EsophagusPostoperative pneumonia in the acute phase is an important prognostic factor in patients with esophageal cancer
Introduction
Worldwide, esophageal cancer is the fifth most common cause of cancer-related deaths in men and the eighth in women.1 Despite the development of treatment strategies, the 5-year overall survival (OS) of esophageal cancer is 15% to 35%, and the prognosis remains dismal.2 Although the efficacy of chemotherapy and chemoradiotherapy for esophageal cancer is improving, esophagectomy is still considered the main axis in multimodal treatment. Esophagectomy with a two- to three-field lymph node dissection is a standard procedure for esophageal cancer in Japan and is one of the most invasive surgical treatments among gastrointestinal surgeries. Morbidity after esophagectomy for esophageal squamous cell carcinoma (ESCC) is still high at 50% to 60%, even in high-volume centers and in spite of recently refined operative techniques and improvements of perioperative management. Pneumonia is the most common adverse event in patients with esophageal cancer surgery and the main cause of postoperative hospital deaths.3, 4, 5 Previously, the correlation between postoperative complications and prognosis was investigated in various types of cancer. Some studies reported a correlation between postoperative pneumonia and prognosis in patients receiving esophagectomy, but the mechanism is still unknown. In patients with recurrence after curative resection, it is assumed that micro-metastasis had already occurred at surgery or the tumor spread during surgical manipulation. Some reports suggested that tumor shedding or spillage during surgical manipulation, which were evaluated by squamous cell carcinoma-related antigen and carcinoembryonic antigen mRNA, were associated with recurrence or poor prognosis in ESCC6,7 Fidler (1970) reported that cancer cells injected into the peripheral veins of mice rapidly decreased with time and that they disappeared 7 days after injection,8 which suggested that tumor cells that spread by surgical manipulation needed to survive >7 days. Moreover, inflammation was reported to induce cancer cell proliferation,9 promote the survival of minimal residual cancer cells,10 and lead to escape from immunologic host response,11 which may lead to tumor implantation and growth. Postoperative pneumonia, both in the acute and subacute phases, often occurs after surgery. However, the impact of pneumonia onset on prognosis remains unknown. Based on these findings, we hypothesized that acute phase inflammation owing to postoperative pneumonia can help cells escape apoptosis and promote the implantation and growth of tumor cells, leading to cancer recurrence. This study aimed to examine the impact of pneumonia according to its onset on prognosis, as well as its associated risk factors.
Section snippets
Patients
We retrospectively analyzed data of consecutive patients who were diagnosed with ESCC and underwent transthoracic esophagectomy at the Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, between 2010 and 2016 collected from the hospital database and electronic charts. We excluded patients who had noncurative resection and patients with cervical esophageal cancer who did not undergo transthoracic esophagectomy or who underwent esophagectomy combined with
Patient characteristics
Esophagectomy was performed in 637 ESCC patients between 2010 and 2016; of these, we excluded 45 patients in whom the tumor was located in the cervical esophagus, 51 patients with R1/2 resection, and 17 patients with incomplete follow-up information (mainly because of follow-up at other hospitals). Thus, a total of 484 patients were included from this study. Table 1 shows the baseline characteristics of all included patients in this study: 451 males and 53 females, with a median age of 67 years
Discussion
The present study showed that overall postoperative complications, anastomotic leakage, and wound infection were not associated with poor prognosis, but postoperative pneumonia was associated with poor prognosis. Furthermore, pneumonia in the acute phase after surgery had an impact on OS and recurrence, whereas pneumonia in the subacute phase after surgery had no influence on the prognosis. The impact of postoperative complications on the long-term survival of patients with esophageal cancer
Funding/Support
The authors received no funding.
Conflict of interest/Disclosure
None of the authors have any conflicts of interest ot disclose.
References (57)
- et al.
Oesophageal carcinoma
Lancet
(2013) - et al.
Early complications after Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy: risk factors and management
J Am Coll Surg
(2002) - et al.
