kshivets o. cardioesophageal cancer surgery

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ARTFICIAL INTELLIGENCE, SYSTEM ANALYSIS AND SIMULATION MODELING IN PREDICTION OF 5-YEAR SURVIVAL OF CARDIOESOPHAGEAL CANCER PATIENTS AFTER COMPLETE LEFT THORACOABDOMINAL ESOPHAGOGASTRECTOMIES Oleg Kshivets, MD, PhD Oleg Kshivets, MD, PhD Department of Surgery, Siauliai Public Hospital & Cancer Department of Surgery, Siauliai Public Hospital & Cancer Center, Lithuania Center, Lithuania The 60 th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

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ARTFICIAL INTELLIGENCE, SYSTEM ANALYSIS AND SIMULATION MODELING IN PREDICTION OF 5-YEAR SURVIVAL OF CARDIOESOPHAGEAL CANCER PATIENTS AFTER COMPLETE LEFT THORACOABDOMINAL ESOPHAGOGASTRECTOMIES

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Page 1: Kshivets O. Cardioesophageal Cancer Surgery

ARTFICIAL INTELLIGENCE, SYSTEM ANALYSIS AND SIMULATION MODELING IN PREDICTION OF

5-YEAR SURVIVAL OF CARDIOESOPHAGEAL CANCER PATIENTS AFTER COMPLETE LEFT

THORACOABDOMINAL ESOPHAGOGASTRECTOMIES

Oleg Kshivets, MD, PhDOleg Kshivets, MD, PhD Department of Surgery, Siauliai Public Hospital & Cancer Center, LithuaniaDepartment of Surgery, Siauliai Public Hospital & Cancer Center, Lithuania

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 2: Kshivets O. Cardioesophageal Cancer Surgery

AbstractAbstract• ARTFICIAL INTELLIGENCE, SYSTEM ANALYSIS AND SIMULATION MODELING IN PREDICTION OF 5-

YEAR SURVIVAL OF CARDIOESOPHAGEAL CANCER PATIENTS AFTER COMPLETE LEFT THORACOABDOMINAL ESOPHAGOGASTRECTOMIES

• Oleg Kshivets Department of Surgery, Siauliai Public Hospital & Cancer Center, Siauliai, Lithuania• OBJECTIVE: We examined the clinicomorphologic factors associated with the low- and high-risk of generalization of

cardioesophageal cancer (CEC) (T1-4N0-3M0) after complete esophagogastrectomies (EG) through left thoracoabdominal incision.    METHODS: We analyzed data of 150 consecutive CEC patients (CECP) (age=54.9±0.7 years; tumor size=6.9±0.2 cm) radically operated and monitored in 1975-2006 (males=116, females=34; combined EG with resection of pancreas, liver, diaphragm, colon transversum, splenectomies=49; lymphadenectomy D2=59, D3=91; esophagogastroanastomosis=89, esophagoenteroanastomosis=61; adenocarcinoma=125, squamos=19, mix=6; T1=16, T2=32, T3=58, T4=44; N0=59, N1=18, N2=71; N3=2; G1=42, G2=30, G3=78). Variables selected for 5-year survival (5YS) study were input levels of 45 blood parameters, sex, age, TNMPG, cell type, tumor size. Survival curves were estimated by the Kaplan-Meier method. Differences in curves between groups of CECP were evaluated using a log-rank test. Multivariate Cox modeling, multi-factor clustering, discriminant analysis, structural equation modeling, Monte Carlo, bootstrap simulation and neural networks computing were used to determine any significant dependence.    RESULTS: 44 CECP (life span: LS=3545.8±238.7 days) lived more than 5 years without any features of CEC progressing (5YS=29.3%). 106 CECP died because of generalization of CEC during the first 5 years after radical procedures (LS=593.5±32.6 days). Cox modeling displayed that 5YS of CECP (n=150) after complete EG significantly depended on: T1-4, combined procedures, histology, G1-3, blood lymphocytes, monocytes, neutrophils, lymphoid infiltration of CEC, age (P=0.000-0.038). Neural networks computing, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS of CECP and combined procedures (rank=1), N0-3 (2), histology (3), gender (4), CEC growth (5), type of operations (6), P1-4 (7), T1-4 (8), adjuvant chemoimmunotherapy (9), G1-3 (10), blood coagulation time (11), blood lymphocytes (12), thrombocytes (13), blood rest nitrogen (14), hemorrhage time (15), ESS (16), age (17), weight (18), blood chlorides (19), tumor size (20).CONCLUSIONS: Correct prediction of CECP survival after radical procedures was 90.7% by logistic regression (odds ratio=86.7), 96% by discriminant analysis and 100% by neural networks computing (area under ROC curve=1.0; error=0.0012).

