Real-world treatment attrition rates in advanced esophagogastric cancer

BACKGROUND Over the last decade,multiple agents have demonstrated efficacy for advanced esophagogastric cancer(EGC).Despite the availability of later lines of therapy,there remains limited real-world data about the treatment attrition rates between lines of therapy.AIM To characterize the use and attrition rates between lines of therapy for patients with advanced EGC.METHODS We identified patients who received at least one cycle of chemotherapy for advanced EGC between July 1,2017 and July 31,2018 across six regional centers in British Columbia(BC),Canada.Clinicopathologic,treatment,and outcomes data were extracted.RESULTS Of 245 patients who received at least one line of therapy,median age was 66 years(IQR 58.2-72.3)and 186(76%)were male,Eastern Cooperative Oncology Group(ECOG)performance status 0/1(80%),gastric vs GEJ(36%vs 64%).Histologies included adenocarcinoma(78%),squamous cell carcinoma(8%),and signet ring(14%),with 31%HER2 positive.72%presented with de novo disease,and 25%had received previous chemoradiation.There was a high level of treatment attrition,with patients receiving only one line of therapy n=122,50%),two lines n=83,34%),three lines n=34,14%),and four lines n=6,2%).Kaplan-Meier analysis demonstrated improved survival with increasing lines of therapy(median overall survival 7.7 vs 16.6 vs 22.8 vs 40.4 mo,P<0.05).On multivariable Cox regression,improved survival was associated with better baseline ECOG and increased lines of therapy(P<0.05).CONCLUSION The steep attrition rates between therapies highlight the unmet need for more efficacious early-line treatment options for patients with advanced EGC.

Effect of two surgical approaches on the lung function and prognosis of patients with combined esophagogastric cancer

BACKGROUND Adenocarcinoma of the esophagogastric junction has a center of origin within 5 cm of the esophagogastric junction.Surgical resection remains the main treatment.A transthoracic approach is recommended for Siewert I adenocarcinoma of the esophagogastric junction and a transabdominal approach is recommended for Siewert III adenocarcinoma of the esophagogastric junction.However,there is a need to determine the optimal surgical approach for Siewert II adenocarcinoma of the esophagogastric junction to improve lung function and the prognosis of patients.AIM To investigate and compare the surgical effects,postoperative changes in pulmonary function,and prognoses of two approaches to treating combined esophagogastric cancer.METHODS One hundred and thirty-eight patients with combined esophagogastric cancer treated by general and thoracic surgeries in our hospital were selected.They were divided into group A comprising 70 patients(transabdominal approach)and group B comprising 68 patients(transthoracic approach)based on the surgical approach.The indexes related to surgical trauma,number of removed lymph nodes,indexes of lung function before and after surgery,survival rate,and survival duration of the two groups were compared 3 years after surgery.RESULTS The duration of surgery,length of hospital stay,and postoperative drainage duration of the patients in group A were shorter than those of the patients in group B,and the volume of blood loss caused by surgery was lower for group A than for group B(P<0.05).At the one-month postoperative review,the first second,maximum ventilation volume,forceful lung volume,and lung volume values were higher for group A than for group B(P<0.05).Preoperatively,the QLQ-OES18 scale scores of the patients in group A were higher than those in group B on re-evaluation at 3 mo postoperatively(P<0.05).The surgical complication rate of the patients in group A was 10.00%,which was lower than that of patients in group B,which was 23.53%(P<0.05).CONCLUSION Transabdominal and transthoracic surgical approaches are comparable in treating combined esophagogastric cancer;however,the former results in lesser surgical trauma,milder changes in pulmonary function,and fewer complications.

Evaluation of routine biopsies in endoscopic screening for esophagogastric junction cancer

AIM: To explore whether routine biopsies at the high incidence spot of esophagogastric junction (EGJ) cancer are justified in endoscopic screening.

Current status and future perspectives for the treatment of resectable locally advanced esophagogastric junction cancer:A narrative review

Incidence rates for esophagogastric junction cancer are rising rapidly worldwide possibly due to the economic development and demographic changes.Therefore,increased attention has been paid to the prevention,diagnosis,and the treatment of esophagogastric junction cancer.Although there are discrepancies in the treatment strategy between Asian and Western countries,surgery remains the mainstay of treatment for esophagogastric junction cancer.Recent developments of perioperative multidisciplinary treatment may lead to better therapeutic effect,higher complete resection rate,and better control of the residual diseases,thus result in prolonged prognosis.In this review,we will focus on the treatment of locally advanced resectable esophagogastric junction cancer,and discuss the current status and future perspectives of the perioperative treatment including chemotherapy,radiation therapy,and immunotherapy,as well as the surgical strategy.Better understanding of the latest treatment strategy and future overlook may enable to standardize and individualize the treatment for esophagogastric junction cancer,thus leading to better prognosis for those patients.