Incidence and management of chylothorax after Ivor Lewis esophagectomy for cancer of the esophagus
J Thorac Cardiovasc Surg
(2016) - et al.
Surgical complications and long-term survival after esophagectomy for cancer in a nationwide Swedish cohort study
Eur J Surg Oncol
(2012) - et al.
Surgical complications do not affect longterm survival after esophagectomy for carcinoma of the thoracic esophagus and cardia
J Am Coll Surg
(2006) - et al.
Postoperative pneumonia is associated with long-term oncologic outcomes of definitive chemoradiotherapy followed by salvage esophagectomy for esophageal cancer
J Gastrointest Surg
(2018) - et al.
Significance of preoperative elevation of serum C-reactive protein as an indicator of prognosis in esophageal carcinoma
Am J Surg
(2001) - et al.
Analysis of pulmonary complications after three-field lymph node dissection for esophageal cancer
Ann Thorac Surg
(2003) - et al.
Pre-operative dental brushing can reduce the risk of postoperative pneumonia in esophageal cancer patients
Surgery
(2010) - et al.
Fiberoptic endoscopic evaluation of swallowing in assessing aspiration after transhiatal esophagectomy
J Am Coll Surg
(2007)
Global cancer statistics
CA Cancer J Clin
Improvement in the results of surgical treatment of advanced squamous esophageal carcinoma during 15 consecutive years
Ann Surg
Prediction of major pulmonary complications after esophagectomy
Ann Thorac Surg
CEA-antigen and SCC-antigen mRNA expression in peripheral blood predict hematogenous recurrence after resection in patients with esophageal cancer
Ann Surg Oncol
The significance of SCC and CEA mRNA in the pleural cavity after lymphadenectomy in esophageal cancer patients who underwent preoperative treatment
World J Surg
Metastasis: quantitative analysis of distribution and fate of tumor emboli labeled with 125 I-5-iodo-2’-deoxyuridine
J Natl Cancer Inst
Methylprednisolone inhibits tumor growth and peritoneal seeding induced by surgical stress and postoperative complications
Ann Surg Oncol
The anti-apoptotic role of interleukin-6 in human cervical cancer is mediated by up-regulation of Mcl-1 through a PI 3-K/Akt pathway
Oncogene
Surgical trauma-induced immunosuppression in cancer: recent advances and the potential therapies
Clin Transl Med
Multicenter randomized phase II study of cisplatin and fluorouracil plus docetaxel (DCF) compared with cisplatin and fluorouracil plus Adriamycin (ACF) as preoperative chemotherapy for resectable esophageal squamous cell carcinoma (OGSG1003)
Ann Oncol
Neoadjuvant chemotherapy of triplet regimens of docetaxel/cisplatin/5-FU (DCF NAC) may improve patient prognosis of cStage II/III esophageal squamous cell carcinoma-propensity score analysis
Gen Thorac Cardiovasc Surg
Video-assisted thoracoscopic esophagectomy: keynote lecture
Gen Thorac Cardiovasc Surg
Minimally invasive esophagectomy for esophageal cancer: comparative analysis of open and hand-assisted laparoscopic abdominal lymphadenectomy with gastric conduit reconstruction
J Surg Oncol
Clinical outcome of esophageal cancer patients with history of gastrectomy
J Surg Oncol
Reconstruction after esophagectomy for esophageal cancer patients with a history of gastrectomy
Gen Thorac Cardiovasc Surg
Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey
Ann Surg
International consensus on standardization of data collection for complications associated with esophagectomy: esophagectomy complications consensus group (ECCG)
Ann Surg
The lipoprotein profile of chylous and nonchylous pleural effusions
Mayo Clin Proc
Cited by (12)
Adding internal medicine perspectives to the management of postoperative pneumonia
2022, Surgery (United States)Preoperative inspiratory muscle weakness as a risk factor of postoperative pulmonary complications in patients with esophageal cancer
2023, Journal of Surgical OncologyPrognostic significance of circulating basophil counts in patients who underwent esophagectomy for esophageal cancer
2023, Langenbeck's Archives of Surgery