Sho Sato

Anastomotic leakage is a severe complication of curative surgery for esophageal cancer, mostly because blood supply to the gastric tube is poor. Although qualitative indocyanine green (ICG) fluorescence imaging has been used to assess blood flow, the subjective nature of this approach poses a challenge. Recently, use of the SPY-PHI system with the SPY-QP software has allowed objective, semiquantitative fluorescence evaluation; however, its utility remains unclear. We investigated the utility of intraoperative SPY-QP-based quantitative perfusion fluorescence imaging for assessing blood flow in the gastric tube and optimizing the anastomotic site to prevent anastomotic leakage in esophageal cancer surgery. This retrospective, single-center study (January 2017 to December 2024) compared two groups of patients who underwent subtotal esophagectomy: the conventional group with qualitative fluorescence assessment (n = 72) and the quantitative group with SPY-QP fluorescence assessment (n = 55). We collected and compared preoperative, intraoperative, and postoperative data, including complications (Clavien-Dindo grade ≥ II) and anastomotic leakage. The quantitative group had a significantly higher proportion of patients who underwent preoperative chemotherapy (p < 0.001), retrosternal reconstruction (p = 0.046) and, Gambee/single-layer anastomoses (p < 0.001), and had significantly less intraoperative blood loss (p < 0.001). This group also showed a significantly lower incidence of overall postoperative complications and anastomotic leakage, along with a shorter postoperative hospital stay (p < 0.001). In multivariate analysis, quantitative SPY-QP fluorescence was identified as a favorable independent factor for reducing anastomotic leakage (p = 0.009). Quantitative blood flow measurement using SPY-QP may contribute to a reduction in the incidence of anastomotic leakage following esophageal cancer surgery by facilitating the objective selection of the optimal anastomotic site.

PURPOSE: Trifluridine/tipiracil (FTD/TPI) plus ramucirumab may improve survival as a later-line therapy for advanced gastric cancer (GC); however, prospective evidence is limited. PATIENTS AND METHODS: We conducted a multicenter, prospective phase II trial of FTD/TPI plus ramucirumab in patients with unresectable or recurrent gastric or gastroesophageal junction adenocarcinoma who had received at least two previous systemic regimens for advanced disease, including a ramucirumab-containing regimen. Eligible patients had an Eastern Cooperative Oncology Group performance status of 0-2 and adequate organ function. Patients received oral FTD/TPI (35 mg/m ² , days 1-5 and 8-12) and ramucirumab (8 mg/kg, days 1 and 15) every 28 days. The primary end point was time to treatment failure (TTF), and the secondary end points were progression-free survival (PFS), overall survival (OS), response, disease control rate (DCR), relative dose intensity (RDI), and safety. RESULTS: Between February 2022 and March 2024, 32 patients were enrolled (median age, 72.5 years; 53.1% male). The median TTF was 4.0 months (95% CI, 2.8 to 5.0), meeting the primary end point. Median PFS and OS were 4.8 (95% CI, 2.8 to 8.3) and 12.2 months (95% CI, 7.8 to 17.2), respectively. Among 26 patients with measurable disease, objective response rate was 11.5%, and DCR was 76.9%. Mean RDI was 78.6% for FTD/TPI and 93.1% for ramucirumab, supporting feasibility in this cohort. Grade ≥3 neutropenia occurred in 53.1% and febrile neutropenia in 9.4%. Frequent nonhematologic events were anorexia (68.8%) and fatigue (59.4%), mostly grade 1 to 2. A modified FTD/TPI schedule was introduced in 15 patients and maintained dose delivery while reducing neutropenia, with no febrile events. CONCLUSION: FTD/TPI plus ramucirumab met its primary end point and was feasible with manageable safety in heavily pretreated advanced GC. Given the single-arm design, the efficacy findings are hypothesis-generating and warrant confirmation in larger randomized trials.

Purpose: Intramural metastasis is defined as the metastatic spread from a primary tumor to the gastrointestinal tract through the intramural lymphatic system. Although several studies have demonstrated the negative impact of intramural metastasis on survival in esophageal cancer, no systematic review including a large number of patients has been conducted yet.Methods: Reports on esophageal cancer with intramural metastasis from 1990 to 2025 were collected. A pooled analysis was performed using a random-effects model to estimate the hazard ratio for overall survival in patients with intramural metastasis compared with patients without intramural metastasis.Results: Eleven studies (4494 patients) were included, in whom 315 patients (7.0%) had conventional intramural metastasis, while 57 patients had discontinuous growth. Among these patients, 4162 were diagnosed with esophageal squamous cell carcinoma. Preoperative chemotherapy was administered to 1153 patients (25.7%). The hazard ratio for overall survival was 2.22, with a 95% confidence interval of 1.81–2.72.Conclusions: Our analysis suggests that the adverse prognostic association of IM was observed across different treatment eras and remained evident in studies including patients who received neoadjuvant treatment. Future studies should explore optimal treatment strategies for patients with intramural metastasis.

