Computed tomography-based nomogram of Siewert type Ⅱ/Ⅲ adenocarcinoma of esophagogastric junction to predict response to docetaxel, oxaliplatin and S-1

BACKGROUND Neoadjuvant chemotherapy(NAC)has become the standard care for advanced adenocarcinoma of esophagogastric junction(AEG),although a part of the patients cannot benefit from NAC.There are no models based on baseline computed tomography(CT)to predict response of Siewert type II or III AEG to NAC with docetaxel,oxaliplatin and S-1(DOS).AIM To develop a CT-based nomogram to predict response of Siewert type II/III AEG to NAC with DOS.METHODS One hundred and twenty-eight consecutive patients with confirmed Siewert type II/III AEG underwent CT before and after three cycles of NAC with DOS,and were randomly and consecutively assigned to the training cohort(TC)(n=94)and the validation cohort(VC)(n=34).Therapeutic effect was assessed by disease-control rate and progressive disease according to the Response Evaluation Criteria in Solid Tumors(version 1.1)criteria.Possible prognostic factors associated with responses after DOS treatment including Siewert classification,gross tumor volume(GTV),and cT and cN stages were evaluated using pretherapeutic CT data in addition to sex and age.Univariate and multivariate analyses of CT and clinical features in the TC were performed to determine independent factors associated with response to DOS.A nomogram was established based on independent factors to predict the response.The predictive performance of the nomogram was evaluated by Concordance index(C-index),calibration and receiver operating characteristics curve in the TC and VC.RESULTS Univariate analysis showed that Siewert type(52/55 vs 29/39,P=0.005),pretherapeutic cT stage(57/62 vs 24/32,P=0.028),GTV(47.3±27.4 vs 73.2±54.3,P=0.040)were significantly associated with response to DOS in the TC.Multivariate analysis of the TC also showed that the pretherapeutic cT stage,GTV and Siewert type were independent predictive factors related to response to DOS(odds ratio=4.631,1.027 and 7.639,respectively;all P<0.05).The nomogram developed with these independent factors showed an excellent performance to predict response to DOS in the TC and VC(C-index:0.838 and 0.824),with area under the receiver operating characteristic curve of 0.838 and 0.824,respectively.The calibration curves showed that the practical and predicted response to DOS effectively coincided.CONCLUSION A novel nomogram developed with pretherapeutic cT stage,GTV and Siewert type predicted the response of Siewert type II/III AEG to NAC with DOS.

Recent advances in multidisciplinary therapy for adenocarcinoma of the esophagus and esophagogastric junction

Esophageal adenocarcinoma(EAC)and adenocarcinoma of the esophagogastric junction(EGJA)have long been associated with poor prognosis.With changes in the spectrum of the disease caused by economic development and demographic changes,the incidence of EAC and EGJA continues to increase,making them worthy of more attention from clinicians.For a long time,surgery has been the mainstay treatment for EAC and EGJA.With advanced techniques,endoscopic therapy,radiotherapy,chemotherapy,and other treatment methods have been developed,providing additional treatment options for patients with EAC and EGJA.In recent decades,the emergence of multidisciplinary therapy(MDT)has enabled the comprehensive treatment of tumors and made the treatment more flexible and diversified,which is conducive to achieving standardized and individualized treatment of EAC and EGJA to obtain a better prognosis.This review discusses recent advances in EAC and EGJA treatment in the surgicalcentered MDT mode in recent years.

Clinical significance of signet ring cells in surgical esophageal and esophagogastric junction adenocarcinoma:A systematic review and meta-analysis