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 3: Kshivets O. Cardioesophageal Cancer Surgery

Data• Males……………………………………………..116• Females………..…………………………………..34• Age=54.9±0.7 years• Tumor Size=6.9±0.2 cm• Only Surgery.…………………………………...132• Adjuvant Chemoimmunotherapy

(5FU+thymalin/taktivin, 5-6 cycles)…………….18

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 4: Kshivets O. Cardioesophageal Cancer Surgery

Radical ProceduresRadical Procedures• Proximal Esophagogastrectomies with Single-

Stage Esophagogastroplasty.………………….81• Total Esophagogastrectomies with Single-Stage

Esophagoenteroplasty..………..………………69• Combined Esophagogastrectomies with Resection

of Diaphragm, Liver, Mesocolon, Colon Transversum, Splenectomy, Left Hemipancreatectomy, etc…………………….49

• Lymphadenectomy D2………………………...59• Lymphadenectomy D3………………………...91

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 5: Kshivets O. Cardioesophageal Cancer Surgery

Schemas of ProceduresSchemas of Procedures

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 6: Kshivets O. Cardioesophageal Cancer Surgery

ProceduresProcedures

Page 7: Kshivets O. Cardioesophageal Cancer Surgery

One-Stage Esophagogastroplasty or EsophagoenteroplastyOne-Stage Esophagogastroplasty or Esophagoenteroplasty

Page 8: Kshivets O. Cardioesophageal Cancer Surgery

Schemas of Combined Procedures

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 9: Kshivets O. Cardioesophageal Cancer Surgery

Schemas of D3 Lymphadenectomy

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 10: Kshivets O. Cardioesophageal Cancer Surgery

Staging• T1……16 N0..…..59 G1…………42• T2……32 N1……18 G2…………30• T3……58 N2……71 G3…………78• T4……44 N3……..2• exophytic growth…………..53• endophytic growth………....85• mix growth..………………..12• adenocarcinoma……………93• squamos cell carcinoma……52• mix carcinoma……………….5

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 11: Kshivets O. Cardioesophageal Cancer Surgery

Survival Rate• 5-Year Survivors…………..…….44 (29.3%) • 10-Year Survivors……………….18 (12.0%)• Losses……………………………106 (70.7%)• General Life Span= 1459.5±132 days• For 5-Year Survivors= 3545.8±238.7 days• For Losses= 593.5±32.6 days• Cumulative 5-Year Survival…….29.3%• Cumulative 10-Year Survival…...22.4%• Cumulative 15-Year Survival…...20.2%

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 12: Kshivets O. Cardioesophageal Cancer Surgery

General Cardioesophageal Cancer Patients Survival after Complete Left Thoracoabdominal Esophagogastrectomies (Kaplan-Meier) (n=150)

Survival FunctionComplete Censored

Survival Cardioesofageal Cancer Patients after Esophagogastrectomies, n=150

Years after Complete Left Thoracoabdominal Esophagogastrectomies

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The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 13: Kshivets O. Cardioesophageal Cancer Surgery

