The surgical approach for esophagogastric junction cancers (EJC), Siewert II, has been controversial regarding margin control, reconstruction, and lymphadenectomy extension. Therefore, predicting the need for total/subtotal esophagectomy and proximal gastrectomy (TEPG) or total gastrectomy with distal esophagectomy (TGDE) can be challenging, with each direction usually excluding the other. Historically, complication rates for TEPG are higher, affecting further systemic treatment and long-term outcomes.
The aim of this study was to describe a surgical strategy for approaching tumors such as Siewert II EGJ, with the intraoperative decision to perform total gastrectomy with lymphadenectomy D2 or esophagectomy with lymphadenectomy based on intraoperative frozen sections.
All patients underwent laparotomy, beginning with greater curvature detachment while preserving the right gastroepiploic, right and left gastric arteries; dissection of the esophageal hiatus for node harvesting; and transection of the distal esophagus and its frozen section. TGDE was preferred if the proximal margin of the distal esophagus was negative; TEPG and gastric tube reconstruction were performed through transhiatal access if the margin was positive.
Among 38 Siewert II patients, 26 (69%) underwent TGDE and 12 (31%) underwent TEPG, regardless of the trend toward higher complication rates, positive margins, and shorter overall survival in the TEPG group, no statistically significant differences were detected.
Although no significant differences in morbidity between the two procedures were noted, type II errors could be a possible cause. This study suggests that unnecessary esophagectomies can be avoided without jeopardizing surgical or oncologic outcomes by opting for a less morbid procedure.
Esophageal cancer remains one of the most aggressive malignancies of the gastrointestinal tract, with high rates of recurrence and mortality despite curative-intent surgery and adjuvant therapies. Identifying factors associated with recurrence is crucial for improving outcomes and guiding personalized treatment.
The aim of this study was to evaluate pretreatment and treatment-related variables associated with recurrence in patients with esophageal cancer undergoing surgical resection.
This retrospective study analyzed data from patients with stage I–III esophageal carcinoma who underwent esophagectomy between 2000 and 2025, using the Fundação Oncocentro de São Paulo (FOSP) database. Clinical, histological, and treatment-related variables were evaluated. Disease-free survival and recurrence patterns were assessed using Cox proportional hazards models and Fine–Gray subdistribution hazard models.
A total of 2,057 patients were included, with a mean follow-up of 36.5 months (±44.8). In the multivariate analysis, advanced tumor stage (stage II: HR 1.68, 95%CI 1.21–2.33; stage III: HR 3.23, 95%CI 2.29–4.56; both p<0.01), location (middle esophagus: HR 1.31, 95%CI 1.11–1.54; p=0.001; upper esophagus: HR 1.54, 95%CI 1.21–1.96; p<0.001), and histological subtype (rare histologies: HR 2.17, 95%CI 1.35–3.49; p=0.001) were associated with worse disease-free survival. Multimodal therapy improved disease-free survival (HR 0.40, 95%CI 0.24–0.66) in stage III tumors. Squamous cell carcinoma was independently associated with locoregional recurrence (SHR 1.52, 95%CI 1.05–2.20; p=0.027). For distant recurrence, squamous cell carcinoma showed a protective effect (SHR 0.52, 95%CI 0.31–0.88; p=0.015), while high tumor grade (grade II: SHR 3.65, 95%CI 1.98–6.72; p<0.001) was associated with an increased risk. Multimodal treatments influenced recurrence patterns but did not independently predict outcomes after adjustment.
Tumor stage, location, and histology were strong predictors of disease-free survival after surgery for esophageal cancer. Histological subtypes significantly influenced recurrence patterns. Squamous cell carcinoma was associated with a higher risk of locoregional recurrence but a lower risk of distant metastasis compared to adenocarcinoma. Multimodal therapy demonstrated a protective effect in stage III disease.
The incidence of esophageal cancer is high in some regions and the surgical treatment requires reference centers, with high volume, to make surgery feasible.
To evaluate patients undergoing minimally invasive esophagectomy by thoracoscopy in prone position for the treatment of esophageal cancer and to recognize the experience acquired over time in our service after the introduction of this technique.
From January 2012 to August 2021, all patients who underwent the minimally invasive esophagectomy for esophageal cancer were retrospectively analyzed. In order to assess the factors associated with the predefined outcomes as fistula, pneumonia, and intrahospital death, we performed univariate and multivariate logistic regression analyses, accounting for age as an important factor.
Sixty-six patients were studied, with mean age of 59.5 years. The main histological type was squamous cell carcinoma (81.8%). The incidence of postoperative pneumonia and fistula was 38% and 33.3%, respectively. Eight patients died during this period. The patient's age, T and N stages, the year the procedure was performed, and postoperative pneumonia development were factors that influenced postoperative death. There was a 24% reduction in the chance of mortality each year, associated with the learning curve of our service.
