BACKGROUND/OBJECTIVES:Currently, a definitive diagnostic strategy for predicting mediastinal lymph-node (MLN) metastasis remains poorly established in Siewert Type I and II esophagogastric junction adenocarcinoma (EGJAC). This study aimed to evaluate long-term survival and identify objective, reliable preoperative risk factors for MLN metastasis to optimize perioperative treatment and surgical approach. METHODS:We retrospectively reviewed a well-defined cohort of 133 patients with Siewert Type I (33.1%) and II (66.9%) EGJAC who underwent R0 resection and complete follow-up at our institution between 2005 and 2025. Preoperative risk factors for histological MLN metastasis were evaluated using receiver operating characteristic (ROC) curve analysis and univariate/multivariate logistic regression models. RESULTS:Thorough upper, middle, and lower MLND were completed in 57.9%, 72.9%, and 94.7% of patients, respectively. Pathological MLN metastasis was confirmed in 31.6% of patients and was significantly associated with poor overall and recurrence-free survival. ROC analysis demonstrated that an MLN short-axis diameter of ≥5 mm on CT, esophageal involvement length (EIL) in upper GI series ≥ 30 mm, and EIL in endoscopy ≥ 60 mm predict histological MLN metastasis. In univariate analysis, Siewert Type I, EIL in upper GI series ≥30 mm, EIL in endoscopy ≥ 60 mm, clinical tumor depth ≥ cT3, and CT node size ≥ 5 mm were correlated with MLN metastasis. Multivariate logistic regression analysis revealed that a clinical tumor depth of ≥cT3, EIL in upper GI series ≥ 30 mm, and a CT node size of ≥5 mm were independent predictors of MLN metastasis. CONCLUSIONS:Clinical tumor depth, EIL, and size of MLN are powerful independent preoperative risk factors for MLN metastasis in Siewert Type I/II EGJAC. Utilizing these objective indices may help identify high-risk patients requiring intensive perioperative multidisciplinary strategies.

BACKGROUND:This study aimed to clarify the correlation between anastomotic leakage and anastomotic position after esophagectomy for esophageal cancer, stratified by gastric conduit blood flow assessed using indocyanine green (ICG) fluorescence imaging. METHODS:A total of 136 patients who underwent esophagectomy with retrosternal gastric conduit reconstruction were included. After creating the gastric conduit, three points were identified: point A (anastomotic site), point B (terminal end of the gastroepiploic artery stained with ICG), and point C (terminal end of the gastric conduit wall stained with ICG). Anastomotic position was defined by the relative location of point A between points B and C, and blood flow speed before reconstruction (pre-speed) was quantified using ICG fluorescence imaging. Associations of anastomotic position and pre-speed with anastomotic leakage were evaluated. RESULTS:Anastomotic leakage occurred in 22 patients (16.2%). Mean distance BA (point B to A) was 2.05 cm in the leakage group and 0.15 cm in the non-leakage group (p = 0.018). Mean distance AC (point A to C) was 4.00 cm in the leakage group and 5.89 cm in the non-leakage group (p = 0.016). Logistic regression revealed that BA > -0.50 cm and pre-speed < 2.19 cm/s were independent risk factors for anastomotic leakage (odds ratio 4.67, p = 0.046, and odds ratio 56.16, p < 0.001, respectively). Among patients with delayed blood flow, the anastomotic leakage rate was significantly lower in the proximal group than in the distal group (p = 0.034). CONCLUSIONS:ICG fluorescence imaging provides useful information for determining an appropriate anastomotic position. Performing the anastomosis at a more proximal site within the gastric conduit may reduce the risk of anastomotic leakage.