Results of Univariate Analysis in Prediction of Cardioesophageal Cancer Patients Survival (n=150)

Cumulative Proportion Surviving (Kaplan-Meier)Complete Censored

Survival Cardioesophageal Cancer Patients with N0 & N1-3P=0.000 by Log-Rank Test

Years After Complete Esophagogastrectomies

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-0.10.00.10.20.30.40.50.60.70.80.91.0

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Cumulative Proportion Surviving (Kaplan-Meier)Complete Censored

Survival Cardioesophageal Cancer PatientsP=0.001 by Log-Rank Test

Years After Esophagogastrectomies

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Page 14: Kshivets O. Cardioesophageal Cancer Surgery

Results of Univariate Analysis in Prediction of Cardioesophageal Cancer Patients Survival (n=150)

Cumulative Proportion Surviving (Kaplan-Meier)Complete Censored

Survival Cardioesophageal Cancer PatientsP=0.0016 by Log-Rank Test

Years After Esophagogastrectomies

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G1 G3

Cumulative Proportion Surviving (Kaplan-Meier)Complete Censored

Survival Cardioesophageal Cancer PatientsP=0.00001 by Log-Rank Test

Years After Esophagogastrectomies

Cum

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exo endo

Page 15: Kshivets O. Cardioesophageal Cancer Surgery

Results of Univariate Analysis in Prediction of Cardioesophageal Cancer Patients Survival (n=150)

Cumulative Proportion Surviving (Kaplan-Meier)Complete Censored

Survival of Cardioesophageal Cancer Patients, n=150P=0.021 by Log-Rank Test

Years After Complete Esophagogastrectomies

Cum

ulat

ive

Prop

ortio

n Su

rviv

ing

0.00.10.20.30.40.50.60.70.80.91.0

0 5 10 15 20 25

Only Surgery, n=132 Adjuvant Chemoimmunotherapy, n=18

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 16: Kshivets O. Cardioesophageal Cancer Surgery

Results of Cox Regression Modeling in Prediction of Cardioesophageal Cancer

Patients Survival after Complete Esophagogastrectomies (n=150) • Factors Wald df P Exp(B) 95%CI for Exp(B)

Lower Upper• Eosinophils% 6.539 1 0.011 1.802 1.147 2.829• Stick.Neutrophils% 12.447 1 0.000 2.298 1.447 3.648• Seg.Neutrophils% 14.680 1 0.000 2.379 1.527 3.706• Lymphocytes% 11.949 1 0.001 2.212 1.410 3.469• Monocytes% 12.832 1 0.000 2.303 1.459 3.634• T1-4 12.579 3 0.006• T(1) 11.124 1 0.001 0.196 0.075 0.510• T(2) 6.870 1 0.009 0.349 0.159 0.767• T(3) 1.409 1 0.235 0.672 0.348 1.296• Ad.CHIT 0.648 1 0.421 0.744 0.362 1.529• Age 10.419 1 0.001 1.042 1.016 1.068• Comb.operation 15.523 6 0.017

The 60th Annual Meeting of Society of Surgical Oncology

March 15-18, 2007, Washington , DC, the USA

Page 17: Kshivets O. Cardioesophageal Cancer Surgery

Results of Cox Regression Modeling in Prediction of Cardioesophageal Cancer

Patients Survival after Complete Esophagogastrectomies (n=150) • Factors Wald df P Exp(B) 95%CI for Exp(B) Lower

Upper• Histology 15.864 2 0.000• Histology(1) 13.556 1 0.000 8.361 2.700 25.894• Histology(2) 15.753 1 0.000 9.631 3.147 29.473• Lymphocytes abs 5.423 1 0.020 6.126 1.332 28.166• Seg.Neutrophils abs 4.899 1 0.027 0.495 0.265 0.923• G1-3 6.539 2 0.038• G(1) 5.907 1 0.015 0.519 0.305 0.881• G(2) 3.578 1 0.059 0.565 0.313 1.021• LIT 32.081 3 0.000• LIT(1) 25.546 1 0.000 6.648 3.189 13.858• LIT(2) 23.429 1 0.000 5.804 2.848 11.829• LIT(3) 1.084 1 0.298 1.424 0.732 2.768