BACKGROUND The clinical significance of signet ring cells(SRCs)in surgical esophageal and esophagogastric junction adenocarcinoma(EEGJA)remains unclear now.AIM To explore the association between the presence of SRCs and the clinicopathological and prognostic characteristics in surgical EEGJA patients by combining and analyzing relevant studies.METHODS The PubMed,Web of Science,and EMBASE electronic databases were searched for the relevant literature up to March 28,2021.The relative risk(RR)with 95%confidence interval(CI)was calculated to assess the relationship between SRCs and clinicopathological parameters of surgical EEGJA patients,and the hazard ratio(HR)with 95%CI was calculated to explore the impact of SRC on the prognosis.All statistical analyses were conducted with STATA 12.0 software.RESULTS A total of ten articles were included,involving 30322 EEGJA patients.The pooled results indicated that the presence of SRCs was significantly associated with tumor location(RR:0.76,95%CI:0.61-0.96,P=0.022;I2=49.4%,P=0.160)and tumor-node-metastasis stage(RR:1.30,95%CI:1.02-1.65,P=0.031;I2=73.1%,P=0.002).Meanwhile,the presence of SRCs in surgical EEGJA patients predicted a poor overall survival(HR:1.36,95%CI:1.12-1.65,P=0.002;I2=85.7%,P<0.001)and disease-specific survival(HR:1.86,95%CI:1.55-2.25,P<0.001;I2=63.1%,P=0.043).CONCLUSION The presence of SRCs is related with advanced tumor stage and poor prognosis and could serve as a reliable and effective parameter for the prediction of postoperative survival and formulation of therapy strategy in EEGJA patients.However,more high-quality studies are still needed to verify the above findings.

Esophagogastric junction adenocarcinoma:Preoperative chemoradiation or perioperative chemotherapy?

Multimodal treatment is currently the standard of care for locally advanced esophagogastric junction(EGJ)adenocarcinoma due to poor results after surgery alone.Neoadjuvant therapy is intended to shrink the tumor and eliminate potential circulating tumor cells.However,which neoadjuvant treatment is best for patients with EGJ tumors remains controversial.We aimed to compare outcomes of preoperative chemoradiation and perioperative chemotherapy for EGJ adenocarcinomas.For this purpose,we performed a thorough review of the literature describing neoadjuvant treatments for EGJ adenocarcinomas or comparing both therapies.Although some studies have shown better locoregional control and higher rates of complete pathologic response after chemoradiation,data suggest that both types of neoadjuvant therapy have similar survival benefits.As current data are heterogeneous and many studies have included significantly different types of patients in their analysis,future studies with better patient selection are still needed to define which neoadjuvant therapy should be chosen.In addition,targeted therapies and immunotherapy have promising results and should be further explored.

The unique phenotypes of adenocarcinoma of the esophagogastric junction in China

Adenocarcinoma of the esophagogastric junction （AEG） was proposed as a distinct disease for its rapidly increasing incidence. However, most studies of AEG were based primarily on the results of western patients and the studies on Chinese patients were deficient. Recently, some retrospective studies on AEG patients from our hospital show distinct clinical and pathological features compared with American patients （1-3）. In this editorial, we will focus on the unique phenotypes of Chinese AEG patients based on our studies and other reports.

Lymph node metastasis and lymphadenectomy of resectable adenocarcinoma of the esophagogastric junction

Based on Siewert classification, adenocarcinomas of the esophagogastric junction （AEGs） have different behaviors of perigastric-mediastinal nodal metastasis. Siewert type I AEGs have higher incidence of mediastinal nodal metastasis than those of type H or III, especially at middle-upper mediastinum. With regard to the necessity of mediastinal lymphadenectomy, theoretically, transthoracic esophagogastrectomy with complete mediastinal lymphadenectomy is suggested for Siewert type I AEGs, while transhiatal total gastrectomy with lower mediastinal and D2 perigastric lymphadenectomy is a standard surgery for type II-III AEGs. Nevertheless, the mediastinal nodal metastasis is an independent factor of poor prognosis for any type of AEG.