Abstract Topic Esophageal Cancer: Oncology/Radiation Therapy Background Esophageal cancer remains associated with high mortality and frequent recurrence despite advances in perioperative treatment. The concept of oligometastasis has gained attention, as selected patients may achieve prolonged survival with multidisciplinary treatment. However, the optimal strategy for oligo-recurrence after curative esophagectomy remains unclear. Methods Among 497 patients who underwent R0 esophagectomy between 2010 and 2020, 161 who developed recurrence were analyzed. Oligo-recurrence was defined as recurrence in a single organ with ≤5 lesions or lymph node recurrence confined to a single region with ≤5 nodes. Early recurrence was defined as recurrence within 6 months after surgery. Patients were categorized into four groups according to oligo-recurrence and timing of recurrence, and overall survival (OS) and survival after recurrence were compared. In addition, outcomes were analyzed according to recurrent organ in the oligo-recurrence cohort. Multivariate analysis was performed to identify prognostic factors. Results Of the 161 recurrent cases, 33 (20%) had non-early oligo-recurrence, 20 (12%) had early oligo-recurrence, 43 (27%) had non-early non-oligo-recurrence, and 65 (40%) had early non-oligo-recurrence. Patients with non-early oligo-recurrence demonstrated the most favorable OS (p<0.0001), whereas early oligo-recurrence showed survival comparable to non-early non-oligo-recurrence.Within the oligo-recurrence cohort, recurrence sites included lymph nodes (n=34), liver (n=7), lung (n=5), and others (n=7). Median survival after recurrence was 49 months for lymph node recurrence and 14 months for liver recurrence (p=0.011). Curative treatment (surgery or chemoradiotherapy) was an independent favorable prognostic factor (HR 0.203, p=0.006). Conclusion In patients with oligo-recurrence after curative esophagectomy, prognosis varies according to both timing and site of recurrence. Curative treatment may improve survival, particularly in lymph node recurrence without early recurrence. Treatment strategies should therefore incorporate both time to recurrence and site of recurrence.

Abstract Topic Esophageal Cancer: Surgical Treatment of Esophageal Cancer Background Management of thoracic esophageal cancer with suspected adjacent organ invasion remains challenging because of diagnostic uncertainty and limited curative options. Recent advances in induction chemotherapy, including DCF and immune checkpoint inhibitors, have enabled downstaging and subsequent conversion to curative-intent treatment in selected patients. Methods We retrospectively reviewed 57 patients with locally advanced, initially unresectable thoracic esophageal squamous cell carcinoma without distant metastasis except supraclavicular lymph nodes, who initiated treatment with induction chemotherapy (DCF or immune checkpoint inhibitor plus chemotherapy) or definitive chemoradiotherapy between January 2014 and December 2024. Patients achieving complete response after non-surgical treatment or R0 resection were defined as cancer free. Cases diagnosed before the 12th edition of the Japanese Classification of Esophageal Cancer were reclassified as cT3br or cT4 based on endoscopic circumferential involvement and computed tomography findings, including compression or displacement of adjacent organs. Treatment pathways, conversion therapy, short-term surgical outcomes, and survival were analyzed. Results The cohort included 34 cT3br and 23 cT4 patients. Initial induction chemotherapy achieved downstaging to resectable disease in 85% of cT3br and 57% of cT4 cases. Conversion surgery was performed in 27 patients, with R0 resection achieved in 25. Median blood loss was 190 mL, operative time 524 minutes, and no in-hospital mortality occurred. Cancer-free status was associated with significantly improved survival in both cT3br and cT4 groups (2-year overall survival: 74% vs 11% and 100% vs 7%, respectively; both p<0.001). Among surgical cases, patients achieving pathological response grade ≥2 showed superior survival compared with non-responders (2-year overall survival: 100% vs 53%, p=0.01). Prognosis did not differ according to the invaded organ. Conclusion In thoracic esophageal cancer with adjacent organ invasion, achieving cancer-free status is strongly associated with improved survival regardless of initial T classification. A multimodal treatment strategy incorporating induction therapy and conversion treatment, including definitive chemoradiotherapy or surgery, represents a feasible curative approach. Careful treatment selection remains essential given the limitations of diagnostic accuracy in assessing organ invasion.