The present study presented the importance of the team's experience and the concentration of the treatment of patients with esophageal cancer in reference centers, allowing to significantly improve the postoperative outcomes.
The effect of neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced esophageal cancer can be determined by assessing the Becker tumor regression grade in the primary tumor, as well as in lymph nodes.
The aim of this study was to investigate the anatomopathological changes caused by neoadjuvant chemoradiotherapy and their impact on clinical parameters. Specifically, we analyzed the Becker tumor regression grade, lymph node status, and regression changes and evaluated their association with the Clavien-Dindo classification of surgical complications and overall patient survival.
This is a retrospective and observational study including 139 patients diagnosed with adenocarcinoma or squamous cell carcinoma of the esophagus and treated with either neoadjuvant chemoradiotherapy followed by surgery or surgery alone. For the 94 patients who underwent neoadjuvant chemoradiotherapy, we evaluated tumor regression by Becker tumor regression grade in primary tumors. We also analyzed lymph node status and regression changes on lymph nodes with or without metastases. Overall survival analysis was performed using Kaplan-Meier curves.
Becker tumor regression grade is associated with lower lymphatic permeation (p<0.01) and vascular invasion (p<0.001), but not with lymph node regression rate (p=0.10). Clavien-Dindo classification was associated neither with lymph node regression rate (odds ratio=0.784, p=0.795) nor with tumor regression grade (p=0.68). Patients who presented with lymphatic permeation and vascular invasion had statistically significantly lower median survival (17 vs. 30 months, p=0.006 for lymphatic permeation, and 14 vs. 29 months, p=0.024 for vascular invasion).
In our series, we were unable to demonstrate an association between Becker tumor regression grade and lymph node regression rate with any postoperative complications. Patients with lower lymphatic permeation and vascular invasion have higher overall survival, correlating with a better response in the Becker tumor regression grade system.
The enzyme methylenetetrahydrofolate reductase is engaged in DNA synthesis through folate metabolism. Inhibiting the activity of this enzyme increases the susceptibility to mutations, and damage and aberrant DNA methylation, which alters the gene expression of tumor suppressors and proto-oncogenes, potential risk factors for esophageal cancer.
This study aimed to investigate the association between methylenetetrahydrofolate reductase 677C>T and methylenetetrahydrofolate reductase 1298A>C polymorphisms and susceptibility to esophageal cancer, by assessing the distribution of genotypes and haplotypes between cases and controls, as well as to investigate the association of polymorphisms with clinical and epidemiological characteristics and survival.
A total of 109 esophageal cancer patients who underwent esophagectomy were evaluated, while 102 subjects constitute the control group. Genomic DNA was isolated from the peripheral blood buffy coat followed by amplification by polymerase chain reaction and real-time analysis. Logistic regression was used to assess associations between polymorphisms and the risk of developing esophageal cancer.
There was no association for methylenetetrahydrofolate reductase 677C>T and methylenetetrahydrofolate reductase 1298A>C polymorphisms and haplotypes, with esophageal cancer susceptibility. Esophageal cancer patients carrying methylenetetrahydrofolate reductase 677TT polymorphism had higher risk of death from the disease. For polymorphic homozygote TT genotype, the risk of death significantly increased compared to wild-type genotype methylenetetrahydrofolate reductase 677CC (reference) cases (p=0.045; RR=2.22, 95%CI 1.02–4.83).
There was no association between methylenetetrahydrofolate reductase 677C>T and methylenetetrahydrofolate reductase 1298A>C polymorphisms and esophageal cancer susceptibility risk. Polymorphic homozygote genotype methylenetetrahydrofolate reductase 677TT was associated with higher risk of death after surgical treatment for esophageal cancer.
Esophagogastroduodenoscopies and colonoscopies are the main diagnostic examinations for esophageal, stomach, and colorectal tumors.
This study aimed to evaluate the estimates of the incidence of esophageal, stomach, and colorectal cancer; population growth; and esophagogastroduodenoscopies and colonoscopies performed by the Unified Health System (SUS), from 2010 to 2018, in the five regions of the country, and to analyze the relationship between these values.
The colorectal tumor had a significant elevation, while the esophageal and gastric maintained the incidences. In the five regions, there was a significant increase in the number of colonoscopies; however, this increase did not follow the increase in the population in the North and Northeast regions. There was no significant increase in the number of esophagogastroduodenoscopies in the North, Northeast, Midwest, and South regions, and in the North region there was a decrease. In the Northeast region, there was a decreasing number, and in the South and Midwest regions, the number of examinations remained stable in the period. The Southeast region recorded an increase in the number of examinations following the population growth.