Clinical comparison of antrum-preserving double tract reconstruction vs roux-en-Y reconstruction after gastrectomy for Siewert types Ⅱ and Ⅲ adenocarcinoma of the esophagogastric junction

AIM:To explore a reasonable method of digestive tract reconstruction,namely,antrum-preserving double-tract reconstruction(ADTR),for patients with adenocarcinoma of the esophagogastric junction(AEG) and to assess its efficacy and safety in terms of longterm survival,complications,morbidity and mortality.METHODS:A total of 55 cases were retrospectively collected,including 18 cases undergoing ADTR and 37 cases of Roux-en-Y reconstruction(RY) for AEG(Siewert types Ⅱ and Ⅲ) at North Sichuan Medical College. The cases were divided into two groups. The clinicopathological characteristics,perioperative outcomes,postoperative complications,morbidity and overall survival(OS) were compared for the two different reconstruction methods.RESULTS:Basic characteristics including sex,age,body mass index(BMI),Siewert type,p T status,p N stage,and lymph node metastasis were similar in the two groups. No significant differences were found between the two groups in terms of perioperative outcomes(including the length of postoperative hospital stay,operating time,and intraoperative blood loss) and postoperative complications(consisting of anastomosis-related complications,wound infection,respiratory infection,pleural effusion,lymphorrhagia,and cholelithiasis). For the ADTR group,perioperativerecovery indexes such as time to first flatus(P = 0.002) and time to resuming a liquid diet(P = 0.001) were faster than those for the RY group. Moreover,the incidence of reflux esophagitis was significantly decreased compared with the RY group(P = 0.048). The postoperative morbidity and mortality rates for overall postoperative complications and the rates of tumor recurrence and metastasis were not significantly different between the two groups. Survival curves plotted using the Kaplan-Meier method and compared by log-rank test demonstrated similar outcomes for the ADTR and RY groups. Multivariate analysis of significantly different factors that presented as covariates on Cox regression analysis to assess the survival and recurrence among AEG patients showed that age,gender,BMI,pleural effusion,time to resuming a liquid diet,lymphorrhagia and tumor-nodemetastasis stage were important prognostic factors for OS of AEG patients,whereas the selection of surgical method between ADTR and RY was shown to be a similar prognostic factor for OS of AEG patients.CONCLUSION:ADTR by jejunal interposition presents similar rates of tumor recurrence,metastasis and longterm survival compared with classical reconstruction with RY esophagojejunostomy; however,it offers considerably improved near-term quality of life,especially in terms of early recovery and decreased reflux esophagitis. Thus,ADTR is recommended as a worthwhile digestive tract reconstruction method for Siewert types Ⅱ and Ⅲ AEG.

Optimal treatment for Siewert type Ⅱ and Ⅲ adenocarcinoma of the esophagogastric junction: A retrospective cohort study with long-term follow-up

AIM To determine the optimal treatment strategy for Siewert type Ⅱ and?Ⅲ?adenocarcinoma of the esophagogastric junction.METHODS We retrospectively reviewed the medical records of 83 patients with Siewert type?Ⅱ?and?Ⅲ?adenocarcinoma of the esophagogastric junction and calculated both an index of estimated benefit from lymph node dissection for each lymph node(LN) station and a lymph node ratio(LNR: ratio of number of positive lymph nodes to the total number of dissected lymph nodes). We used Cox proportional hazard models to clarify independent poor prognostic factors. The median duration of observation was 73 mo.RESULTS Indices of estimated benefit from LN dissection were as follows, in descending order: lymph nodes(LN) along the lesser curvature, 26.5; right paracardial LN, 22.8; left paracardial LN, 11.6; LN along the left gastric artery, 10.6. The 5-year overall survival(OS) rate was 58%. Cox regression analysis revealed that vigorous venous invasion(v2, v3)(HR = 5.99; 95%CI: 1.71-24.90) and LNR of > 0.16(HR = 4.29, 95%CI: 1.79-10.89) were independent poor prognostic factors for OS.CONCLUSION LN along the lesser curvature, right and left paracardial LN, and LN along the left gastric artery should be dissected in patients with Siewert type?Ⅱ?or?Ⅲ?adenoca rcinoma of the esophagogastric junction. Patients with vigorous venous invasion and LNR of > 0.16 should be treated with aggressive adjuvant chemotherapy to improve survival outcomes.