Esophageal adenosquamous carcinoma is a rare histological subtype of esophageal cancer characterized by the coexistence of squamous cell carcinoma and adenocarcinoma components. Preoperative diagnosis is challenging because biopsy specimens often contain only the squamous component. A 75-year-old man presented with dysphagia. Esophagogastroduodenoscopy revealed a type 3 tumor in the middle thoracic esophagus. Histopathological examination of the biopsy specimens demonstrated predominantly squamous cell carcinoma with a minor mucin-producing adenocarcinoma component, raising suspicion of adenosquamous carcinoma. Given the patient’s history of myocardial infarction and poor cardiac function, neoadjuvant chemotherapy was considered unsuitable. The patient underwent thoracoscopic esophagectomy with lymph node dissection. Pathological examination confirmed adenosquamous carcinoma, with the superficial portion composed predominantly of moderately differentiated squamous cell carcinoma, whereas the deeper layers contained mucinous carcinoma and signet-ring cells. Extensive lymph node metastases were identified in the cervical, thoracic, and abdominal regions, the majority of which predominantly comprised mucinous carcinoma. At seven months postoperatively, mediastinal lymph node recurrence was detected. Due to the patient’s deteriorating general condition, systemic chemotherapy was contraindicated, and the patient died 11 months postoperatively. We report a rare case of esophageal adenosquamous carcinoma with mucinous carcinoma-predominant lymph node metastases. The predominance of mucinous carcinoma in metastatic lesions may reflect the aggressive biological behavior of the adenocarcinoma component and could be associated with poor clinical outcomes. Although esophageal adenosquamous carcinoma is generally managed using surgery-based multidisciplinary strategies based on the treatment principles for esophageal squamous cell carcinoma, no standard chemotherapy regimen has been established for esophageal adenosquamous carcinoma. Further accumulation of cases is needed to determine the optimal treatment strategies for this rare disease.

Aim:This study aimed to clarify patient background characteristics, preoperative findings, surgical factors, and postoperative outcomes according to hernia type in patients who underwent surgery for hiatal hernia in Japan. Methods:We conducted a retrospective, questionnaire-based clinical review of patients who underwent surgery between January 2001 and December 2015 at institutions with board-certified esophagologists accredited by the Japan Esophageal Society. Data from 960 cases across 80 institutions in Japan were analyzed. Results:Of the 960 cases, data on hernia type were available in 838 and included in the analysis. The distribution was as follows: Type I, 524 cases (63%); Type II, 53 (6%); Type III, 171 (20%); and Type IV, 90 (11%). Compared with Types II-IV, Type I patients were younger, more often male, had longer symptom duration, more heartburn, fewer comorbidities, and more severe esophagitis. Strictures were rare, and surgery was more often indicated due to refractoriness to medical treatment. Type I cases had higher rates of laparoscopic surgery and Toupet fundoplication, with shorter operative times, fewer complications, and shorter hospital stays. They had lower rates of postoperative dysphagia. Risk factors for postoperative dysphagia included Types II-IV hernia (OR 1.676, p = 0.002), preoperative dysphagia (OR 1.898, p = 0.006), and esophageal strictures (OR 3.102, p = 0.016). Hernia type was not associated with postoperative recurrence. Conclusion:Patients with Type I hernia differed from those with Types II-IV in background characteristics, preoperative findings, surgical factors, and postoperative outcomes. Given the higher risk of postoperative dysphagia in Types II-IV, careful attention to surgical technique is warranted.