Introduction: Surgery for gastric cancer in elderly patients is challenging because of comorbidities and diminished physiological reserve. Robotic gastrectomy (RG) may improve outcomes via technical precision; however, its impact on the elderly remains unclear. This study evaluated the short‐term outcomes of RG between elderly and non‐elderly patients, and between RG and laparoscopic gastrectomy (LG) in elderly patients using propensity score matching (PSM). Methods: We retrospectively analyzed elderly patients who underwent RG or LG and non‐elderly patients who underwent RG for gastric cancer between April 2020 and December 2024. Patients were divided into elderly RG (≥ 80 years, n = 33), non‐elderly RG (< 80 years, n = 118), and elderly LG groups ( n = 46). PSM (1:1) adjusted between elderly and non‐elderly RG groups, and between elderly RG and LG groups. Short‐term surgical outcomes and postoperative complications were compared. Results: After PSM, there was no significant difference in surgical complication rates (16% vs. 6%; p = 0.43) between elderly and non‐elderly RG groups. However, the elderly group had numerically higher non‐surgical complications (12% vs. 3%; p = 0.35), primarily driven by non‐surgical issues, such as acute heart failure, atelectasis, and urinary tract infections. Postoperative complication rates were also similar between elderly RG and LG groups. Conclusion: RG appears to be a safe and feasible procedure for elderly patients aged ≥ 80 years, providing surgical stability comparable to that in younger and elderly patients who underwent LG. While the robotic platform may contribute to mitigating surgery‐related risks, the higher incidence of non‐surgical complications underscores the necessity of tailored perioperative management addressing elderly‐specific vulnerabilities in this population.

Background: Indocyanine green-guided (ICG-guided) lymphadenectomy during gastrectomy for cancer has been proposed to enhance the accuracy of lymphadenectomy. The impact of ICG-guided lymphadenectomy on patient survival remains debated. Methods: The findings of the systematic review were reconstructed into an individual patient data (IDP) meta-analysis with restricted mean survival time difference (RMSTD). Overall survival (OS) and disease-free (DFS) survival were primary outcomes. RMSTD, standardized mead difference (SMD), and 95% confidence intervals (CI) were used as pooled effect size measures. Results: Three studies (6325 patients) were included; 42% of patients underwent ICG-guided lymphadenectomy. The patients’ age ranged from 47 to 72 years and 58% were males. Proximal, distal, and total gastrectomy were completed in 6.8%, 80.4%, and 12.8% of patients, respectively. The surgical approach was laparoscopic (62.3%) and robotic (37.7%). ICG-guided lymphadenectomy was associated with a higher number of harvested lymph nodes compared to non-ICG-guided lymphadenectomy (SMD 0.50; 95% CI 0.45–0.55). At the 42-month follow-up, OS and DFS estimates for ICG-guided vs. non-ICG-guided lymphadenectomy were 0.5 months (95% CI −0.01, 1.1) and 1.3 months (95% CI 0.39, 2.15), respectively. Conclusions: Our analysis suggests that ICG-guided lymphadenectomy offers equivalent long-term OS and DFS compared to non-ICG-guided lymphadenectomy.

Background The real-world efficacy, feasibility, and prognostic factors of immune-checkpoint inhibitor combination therapy for unresectable or metastatic esophageal cancer are not fully established. Methods This multi-institutional retrospective cohort study evaluated 77 consecutive patients treated with immune-checkpoint-inhibitor combination therapy for esophageal cancer between March 2021 and December 2022. We assessed tumor response, safety, and long-term survival. Results In patients with measurable lesions, the response rate was 60%, and the disease control rate for all enrolled patients was 78%. Five patients (6.5%) underwent successful conversion surgery. Grade 3 or higher adverse events occurred in 35% of patients, but no treatment-related deaths were reported. Median progression-free survival was 9.7 (95% confidence interval: 6.5-13 months). C-reactive protein levels and performance status were identified as significant predictors of progression-free survival through Cox proportional hazards analysis. Conclusions Immune-checkpoint-inhibitor combination therapy for esophageal cancer demonstrated comparable tumor response, safety, and long-term survival to previous randomized clinical trials. Patients with good performance status and low C-reactive protein levels may be suitable candidates for this treatment.