Comparison of survival outcomes between transthoracic and transabdominal surgical approaches in patients with Siewert-Ⅱ/Ⅲesophagogastric junction adenocarcinoma:a single-institution retrospective cohort study

Objective： To compare the survival outcomes of transabdominal （TA） and transthoracic （TT） surgical approaches in patients with Siewert-II/III esophagogastric junction adenocarcinoma. Methods： This retrospective study was conducted in patients with Siewert-II/III esophagogastric junction adenocarcinoma who underwent either TT or TA operations in the West China Hospital between January 2006 and December 2009. Results： A total of 308 patients （109 in the TT and 199 in the TA groups） were included in this study with a follow-up rate of 87.3%. The median （P25, P75） number of harvested perigastric lymph nodes was 8 （5, 10） in the TT group and 23 （16, 34） in the TA group （P〈0.001）, and the number of positive perigastric lymph nodes was 2 （0, 5） in the TT group and 3 （1, 8） in the TA group （P〈0.004）. The 5-year overall survival （OS） rate was 36% in the TT group and 51% in the TA group （P=0.005）. Subgroup analysis by Siewert classification showed that 5-year OS rates for patients with Siewert II tumors were 38% and 48% in TT and TA groups, respectively （P=0.134）, whereas the 5-year OS rate for patients with Siewert III tumors was significantly lower in the TT group than that in the TA group （33% vs. 53%; P=0.010）. Multivariate analysis indicated that N2 and N3 stages, RI/R2 resection and a TT surgical approach were prognostic factors for poor OS. Conclusions： Improved perigastric lymph node dissection may be the main reason for better survival outcomes observed with a TA gastrectomy approach than with TT gastrectomy for Siewert III tumor patients.

Autoantibodies: Potential clinical applications in early detection of esophageal squamous cell carcinoma and esophagogastric junction adenocarcinoma

Esophageal squamous cell carcinoma(ESCC)and esophagogastric junction adenocarcinoma(EGJA)are the two main types of gastrointestinal cancers that pose a huge threat to human health.ESCC remains one of the most common malignant diseases around the world.In contrast to the decreasing prevalence of ESCC,the incidence of EGJA is rising rapidly.Early detection represents one of the most promising ways to improve the prognosis and reduce the mortality of these cancers.Current approaches for early diagnosis mainly depend on invasive and costly endoscopy.Non-invasive biomarkers are in great need to facilitate earlier detection for better clinical management of patients.Tumor-associated autoantibodies can be detected at an early stage before manifestations of clinical signs of tumorigenesis,making them promising biomarkers for early detection and monitoring of ESCC and EGJA.In this review,we summarize recent insights into the iden-tification and validation of tumor-associated autoantibodies for the early detection of ESCC and EGJA and discuss the challenges remaining for clinical validation.

Combination chemotherapy with paclitaxel,cisplatin and fluorouracil for patients with advanced and metastatic gastric or esophagogastric junction adenocarcinoma:a multicenter prospective study

Objective： To evaluate the efficacy and toxicity of the combination regimen of paclitaxel, cisplatin and 5-FU （PCF） as first-line or second-line therapy in patients with advanced gastric and esophagogastric junction （EGJ） adenocarcinoma in China. Methods： The patients were treated with paclitaxel 150 mg/m2 on dl; fractionated cisplatin 15 mg/m2 and continuous infusion 5-FU 600 mg/（mLd） intravenously on d 1-d5 of a 21-d cycle until disease progression or unacceptable toxicities. Results： Seventy-five patients have been enrolled, among which, 41 received PCF regimen as the first-line therapy （group A） and 34 received the regimen as the second-line therapy （group B） with the median age of 59 years old and Karnofsky performance status （KPS） score 〉80. Toxicities were analyzed in all 75 patients. Seventy-one patients were evaluable for efficacy. The median overall survival （mOS） was 12.0 months （95% CI： 7.9-16.2 months） in group A and 7.3 months （95% CI： 4.3-10.3 months） in group B, respectively. The median progression-free survival （mPFS） was 5.7 months （95% CI： 4.1-7.2 months） and 5.0 months （95% CI： 3.1-6.9 months）, respectively. The response rate （CR^PR） was 40% （16/40; 95% CI： 24.9-56.7%） in group A and 22.6% （7/31; 95% CI： 9.6-41.1%） in group B. Major grade 3 or 4 adverse events include neutropenia （41.3 %）, febrile neutropenia （9.3 %）, nausea/anorexia （10.7%）, and vomiting （5.3 %）. There was no treatment-related death. Conclusions： The combination chemotherapy with PCF is active and tolerable as first-line and second- line therapy in Chinese patients with advanced gastric and EGJ adenocarcinoma. The response and survival of PCF are same as those of DCF, but the tolerance is much better.