An increasing number of patients are undergoing conversion surgery owing to the rising popularity of relatively strong regimens such as immune checkpoint inhibitor (ICI)-combined chemotherapy for the treatment of unresectable esophageal or esophagogastric junction (EGJ) cancer. However, the perioperative safety of conversion surgery after ICI combined with chemotherapy remains unclear. We report two cases of postoperative immune-related adverse events (irAEs) in patients who underwent conversion surgery after the induction of ICI-combined chemotherapy. Case 1: A patient with unresectable EGJ adenocarcinoma and para-abdominal aortic lymph node (LN) metastasis developed adrenal insufficiency after four courses of nivolumab + S1 + oxaliplatin (Nivo+ SOX) therapy. As significant tumor shrinkage was observed, conversion surgery was performed. While the postoperative course was uneventful, two months after surgery, hypothyroidism developed and was determined to be an irAE. Thyroid hormone replacement therapy was administered and the symptoms improved. Case 2: A patient with EGJ adenocarcinoma and extensive metastasis to mediastinal, supraclavicular, and para-aortic LNs, along with aortic invasion, also received four courses of Nivo + SOX. Hypothyroidism developed during treatment and was managed with thyroid hormone replacement therapy. Following notable tumor regression, the patient underwent conversion surgery. The patient’s postoperative course was uneventful and was discharged. However, one month after surgery, the patient was readmitted with severe respiratory distress and was diagnosed with interstitial pneumonia. Intensive care with extracorporeal membrane oxygenation (ECMO) was initiated following steroid and endoxan pulse therapy, but the patient died four months after surgery. The risk of irAEs should always be considered in patients receiving ICIs, even after conversion surgery. This condition should be differentiated from complications of esophagectomy and managed promptly.

The recurrence rates in patients with esophageal cancer who are treated by curative esophagectomy is very poor. On the other hand, some patients with recurrence after esophagectomy have achieved long-term survival with multidisciplinary treatment. Recently, the concept of oligo-recurrence has gained attention. We investigated the characteristics and prognosis of patients with oligo-recurrence after esophagectomy. We included 135 patients with recurrence among 490 patients who underwent esophagectomy for esophageal cancer between January 2010 and March 2021 at our hospital. Oligo-recurrence was defined as five or fewer recurrences in a single organ or five or fewer recurrences in a single lymph node. Patients were divided into two groups: the oligo-recurrence group and the non oligo-recurrence group. We evaluated the prognosis of patients with oligo-recurrence, focusing especially on its correlation with the site of recurrence, treatment after recurrence. Of the 135 recurrence patients, 46 (34%) were in the oligo-recurrence group and 89 (66%) were in the non oligo-recurrence group. The overall survival was 38 months in the oligo-recurrence group and 18 months in the non oligo-recurrence group (p < 0.001). Survival after recurrence was 23 months in the oligo-recurrence group and 7 months in the non oligo-recurrence group (p < 0.001). The prognosis was better in the lymph node recurrence group than in the liver recurrence group (p = 0.04). 25 lymph node recurrence patients (86%) received chemoradiotherapy, all liver recurrence patients received chemotherapy, and 4 lung recurrence patients (80%) patients underwent lung resection. Oligo-recurrence after radical esophagectomy for esophageal cancer may be associated with a favorable prognosis. Radical treatment may be useful in lymph node and lung oligo-recurrence.

Background:β-hydroxy-β-methylbutyrate (HMB) is a metabolite of the essential amino acid leucine that promotes muscle protein synthesis and inhibits muscle cell degradation. This study aimed to clarify the effects of HMB on skeletal muscle mass loss using a mouse model of esophageal squamous cell carcinoma (ESCC). Methods:ESCC cells (TE-8) (5×106 cells/body) were subcutaneously transplanted into 10 nude mice to generate a mouse model of ESCC. Thirteen mice were divided into three groups: (I) non-tumor group (n=3), non-ESCC mice fed a normal diet; (II) ESCC + HMB group (n=5), ESCC-bearing mice fed HMB; (III) ESCC control group (n=5), ESCC-bearing mice fed a normal diet. A powdered Ca-HMB product was used as the HMB source. Body weight, grip strength, and gastrocnemius muscle weight of the three groups of mice were measured and compared. Results:Body weight did not differ between the ESCC + HMB and ESCC control groups. Grip strength and gastrocnemius muscle weight were significantly higher in the ESCC + HMB group than those in the ESCC control group (grip strength, P=0.03; gastrocnemius muscle weight, P<0.01). No significant difference in grip strength or gastrocnemius muscle weight was observed between the ESCC + HMB and non-tumor groups (grip strength, P=0.94; gastrocnemius muscle weight, P=0.65). No difference in grip strength or gastrocnemius muscle weight was observed between non-tumor mice and ESCC mice (grip strength: P=0.35, gastrocnemius muscle weight: P=0.37). Conclusions:HMB administration to ESCC-bearing mice maintained grip strength and gastrocnemius muscle weight at levels comparable to those of non-transplanted (non-ESCC) mice. Future studies should elucidate the mechanisms by which HMB counteracts cachexia and confirm these physiological findings with molecular biological evidence.