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 18: Kshivets O. Cardioesophageal Cancer Surgery

Results of Discriminant Analysis in Prediction of Cardioesophageal Cancer Patients Survival after Complete Esophagogastrectomies (n=150)

• Discriminant Function Analysis Summary • Wilks' Lambda: 0.305 approx. F (61,88)=3.281 p< 0.0000

• Wilks' Partial F-remove P-level • Lambda Lambda (1,88) • LIT 0.403 0.757 28.238 0.000• Comb.Operation 0.319 0.956 4.032 0.048• Erythrocytes 0.319 0.956 4.012 0.048• Weight 0.319 0.958 3.893 0.052• Glucose 0.318 0.962 3.503 0.065• Growth 0.312 0.979 1.904 0.171• G1-3 0.308 0.990 0.854 0.358• Ad.CHIT 0.307 0.995 0.402 0.528• T1-4 0.306 0.999 0.128 0.722• N0-3 0.306 0.999 0.064 0.801

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 19: Kshivets O. Cardioesophageal Cancer Surgery

Results of Logistic Regression Analysis in Prediction of Cardioesophageal Cancer Patients Survival after Complete

Esophagogastrectomies (n=150)

• Est. S.E. Wald P Odds 95.0% C.I.for Odds Ratio Ratio Lower Upper

• Const.B 18.24 9.25 3.89 0.049 8.3e+7 0.95 5.8e+12• Seg.Neut.% -0.21 0.10 4.44 0035 0.81 0.67 0.99• Monocytes abs-5.46 2.51 4.74 0.030 0.00 0.00 0.608• LIT 1.99 0.42 22.38 0.000 7.28 3.18 16.70• G1-3 -0.59 0.42 2.02 0.155 0.55 0.24 1.26• Growth 1.54 0.71 4.75 0.029 4.69 1.15 19.04• Comb.Oper. -0.47 0.16 8.75 0.003 0.63 0.46 0.86• T1-4 -0.26 0.48 0.29 0.589 0.77 0.30 1.99• N0-3 -0.20 0.40 0.26 0.613 0.817 0.370 1.80

Chi2=105.11; df=15; P=0.0000; Odds ratio=86.70

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 20: Kshivets O. Cardioesophageal Cancer Surgery

Results of Correspondence Analysis in Prediction of Cardioesophageal Cancer Patients Survival (n=150)

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 21: Kshivets O. Cardioesophageal Cancer Surgery

Results of Multi-Factor Clustering of Clinicopathological Data in Prediction of Cardioesophageal Cancer Patients Survival (n=150)

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 22: Kshivets O. Cardioesophageal Cancer Surgery

Neural Networks in Prediction of Cardioesophageal Cancer Patients Survival after Complete Esophagogastrectomies (n=150)

• Baseline Errors=0.0012• Area under ROC curve=1.00• Correct Classification Rate=100%

• Losses 5-year survivors • Total106 44

Correct106 44

Wrong 0 0

• Genetic Algorithm Selection• Useful for L ESS Haemor.Time Protein PI D Histology G1-3 Growth Sabs • Survival Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes• Useful for Lymabs Comb.Oper. P1-4 L/CC S/CC T1-4 N0-3 Chlorides Stot• Survival Yes Yes Yes Yes Yes Yes Yes Yes Yes

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 23: Kshivets O. Cardioesophageal Cancer Surgery

Results of Kohonen Self-Organizing Neural Networks Computing in Prediction of Cardioesophageal Cancer Patients Survival after Complete Esophagogastrectomies (n=150)

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 24: Kshivets O. Cardioesophageal Cancer Surgery

