rate,and procedural duration were comparable between the groups.The S-D group demonstrated a significantly shorter length of hospital stay(P<0.001)and lower overall medical expenses(P<0.001)compared with the M-D group.CONCLUSION The S-D discharge strategy may be feasible and effective for esophagogastric ESD,and the procedural-related AEs can be managed successfully.

Artificial intelligence-assisted endoscopic detection of esophageal neoplasia in early stage:The next step?

Esophageal cancer(EC)is a common malignant tumor of the digestive tract and originates from the epithelium of the esophageal mucosa.It has been confirmed that early EC lesions can be cured by endoscopic therapy,and the curative effect is equivalent to that of surgical operation.Upper gastrointestinal endoscopy is still the gold standard for EC diagnosis.The accuracy of endoscopic examination results largely depends on the professional level of the examiner.Artificial intelligence(AI)has been applied in the screening of early EC and has shown advantages;notably,it is more accurate than less-experienced endoscopists.This paper reviews the application of AI in the field of endoscopic detection of early EC,including squamous cell carcinoma and adenocarcinoma,and describes the relevant progress.Although up to now most of the studies evaluating the clinical application of AI in early EC endoscopic detection are focused on still images,AIassisted real-time detection based on live-stream video may be the next step.

Artificial intelligence and early esophageal cancer

The development of esophageal cancer(EC)from early to advanced stage results in a high mortality rate and poor prognosis.Advanced EC not only poses a serious threat to the life and health of patients but also places a heavy economic burden on their families and society.Endoscopy is of great value for the diagnosis of EC,especially in the screening of Barrett’s esophagus and early EC.However,at present,endoscopy has a low diagnostic rate for early tumors.In recent years,artificial intelligence(AI)has made remarkable progress in the diagnosis of digestive system tumors,providing a new model for clinicians to diagnose and treat these tumors.In this review,we aim to provide a comprehensive overview of how AI can help doctors diagnose early EC and precancerous lesions and make clinical decisions based on the predicted results.We analyze and summarize the recent research on AI and early EC.We find that based on deep learning(DL)and convolutional neural network methods,the current computer-aided diagnosis system has gradually developed from in vitro image analysis to real-time detection and diagnosis.Based on powerful computing and DL capabilities,the diagnostic accuracy of AI is close to or better than that of endoscopy specialists.We also analyze the shortcomings in the current AI research and corresponding improvement strategies.We believe that the application of AI-assisted endoscopy in the diagnosis of early EC and precancerous lesions will become possible after the further advancement of AI-related research.

Chromosome 11 aneusomy in esophageal cancers and precancerous lesions-an early event in neoplastic transformation:An interphase fluorescence in situ hybridization study from south India

AIM: To detect aneusomic changes with respect to chromosome 11 copy number in esophageal precancers and cancers wherein the generation of cancer-specific phenotypes is believed to be associated with specific chromosomal aneuploidies. METHODS: We performed fluorescence in situ hybridization (FISH) on esophageal tissue paraffin sections to analyze changes in chromosome 11 copy number using apotome-generated images by optical sectioning microscopy. Sections were prepared from esophageal tumor tissue, tissues showing preneoplastic changes and histologically normal tissues (control) obtained from patients referred to the clinic for endoscopic evaluation. RESULTS: Our results demonstrated that aneusomy was seen in all the cancers and preneoplastic tissues, while none of the controls showed aneusomic cells. There was no increase in aneusomy from precancers to cancers. CONCLUSION: Our results suggest that evaluation of chromosome 11 aneusomy in esophageal tissue using FISH with an appropriate signal capture-analysis system, can be used as an ancillary molecular marker predictive of early neoplastic changes. Future studies can be directed towards the genes on chromosome 11,which may play a role in the neoplastic transformation of esophageal precancerous lesions to cancers.

Diffuse xanthoma in early esophageal cancer: A case report

BACKGROUND Gastrointestinal xanthomas are asymptomatic and infrequent non-neoplastic lesions that commonly occur in the stomach with Helicobacter pylori-associated gastritis and rarely in the esophagus.To date,there have been no reports of esophageal xanthoma combined with esophageal cancer.Herein,we present the first case in the literature of a diffuse xanthoma complicated with early esophageal cancer.Moreover,this combination makes the endoscopic diagnosis difficult if it is not in mind.CASE SUMMARY A 68-year-old man visited our department with a 2-mo history of epigastric discomfort.He underwent surgery for gastric cancer 6 years ago.Esophagogastroduodenoscopy showed a semi-circumferential irregular yellowish-colored and granular lesion in the esophagus(30-35 cm from the incisors).Using magnifying endoscopy with narrow band imaging,aggregated minute and yellowish-colored spots with tortuous microvessels on the surface were observed,and background coloration was clearly seen in the lesion.As endoscopic biopsy suggested a histologically high-grade dysplasia;the lesion was completely resected en bloc by endoscopic submucosal dissection(ESD).The resected specimen was confirmed to be a squamous cell carcinoma in situ with extensive foamy cells in the superficial mucosal layer.Immunohistochemically,the observed foamy cells were strongly positive for CD68,which is characteristic of xanthoma.The clinical course was favorable,and no recurrence was observed 2 years and 7 mo after ESD.CONCLUSIONDiffuse xanthoma concurrent with early esophageal cancer is extremely rare.The characteristic endoscopic features may assist endoscopists in diagnosing similar lesions.