Immune checkpoint inhibitor therapy has dramatically improved patient prognosis, and thereby transformed the treatment in various cancer types including esophageal squamous cell carcinoma (ESCC) in the past decade. Monoclonal antibodies that selectively inhibit programmed cell death-1 (PD-1) activity has now become standard of care in the treatment of ESCC in metastatic settings, and has a high expectation to provide clinical benefit during perioperative period. Further, anti-cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) monoclonal antibody has also been approved in the treatment of recurrent/metastatic ESCC in combination with anti-PD-1 antibody. Well understanding of the existing evidence of immune-based treatments for ESCC, as well as recent clinical trials on various combinations with chemotherapy for different clinical settings including neoadjuvant, adjuvant, and metastatic diseases, may provide future prospects of ESCC treatment for better patient outcomes.

Background The azygos lobe is a relatively rare anatomical variation, and there have been no reports, until date, of thoracoscopic McKeown esophagectomy for esophageal cancer in a patient with an azygos lobe. The azygos lobe can be diagnosed by chest X-ray or CT, and is usually not associated with any symptoms. However, surgeons should be aware that transthoracic surgical procedures in patients with an azygos lobe could be associated with a high risk of complications. Case presentation An 83-years-old man was brought to our emergency room with fever, severe headache, and difficulty in moving. MRI revealed a brain abscess, which was treated by abscess drainage and systemic antibiotic treatment. Further examinations to determine the cause of the brain abscess revealed esophageal cancer. In addition, CT revealed an azygos lobe in the right thoracic cavity. Although intrathoracic adhesions were anticipated on account of a previous history of bacterial pyothorax, we decided to perform esophagectomy via a thoracoscopic approach. Despite the difficulty in dissecting the intrathoracic adhesions, we were able to obtain the surgical field thoracoscopically. Then, we found the azygos lobe, as diagnosed preoperatively, and the azygos vein was supported by the mesentery draining into the superior vena cava. After dividing the mesentery, we clipped and cut the vessel, and both ends were further ligated. After these procedures, we safely performed esophagectomy with 3-field lymph node dissection. The postoperative course was uneventful, and the patient was discharged on the 21st postoperative day. Conclusions Although there was a firm adhesion in the thoracic cavity, preoperative recognition of the azygos lobe could help in preventing intraoperative injury. Especially, esophageal surgeons are required to deal with the azygos lobe safely to avoid serious intraoperative injury.