Application of computed tomography-based radiomics in differential diagnosis of adenocarcinoma and squamous cell carcinoma at the esophagogastric junction

BACKGROUND The biological behavior of carcinoma of the esophagogastric junction(CEGJ)is different from that of gastric or esophageal cancer.Differentiating squamous cell carcinoma of the esophagogastric junction(SCCEG)from adenocarcinoma of the esophagogastric junction(AEG)can indicate Siewert stage and whether the surgical route for patients with CEGJ is transthoracic or transabdominal,as well as aid in determining the extent of lymph node dissection.With the development of neoadjuvant therapy,preoperative determination of pathological type can help in the selection of neoadjuvant radiotherapy and chemotherapy regimens.AIM To establish and evaluate computed tomography(CT)-based multiscale and multiphase radiomics models to distinguish SCCEG and AEG preoperatively.METHODS We retrospectively analyzed the preoperative contrasted-enhanced CT imaging data of single-center patients with pathologically confirmed SCCEG(n=130)and AEG(n=130).The data were divided into either a training(n=182)or a test group(n=78)at a ratio of 7:3.A total of 1409 radiomics features were separately extracted from two dimensional(2D)or three dimensional(3D)regions of interest in arterial and venous phases.Intra-/inter-observer consistency analysis,correlation analysis,univariate analysis,least absolute shrinkage and selection operator regression,and backward stepwise logical regression were applied for feature selection.Totally,six logistic regression models were established based on 2D and 3D multi-phase features.The receiver operating characteristic curve analysis,the continuous net reclassification improvement(NRI),and the integrated discrimination improvement(IDI)were used for assessing model discrimination performance.Calibration and decision curves were used to assess the calibration and clinical usefulness of the model,respectively.RESULTS The 2D-venous model(5 features,AUC:0.849)performed better than 2D-arterial(5 features,AUC:0.808).The 2D-arterial-venous combined model could further enhance the performance(AUC:0.869).The 3D-venous model(7 features,AUC:0.877)performed better than 3D-arterial(10 features,AUC:0.876).And the 3D-arterial-venous combined model(AUC:0.904)outperformed other single-phase-based models.The venous model showed a positive improvement compared with the arterial model(NRI>0,IDI>0),and the 3D-venous and combined models showed a significant positive improvement compared with the 2D-venous and combined models(P<0.05).Decision curve analysis showed that combined 3D-arterial-venous model and 3D-venous model had a higher net clinical benefit within the same threshold probability range in the test group.CONCLUSION The combined arterial-venous CT radiomics model based on 3D segmentation can improve the performance in differentiating EGJ squamous cell carcinoma from adenocarcinoma.

Laparoscopic-assisted vs open transhiatal gastrectomy for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction: A retrospective cohort study