The current number of esophagogastroduodenoscopies and colonoscopies performed by the SUS did not follow the population growth, in order to attend the population and diagnose esophageal, stomach, and colorectal tumors. Therefore, the country needs to have adequate and strategic planning on how it will meet the demand for these tests and serve the population well, incorporating new technologies.
Esophageal cancer neoadjuvant therapy followed by surgery increases the likelihood of treatment success.
To evaluate variables that can influence the number of retrieved lymph nodes, the number of retrieved metastatic lymph nodes and lymphnodal recurrence in esophagectomy after neoadjuvant chemoradiotherapy.
Patients of a single institute were evaluated after completion of trimodal therapy. Univariate and multivariate analyses were performed to evaluate variables that can influence in the number of retrieved lymph nodes and retrieved metastatic lymph nodes.
One hundred and forty-nine patients were included. Thoracoscopy access was considered an independent factor for the number of lymph nodes retrieved, but was neither related to the number of positive lymph nodes retrieved nor to lymphnodal recurrence. Pathological complete response on the primary tumor and male were independent variables associated with the number of positive lymph node retrieved. Pathological complete response on the primary tumor site did not statistically influence the likelihood of a lower number of lymph nodes retrieved.
Patients submitted to esophagectomy after neoadjuvant chemoradiotherapy, thoracoscopic access is more accurate for pathological staging, even in a complete pathological response. With a proper patient selection, transhiatal surgery may preserve the quality of lymphadenectomy of the positive lymph nodes.
The identification of prognostic factors of esophageal cancer has allowed to predict the evolution of patients.
Assess different prognostic factors of long-term survival of esophageal cancer and evaluate a new prognostic factor of long-term survival called lymphoparietal index (N+/T).
Prospective study of the Universidad de Chile Clinical Hospital, between January 2004 and December 2013. Included all esophageal cancer surgeries with curative intent and cervical anastomosis. Exclusion criteria included: stage 4 cancers, R1 resections, palliative procedures and emergency surgeries.
Fifty-eight patients were included, 62.1% were men, the average age was 63.3 years. A total of 48.3% were squamous, 88% were advanced cancers, the average lymph node harvest was 17.1. Post-operative surgical morbidity was 75%, with a 17.2% of reoperations and 3.4% of mortality. The average overall survival was 41.3 months, the 3-year survival was 31%. Multivariate analysis of the prognostic factors showed that significant variables were anterior mediastinal ascent (p=0.01, OR: 6.7 [1.43-31.6]), anastomotic fistula (p=0.03, OR: 0.21 [0.05-0.87]), N classification (p=0.02, OR: 3.8 [1.16-12.73]), TNM stage (p=0.04, OR: 2.8 [1.01-9.26]), and lymphoparietal index (p=0.04, RR: 3.9 [1.01-15.17]. The ROC curves of lymphoparietal index, N classification and TNM stage have areas under the curve of 0.71, 0.63 and 0.64 respectively, with significant statistical difference (p=0.01).
The independent prognostic factors of long-term survival in esophageal cancer are anterior mediastinal ascent, anastomotic fistula, N classification, TNM stage and lymphoparietal index. In esophageal cancer the new lymphoparietal index is stronger than TNM stage in long-term survival prognosis.
Multimodal therapy with neoadjuvant chemoradiotherapy, followed by esophagectomy has offered better survival results, compared to isolated esophagectomy, in advanced esophageal cancer. In addition, patients who have a complete pathological response to neoadjuvant treatment presented greater overall survival and longer disease-free survival compared to those with incomplete response.
To compare the results of overall survival and disease-free survival among patients with complete and incomplete response, submitted to neoadjuvant chemoradiotherapy, with two therapeutic regimens, followed by transhiatal esophagectomy.
Retrospective study, approved by the Research Ethics Committee, analyzing the medical records of 56 patients with squamous cell carcinoma of the esophagus, divided into two groups, submitted to radiotherapy (5040 cGY) and chemotherapy (5-Fluorouracil + Cisplatin versus Paclitaxel + Carboplatin) neoadjuvants and subsequently to surgical treatment, in the period from 2005 to 2012, patients.
The groups did not differ significantly in terms of gender, race, age, postoperative complications, disease-free survival and overall survival. The 5-year survival rate of patients with incomplete and complete response was 18.92% and 42.10%, respectively (p> 0.05). However, patients who received Paclitaxel + Carboplatin, had better complete pathological responses to neoadjuvant, compared to 5-Fluorouracil + Cisplatin (47.37% versus 21.62% - p = 0.0473, p <0.05).
There was no statistical difference in overall survival and disease-free survival for patients who had a complete pathological response to neoadjuvant. Patients submitted to the therapeutic regimen with Paclitaxel and Carboplastin, showed a significant difference with better complete pathological response and disease progression. New parameters are indicated to clarify the real value in survival, from the complete pathological response to neoadjuvant, in esophageal cancer.
Desenvolvido por Surya MKT