Abstract Background We conducted this study to investigate the effectiveness of a modified incision line on the lesser curvature for gastric conduit formation during esophagectomy in enhancing the perfusion of the gastric conduit, as determined by indocyanine green (ICG) fluorescence imaging, and reducing the incidence of anastomotic leakage. Methods A total of 272 patients who underwent esophagectomy at our institution between June 2014 and August 2022 were enrolled in the study. The patients were divided into two groups in accordance with the type of cutline on the lesser curvature: the Conventional group, consisting of patients operated on until 2018 (Conventional group; n = 141), in which the traditional cutline (5.0 cm from the pylorus in routine) was adopted, and the Current group, consisting of patients operated on from 2019 until date (Current group; n = 131), in which a modified cutline on the lesser curvature was adopted, that allowed preservation of the entire right gastric artery was adopted (hereinafter, modified cutline) was adopted. Gastric conduit perfusion during the surgery was assessed by intraoperative ICG fluorescence imaging, and the clinical outcomes after esophagectomy were also evaluated. Results All patients underwent esophagectomy with regional lymph node dissection and gastric conduit reconstruction via the retrosternal route. The distance from the pylorus to the cutline was significantly longer in the Current group as compared with the Conv group (median: 9.0 cm vs. 5.0 cm, p < 0.001). The blood flow speed in the gastric conduit wall assessed by ICG fluorescence imaging was significantly higher in the Current group than that in the Conventional group (median: 2.81 cm/sec vs. 2.54 cm/sec, p = 0.001). Furthermore, the incidence of anastomotic leakage was significantly lower (p = 0.024) and the hospital stay significantly shorter (p < 0.001) in the Current group as compared with the Conventional group. Logistic regression analysis using the data of the entire cohort identified the blood flow velocity in the gastric conduit wall as the only variable that was significantly (negatively) associated with anastomotic leakage. Conclusions ICG fluorescence imaging is a feasible, reliable method for intraoperative assessment of gastric conduit perfusion. Use of the modified lesser curvature cutline could enhance gastric conduit perfusion, promote blood circulation around the anastomosis and ultimately reduce the risk of anastomotic leakage after esophagectomy.

As a result of the recent advances in first-line treatment including chemotherapy, radiation therapy, targeted therapy, and immune checkpoint inhibitor immunotherapy (ICI) for locally advanced/metastatic initially unresectable esophageal and esophagogastric junction cancer, surgery aiming at cure after initial treatment, so-called “conversion surgery” has become more common in this field. Several studies have indicated encouraging survival outcomes for patients after conversion surgery with R0 resection. However, various issues, such the utility and the safety of conversion surgery remain unclear. In this review, we will focus on the surgical treatment for initially unresectable esophageal and esophagogastric junction cancer after first- or later- line treatment and review recent evidence regarding the safety and the efficacy of conversion surgery. Multidisciplinary treatment including surgery may serve as a novel treatment strategy for esophageal and esophagogastric junction cancer, thus provide a curative treatment option and potentially contribute to better prognosis for initially untreatable diseases.

This study aimed to investigate the effectiveness of a modified incision line on the lesser curvature for gastric conduit formation during esophagectomy in enhancing the perfusion of gastric conduit as determined by indocyanine green fluorescence imaging and reducing the incidence of anastomotic leakage. A total of 272 patients who underwent esophagectomy at our institute between 2014 and 2022 were enrolled in this study. These patients were divided based on two different types of cutlines on the lesser curvature: conventional group (n = 141) following the traditional cutline and modified group (n = 131) adopting a modified cutline. Gastric conduit perfusion was assessed by ICG fluorescence imaging, and clinical outcomes after esophagectomy were evaluated. The distance from the pylorus to the cutline was significantly longer in the modified group compared with the conventional group (median: 9.0 cm vs. 5.0 cm, p < 0.001). The blood flow speed in the gastric conduit wall was significantly higher in the modified group than that in the conventional group (median: 2.81 cm/s vs. 2.54 cm/s, p = 0.001). Furthermore, anastomotic leakage was significantly lower (p = 0.024) and hospital stay was significantly shorter (p < 0.001) in the modified group compared with the conventional group. Multivariate analysis identified blood flow speed in the gastric conduit wall as the only variable significantly associated with anastomotic leakage. ICG fluorescence imaging is a feasible, reliable method for the assessment of gastric conduit perfusion. Modified lesser curvature cutline could enhance gastric conduit perfusion, promote blood circulation around the anastomotic site, and reduce the risk of anastomotic leakage after esophagectomy.