BACKGROUND The studies of laparoscopic-assisted transhiatal gastrectomy(LTG) in patients with Siewert type Ⅱ adenocarcinoma of the esophagogastric junction(AEG) are scarce.AIM To compare the surgical efficiency of LTG with the open transhiatal gastrectomy(OTG) for patients with Siewert type Ⅱ AEG.METHODS We retrospectively evaluated a total of 578 patients with Siewert type Ⅱ AEG who have undergone LTG or OTG at the First Medical Center of the Chinese People’s Liberation Army General Hospital from January 2014 to December 2019. The short-term and long-term outcomes were compared between the LTG(n = 382) and OTG(n = 196) groups.RESULTS Compared with the OTG group, the LTG group had a longer operative time but less blood loss, shorter length of abdominal incision and an increased number of harvested lymph nodes(P < 0.05). Patients in the LTG group were able to eat liquid food, ambulate, expel flatus and discharge sooner than the OTG group(P < 0.05). No significant differences were found in postoperative complications and R0 resection. The 3-year overall survival and disease-free survival performed better in the LTG group compared with that in the OTG group(88.2% vs 79.2%, P = 0.011;79.7% vs 73.0%, P = 0.002, respectively). In the stratified analysis, both overall survival and disease-free survival were better in the LTG group than those in the OTG group for stage Ⅱ/Ⅲ patients(P < 0.05) but not for stage I patients.CONCLUSION For patients with Siewert type Ⅱ AEG, LTG is associated with better short-term outcomes and similar oncology safety. In addition, patients with advanced stage AEG may benefit more from LTG in the long-term outcomes.

Exploration and optimization of surgical techniques for laparoscopic transhiatal lower mediastinal lymph node dissection for adenocarcinoma of esophagogastric junction: A prospective IDEAL 2a study with qualitative design

Objective: To explore the change and feasibility of surgical techniques of laparoscopic transhiatal(TH)-lower mediastinal lymph node dissection(LMLND) for adenocarcinoma of the esophagogastric junction(AEG)according to Idea, Development, Exploration, Assessment, and Long-term follow-up(IDEAL) 2a standards.Methods: Patients diagnosed with AEG who underwent laparoscopic TH-LMLND were prospectively included from April 14, 2020, to March 26, 2021. Clinical and pathological information as well as surgical outcomes were quantitatively analyzed. Semistructured interviews with the surgeon after each operation were qualitatively analyzed.Results: Thirty-five patients were included. There were no cases of transition to open surgery, but three cases involved combination with transthoracic surgery. In qualitative analysis, 108 items under three main themes were detected: explosion, dissection, and reconstruction. Revised instruction was subsequently designed according to the change in surgical technique and the cognitive process behind it. Three patients had anastomotic leaks postoperatively, with one classified as Clavien-Dindo Ⅲa.Conclusions: The surgical technique of laparoscopic TH-LMLND is stable and feasible;further IDEAL 2b research is warranted.

Thoracoscopic esophagectomy is related to better outcomes in early adenocarcinoma of esophagogastric junction tumors

BACKGROUND Thoracoscopic esophagectomy is related to an extended lymphadenectomy,and a high number of retrieved lymph nodes,compared to the transhiatal approach;however,its association with an improvement in overall survival(OS)is debatable.AIM To compare thoracoscopic esophagectomy with transhiatal esophagectomy in patients with adenocarcinoma of the esophagogastric junction(AEGJ)in terms of survival,number of lymph nodes,and complications.METHODS In total,147 patients with AEGJ were selected retrospectively from 2002 to 2019,and divided into Group A for thoracoscopic esophagectomy,and group B for transhiatal esophagectomy.OS,disease-free survival,postoperative complications,and number of nodes,were similarly evaluated.RESULTS One hundred and thirty(88%)were male;the mean age was 64 years.Group A had a mean age of 61.1 years and group B 65.7 years(P=0.009).Concerning the extent of lymphadenectomy,group A showed a higher number of retrieved lymph nodes(mean of 31.89±8.2 vs 20.73±7;P<0.001),with more perioperative complications,such as hoarseness,surgical site infections,and respiratory complications.Although both groups had similar OS rates,subgroup analysis showed better survival of transthoracic esophagectomy in patients with earlier diseases.CONCLUSION Both methods are safe,having similar morbidity and mortality rates.Transthoracic thoracoscopic esophagectomy allows a more extensive resection of the lymph nodes and may have better oncological outcomes during earlier stages of the disease.Prospective studies are warranted to better evaluate these findings.