Association of anastomotic leakage with long-term oncologic outcomes of patients with esophagogastric junction cancer

BACKGROUND Despite improvements in surgical procedures and peri-operative patients management,the postoperative complications in esophagogastric junction(EGJ)cancer remain high because of technical aspects.Several studies have indicated the negative influence of postoperative infectious complications on long-term survival after gastrointestinal surgery.However,no study has shown the association between postoperative complications and long-term survival of patients with EGJ cancer.AIM To elucidate influence of postoperative complications on the long-term outcomes of patients with EGJ cancer.METHODS A total of 122 patients who underwent surgery for EGJ cancer at the Keio University were included in this study.We examined the association between complications and long-term oncologic outcomes.RESULTS In all patients,the 3-year overall survival(OS)rate was 71.9%,and the recurrencefree survival(RFS)rate was 67.5%.Compared with patients without anastomotic leakage,those with anastomotic leakage had poor median OS(8 mo vs not reached,P=0.028)and median RFS(5 mo vs not reached,P=0.055).Among patients with cervical anastomosis,there were not significant differences between patients with and without anastomotic leakage.However,among patients who underwent intrathoracic anastomosis,patients with anastomotic leakage had significantly worse OS(P=0.002)and RFS(P=0.005).CONCLUSION Anastomotic leakage was significantly associated with long-term oncologic outcomes of patients with EGJ cancer,especially those who underwent intrathoracic anastomosis.Cervical anastomosis with subtotal esophagectomy may be an option for the patients who are at high risk for anastomotic leakage.

Total esophagogastrectomy plus extended lymphadenectomy with transverse colon interposition:A treatment for extensive esophagogastric junction cancer

AIM:To review the post-operative morbidity and mortality of total esophagogastrectomy(TEG) with second barrier lymphadenectomy(D2) with interposition of a transverse colon and to determine the oncological outcomes of TEG D2 with interposition of a transverse colon.METHODS:This study consisted of a retrospective review of patients with a cancer diagnosis who underwent TEG between 1997 and 2013. Demographic data,surgeryprotocols,complications according to Clavien-Dindo classifications,final pathological reports,oncological follow-ups and causes of death were recorded. We used the TNM 2010 and Japanese classifications for nodal dissection of gastric cancer. We used descriptive statistical analysis and Kaplan-Meier survival curves. A P-value of less than 0.05 was considered statistically significant.RESULTS:The series consisted of 21 patients(80.9% men). The median age was 60 years. The 2 main surgical indications were extensive esophagogastric junction cancers(85.7%) and double cancers(14.2%). The mean total surgery time was 405 min(352-465 min). Interposition of a transverse colon through the posterior mediastinum was used for replacement in all cases. Splenectomy was required in 13 patients(61.9%),distal pancreatectomy was required in 2 patients(9.5%) and resection of the left adrenal gland was required in 1 patient(4.7%). No residual cancer surgery was achieved in 75.1% of patients. A total of 71.4% of patients had a postoperative complication. Respiratory complications were the most frequently observed complication. Postoperative mortality was 5.8%. Median follow-up was 13.4 mo. Surgery specific survival at 5 years of follow-up was 32.8%; for patients with curative surgery,it was 39.5% at 5 years.CONCLUSION:TEG for cancer with interposition of a transverse colon is a very complex surgery,and it presents high post-operative morbidity and adequate oncological outcomes.

Development of a novel staging classification for Siewert Ⅱ adenocarcinoma of the esophagogastric junction after neoadjuvant chemotherapy

BACKGROUND Stage classification for Siewert Ⅱ adenocarcinoma of the esophagogastric junction(AEG)treated with neoadjuvant chemotherapy(NAC)has not been established.AIM To investigate the optimal stage classification for Siewert Ⅱ AEG with NAC.METHODS A nomogram was established based on Cox regression model that analyzed variables associated with overall survival(OS)and disease-specific survival(DSS).The nomogram performance in terms of discrimination and calibration ability was evaluated using the likelihood-ratio test,Akaike information criterion,Harrell concordance index,time-receiver operating characteristic curve,and decision curve analysis.RESULTS Data from 725 patients with Siewert type Ⅱ AEG who underwent neoadjuvant therapy and gastrectomy were obtained from the Surveillance,Epidemiology,and End Results database.Univariate and multivariate analyses revealed that sex,marital status,race,ypT stage,and ypN stage were independent prognostic factors of OS,whereas sex,race,ypT stage,and ypN stage were independent prognostic factors for DSS.These factors were incorporated into the OS and DSS nomograms.Our novel nomogram model performed better in terms of OS and DSS prediction compared to the 8th American Joint Committee of Cancer pathological staging system for esophageal and gastric cancer.Finally,a user-friendly web application was developed for clinical use.CONCLUSION The nomogram established specifically for patients with Siewert type Ⅱ AEG receiving NAC demonstrated good prognostic performance.Validation using external data is warranted before its widespread clinical application.

Surgical management of esophagogastric junction tumors

Surgical resection with lymphadenectomy is the mainstay of treatment for all resectable esophagogastric junction tumors, prior to systemic generalization of the disease. This makes accurate pre-treatment staging and classification of the tumors most demanding. A well-established and internationally accepted classification for adenocarcinomas of the esophagogastric junction （AEG） helps to choose the appropriate surgical approach and to make results from different institutions comparable. Distal esophageal adenocarcinomas （AEGⅠ） are distinguished from true cardia carcinomas （AEGⅡ） and subcardiac gastric cancers （AEGⅢ）. Substantial advancements in this surgical field during the preceding decades have clearly revealed that individualization of the surgical strategy is the key to successfully approaching these entities. In this review we discuss the surgical management of esophagogastric junction tumors with a tailored surgical strategy.