Abstract Background Mediastinal lymph node dissection (LND) is a critical factor to decide the surgical strategy for Esophagogastric junction (EGJ) cancers. As a result of a prospective multicenter study in Japan, surgical algorithm including the extent of LND for EGJ cancers has recently been proposed according to the length of esophageal invasion. However, preoperative measure predicting upper mediastinal LN metastasis is still lacking, and the oncologic efficacy of mediastinal LND remain unknown. Methods The aim of this study was to identify preoperative factors predicting mediastinal LN metastasis, and we hypothesized that preoperative CT image would be of utility. Patients who underwent surgical treatment for Siewert Type I/II EGJ cancer with esophageal invasion with curative intent between 2000 and 2022 at the Tokai University Hospital were retrospectively reviewed. Results A total of 103 patients were enrolled. Among them, 55, 74, and 74 patients underwent upper, middle, and lower mediastinal LND, respectively. Upper/middle/lower mediastinal LN metastasis was observed in 14/13/23 of those patients, respectively, with lower thoracic paraesophageal LNs (29%), middle thoracic paraesophageal LNs (18%), and right recurrent nerve LNs (16%) being the three most common metastatic sites. Estimated invasion depth of the primary lesion≧cT3 (p≦0.007), tumor size≧4cm (p≦0.002), esophageal invasion length≧4cm (p≦0.007) and minor axis of the LN≧5mm by preoperative CT image (p<0.001) were significant preoperative factors related to mediastinal LN metastasis. Conclusion Clinical T factor, tumor size, the size of mediastinal LN by CT image, as well as esophageal invasion length, were important preoperative factors to predict mediastinal LN metastasis, and those factors should be taken into consideration to decide the surgical strategy for EGJ cancers with esophageal invasion. Survival impact of mediastinal LND still remain unclear, and further accumulation of cases and prospective studies are awaited.

Abstract Background For the primary treatment of unresectable or recurrent esophageal cancer, combination therapy with immune checkpoint inhibitors (ICI) such as pembrolizumab (Pem) with CF (cisplatin and 5-fluorouracil), nivolumab (Nivo) with CF, and Nivo with ipilimumab (Ipi) has been shown the significantly improve prognosis compared to standard CF therapy in international collaborative phase III trials. As a result, these ICIs have been approved as primary treatment agents in Japan, with treatment guidelines strongly recommending therapies including ICIs. We evaluated the treatment outcomes at our institute and discussed their utility. Methods We examined the treatment outcomes of 26 esophageal cancer patients who underwent primary treatment with Pem+CF, Nivo+CF, or Nivo+Ipi from January 2018 to January 2023. The median observation period was 7.0 months. Results There were 20 male and 6 female patients, with a median age of 69 years. Histologically, there were 24 cases of squamous cell carcinoma and 2 cases of adenocarcinoma. Of the 26 patients, 9 were postoperative recurrences and 17 were unresectable diseases. They were treated with Pem+CF (12 cases), Nivo+CF (7 cases), or Nivo+Ipi (7 cases) as primary therapy. The initial response was complete response (CR) in 1 case, partial response (PR) in 14 cases, stable disease (SD) in 2 cases, and progressive disease (PD) in 9 cases, resulting in an overall response rate of 57.6%. The median progression-free survival was 5.0 months, and the median overall survival was 15.2 months. There was no significant difference in prognosis according to the regimens. Grade 3 or higher adverse events included neutropenia in 3 cases, pituitary insufficiency in 1 case, and adrenal insufficiency in 1 case. One case with lung metastasis and two cases with para-aortic lymph node metastasis showed disappearance of metastatic lesions after chemotherapy including ICIs, leading to conversion esophagectomy. One case had anastomotic failure, but no other postoperative complications were observed. All patients are currently under observation without recurrence. Conclusion ICIs for unresectable or recurrent esophageal cancer showed a prolongation of prognosis in real-world clinical practice, suggesting their significance as part of a multimodal treatment approach including conversion surgery.