Model established based on blood markers predicts overall survival in patients after radical resection of types Ⅱ and Ⅲ adenocarcinoma of the esophagogastric junction

BACKGROUND In recent years, the incidence of types Ⅱ and Ⅲ adenocarcinoma of the esophagogastric junction(AEG) has shown an obvious upward trend worldwide. The prognostic prediction after radical resection of AEG has not been well established.AIM To establish a prognostic model for AEG(types II and III) based on routine markers.METHODS A total of 355 patients who underwent curative AEG at The First Affiliated Hospital of Anhui Medical University from January 2014 to June 2015 were retrospectively included in this study. Univariate and multivariate analyses were performed to identify the independent risk factors. A nomogram was constructed based on Cox proportional hazards models. The new score models was analyzed by C index and calibration curves. The receiver operating characteristic(ROC) curve was used to compare the predictive accuracy of the scoring system and tumor-node-metastasis(TNM) stage. Overall survival was calculated using the Kaplan-Meier curve amongst different risk AEG patients.RESULTS Multivariate analysis showed that TNM stage(hazard ratio [HR] = 2.286, P = 0.008), neutrophil-tolymphocyte ratio(HR = 2.979, P = 0.001), and body mass index(HR = 0.626, P = 0.026) were independent prognostic factors. The new scoring system had a higher concordance index(0.697),and the calibration curves of the nomogram were reliable. The area under the ROC curve of the new score model(3-year: 0.725, 95% confidence interval [CI]: 0.676-0.777;5-year: 0.758, 95%CI:0.708-0.807) was larger than that of TNM staging(3-year: 0.630, 95%CI: 0.585-0.684;5-year: 0.665,95%CI: 0.616-0.715).CONCLUSION Based on the serum markers and other clinical indicators, we have developed a precise model to predict the prognosis of patients with AEG(types II and III). The new prognostic nomogram could effectively enhance the predictive value of the TNM staging system. This scoring system can be advantageous and helpful for surgeons and patients.

A modified double-tract reconstruction following laparoscopic proximal gastrectomy for Siewert Ⅱ adenocarcinoma of the esophagogastric junction (with video)

Objective:The incidence of adenocarcinoma of the esophagogastric junction(AEG)is increasing.For patients with resectable Siewert II AEG,there is still a lack of consensus with regards to which surgical procedure can well balance survival time and quality of life.This study aims to describe a modified double-tract reconstruction(DTR)method following laparoscopic proximal gastrectomy(LPG)and to evaluate the feasibility,safety,and effects of this novel method.Method:This study retrospectively reviewed 29 patients who received modified DTR after LPG for Siewert Ⅱ AEG at a single center between August 2015 and October 2020.Clinicopathological characteristics,surgical outcomes,nutritional status and dietary ability were analyzed.Result:The mean surgical time was 206.4±39.2 min,mean intraoperative blood loss was 175.9±41.4 mL,and median postoperative hospital stay was 11 d(range,9-70 d).The early complication rate was 13.8%(n=4),and the late complication rate was 6.9%(n=2).No reflux esophagitis or reflux symptom was recorded.There were no perioperative deaths within three months post-operatively.At the third follow-up month after surgery,most patients(25/29,86.2%)were experiencing sufficient oral food intake,with a median frequency of 5 meal/d(range,3-6 meal/d).The median total weight loss was 8 kg(range,0-15 kg)and there were no case of post-operative malnutrition.Conclusion:The modified DTR method following LPG represents a novel,safe,and feasible method that provides sufficient nutritional support with few diet-related discomforts.Prospective large-scale randomized trials are now needed to validate the clinical applicability of this method.

A case of Photodynamic Therapy for Advanced Adenocarcinoma of Esophagogastric Junction