Although treatment strategy differs between countries, surgery remain the mainstay of treatment for localized esophagogastric junction cancer. Tumor proximal margin is one of the critical factors to achieve curative resection during esophagogastric junction cancer surgery. Thus, an accurate preoperative marking of the tumor is essential, however, accuracy of conventional methods was highly dependent upon endoscopists skills. Here, we present a case of a patient with locally advanced Siewert type II esophagogastric junction cancer treated by robot-assisted minimally invasive esophagectomy utilizing near-infrared fluorescence clip as a novel marking method. A male patient in his 70 s was diagnosed as having cT3N1M1 esophagogastric junction cancer and was treated by immunochemotherapy followed by surgery. Near-infrared fluorescence marking clips were placed 2 cm above the tumor proximal end under endoscopy prior to surgery. Location of the clips were confirmed by fluorescence imaging during robotic surgery, and the esophagus was dissected by a surgical stapler without intraoperative endoscopy. Histopathologically, the tumor was diagnosed as ypT2N0M0, with negative margins. Near-infrared fluorescence clip may enable easy, safe, and an accurate preoperative marking, and may be considered during endoscopic surgeries.

ObjectivesThis study aimed to assess the superiority of 3D flexible thoracoscope against 2D thoracoscope for lymph node dissection (LND) and prognosis for prone-position thoracoscopic esophagectomy (TE) in esophageal cancer. MethodsThree hundred and sixty-seven esophageal cancer patients who underwent prone-position TE with 3-field LND between 2009 and 2018 were evaluated. 2D and 3D thoracoscope was used in 182 (2D group) and 185 cases (3D group), respectively. Short-term surgical outcomes, numbers of retrieved mediastinal lymph node (LN), and rates of LN recurrence were compared. Risk factors for mediastinal LN recurrence and long-time prognosis were also evaluated. ResultsNo differences in postoperative complications were observed between the groups. The numbers of retrieved mediastinal LN were significantly higher, and the rates of LN recurrence were significantly lower in the 3D group compared to 2D group. Use of 2D thoracoscope was a significant independent factor of middle mediastinal LN recurrence by multivariable analysis. Survival was compared by cox regression analysis, and the 3D group had a significantly better prognosis than the 2D group. ConclusionsProne position TE using 3D thoracoscope may improve the accuracy of mediastinal LND and prognosis without increasing postoperative complications for esophageal cancer.

Abstract Background Robot-assisted thoracoscopic esophagectomy (RAMIE) is a precise and safe procedure with its advantages. On the other hand, RAMIE has several disadvantages. The lack of tactile function must be fully recognized, and surgical procedures must take the characteristics into account. We examined whether the findings obtained by intraoperative recurrent nerve monitoring (NIM) are useful in reducing recurrent laryngeal nerve paralysis (RLNP) after RAMIE. Methods Overall, 81 cases of RAMIE through February 2023 were included in the study. NIM was performed in 41 patients in the first term using a combination of continuous and intermittent methods (NIM group). In the subsequent 40 patients, NIM was not performed (non-NIM group) in order to confirm the learning effect of NIM and to shorten the operation time. RLNP was confirmed by a combination of symptoms and postoperative laryngoscopy. Clinical and oncological factors and short-term outcomes of the two groups were compared. Results All postoperative RLNP occurred on the left side. Six patients (14.6%) in the NIM group had Grade 1 or higher RLNP. The causes of RLNP were all found during thoracic manipulation; 4 cases of over-traction of RLN and 2 cases of crush injury by robotic forceps. There was a significant decrease in RLNP of Grade 2 or higher; 4 patients (9.7%) in the NIM group and 0 in the non-NIM group (p = 0.04). In the non-NIM group, there was a reduction in thoracic operative time, total operative time, and thoracic blood loss. Conclusion NIM made us aware of surgical maneuvers that cause RLNP after RAMIE. Although the proficiency of the RAMIE technique may have played a role in the reduction of RLNP in the later period, avoidance of risky surgical procedures due to the learning effect from the NIM was thought to have contributed to the decrease in RLNP.

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.