Photodynamic therapy(PDT)is a new minimally invasive technique for the treatment of tumors.Compared with traditional treatments such as surgery,radiotherapy and chemotherapy,PDT has the advantages of targeted killing of primary and recurrent tumor cells,less damage to surrounding normal tissue,less complications and high repetition rate.The purpose of this study was to investigate the short-term efficacy and adverse reactions of photodynamic therapy in advanced elderly patients with esophageal-gastric junction adenocarcinoma without surgical indications.A patient with advanced adenocarcinoma of esophagus and fundus was treated with photodynamic therapy under gastroscope.Intravenous drip of Cipofen(hematoporphyrin injection 150mg/0.9%saline 250ml)for 1 hour to keep the patient away from light.48 hours after administration,photodynamic therapy was performed with"Leimai"PDT630-A photodynamic therapy apparatus,3cm columnar optical fiber,laser treatment wavelength of 630nm,transmission efficiency of 0.70,output power of 1.4W,irradiation at the lower segment of the esophagus and cardia for 150s.The curative effect was evaluated by comparing gastroscopy before and after photodynamic therapy.Before treatment,there were proliferative lesions in the lower part of esophagus and cardia,erosion and necrosis on the surface,stricture of esophageal cavity,huge ulcer near gastric fundus,filthy moss and dam-like hyperplasia and eminence of surrounding mucosa.After treatment,the local mucosa at the entrance of cardia became white and there was no bleeding.Within four days after treatment,the symptoms of nausea and vomiting disappeared;the adverse reaction of retrosternal discomfort began to occur on the second day after operation,and the adverse reaction was not improved after photodynamic therapy.Photodynamic therapy has a significant short-term effect on advanced elderly patients with adenocarcinoma of the esophagogastric junction,which can significantly alleviate the clinical symptoms and relieve the pain of the patients.However,the adverse reactions can not be ignored.Therefore,photodynamic targeting therapy for tumor needs to be futher studied.It is believed that with the continuous development of high-performance photosensitizers and new generation lasers,and the continuous progress of endoscopy and image guidance technology,photodynamic therapy will become an important adjuvant or palliative treatment for tumor prevention and treatment.

Risk factors associated with early recurrence of adenocarcinoma of gastroesophageal junction after curative resection

Objective： To clarify the important clinicopathological factors affecting the early recurrence of adenocarcinoma of esophagogastric junction （/kEG）. Methods： We retrospectively reviewed the clinical data of 147 AEG patients who underwent R0 resection during the period from December 1995 to December 2007. Risk factors asssociated with the early recurrence were analyzed by X2 test and logistic regression test. Results： The mean time to tumor recurrence was 16.3 months after R0 resection, and the 1-year recurrence rate was 48.3%. Univariate analysis showed that the histological grade （poorly and moderately differentiated）, number of positive lymph nodes, and vascular invasion were significantly related with the early recurrence （P〈0.05）. Logistic multivariate regression analysis showed that only histological grade and vascular invasion were independently related with early tumor recurrence （P〈0.05）, Conclusions： Histological grade and vascular tumor recurrence after R0 resection for/kEG. invasion are independent factors for predicting the early

Overview of genetic and epigenetic alterations in the pathogenesis of esophagogastric junctional adenocarcinoma and esophageal adenocarcinoma: recent fi ndings by next generation sequencing

Esophagogastric junctional adenocarcinoma is commonly treated as esophageal adenocarcinoma(EAC)and has dramatically increased in Western countries for several decades.The similar trend has been observed in Asian countries(not in China).Barrett’s esophagus(BE)is a widely accepted precursor of EAC.Recent advances of next-generation sequencing could provide researchers with a better understanding of genetic and epigenetic alterations in the carcinogenesis of EAC.In this review,we have summarized the recently reported major genetic and epigenetic alterations in both BE and EAC.Sonic hedgehog/bone morphogenetic protein axis,which is a key signaling for esophageal development,plays an important role in BE intestinal metaplasia.Single nucleotide polymorphisms related to esophageal organogenesis,such as FOXF1 and FOXP3,are frequently detected in BE patients.During the progression of BE to adenocarcinoma,lacking of normal function of TP53 and CDKN2A by loss of heterozygosity(LOH),mutation,or promoter methylation has been frequently observed.LOH at 9p(coding CDKN2A)is an earlier event to EAC carcinogenesis compared to that at 17q(coding TP53)LOH.In order to further elucidate the pathogenesis of BE and EAC,it will be necessary to analyze these genetic/epigenetic alterations in combination with clinical data in a large-scale cohort.