Results of Neural Networks Computing in Prediction of Cardioesophageal Cancer Patients Survival after Complete Esophagogastrectomies (n=150)

Error=0.0011; Area under ROC Curve=1.00; Correct Classification Rate=100%

– Factor Rank Error Ratio• Comb.Operat. 1 0.199 159.5• N0-3 2 0.185 148.0• Histology 3 0.172 138.0• Sex 4 0.166 133.1• Growth 5 0.164 130.9• Oper. Type 6 0.153 122.6• P1-4 7 0.117 94.0• T1-4 8 0.109 87.2• Ad.CHIT 9 0.106 84.7• G1-3 10 0.071 57.1• Coag.Time 11 0.029 23.5• Lymph.% 12 0.029 23.2

– Factor Rank Error Ratio• Thr.tot 13 0.023 18.2• Rest Nitrogens 14 0.019 15.2• Haem.Time 15 0.007 5.6• ESS 16 0.005 3.8• Age 17 0.003 2.6• Weight 18 0.003 2.5• Chlorides 19 0.002 1.9• D 20 0.002 1.8• St.Neutr.tot 21 0.002 1.6• Protein 22 0.002 1.5• L/CC 23 0.002 1.4• Erythrocytes 24 0.002 1.4

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 25: Kshivets O. Cardioesophageal Cancer Surgery

Results of Bootstrap Simulation in Prediction of Cardioesophageal Cancer Patients Survival after Complete Esophagogastrectomies (n=150)

• Number of Samples=3333• Significant Factors Rank Kendall’s Tau-A P<• LIT 1 0.316 0.000• D 2 -0.196 0.000• P1-4 3 -0.189 0.000• Leucocytes/CC 4 0.188 0.000• HC/CC 5 0.187 0.000• Erythrocytes/CC 6 0.186 0.000• Lymphocytes/CC 7 0.185 0.000• T1-4 8 -0.184 0.000• N0-3 9 -0.176 0.000• Seg.Neutrophils/CC 10 0.167 0.000• Thrombocytes/CC 11 0.160 0.000• Monocytes/CC 12 0.146 0.000

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 26: Kshivets O. Cardioesophageal Cancer Surgery

Results of Bootstrap Simulation in Prediction of Cardioesophageal Cancer Patients Survival after Complete Esophagogastrectomies (n=150)

• Number of Samples=3333• Significant Factors Rank Kendall’s Tau-A P<• Eosinophils/CC 13 0.124 0.000• Operation Type 14 -0.119 0.000• G1-3 15 -0.119 0.000• Histology 16 -0.118 0.000• Chlorides 17 0.106 0.000• Coagulation Time 18 -0.096 0.000• Growth 19 -0.092 0.000• Stick Neutrophils/CC 20 0.068 0.000• Protein 21 0.063 0.000• Combined Operation 22 0.048 0.000• Rest Nitrogens 23 0.042 0.001• Colour Index 24 0.041 0.000

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 27: Kshivets O. Cardioesophageal Cancer Surgery

Results of Bootstrap Simulation in Prediction of Cardioesophageal Cancer Patients Survival after Complete Esophagogastrectomies (n=150)

• Number of Samples=3333• Significant Factors Rank Kendall’s Tau-A P<• ESS 25 0.038 0.002• Erythrocytes tot 26 0.038 0.002• Thrombocytes 27 -0.033 0.005• Adjuvant CHIT 28 0.031 0.005• Eosinophils tot 29 0.028 0.018• Leucocytes tot 30 0.027 0.023• Sex 31 0.027 0.023• Weight 32 0.026 0.024• Haemorrhage Time 33 0.026 0.024• Monocytes tot 34 0.024 0.05

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 28: Kshivets O. Cardioesophageal Cancer Surgery

Prediction of Cardioesophageal Cancer Patients Survival after Complete Esophagogastrectomies (n=150)

• Classification of Cases by Logistic Regression, n=150, Odds Ratio=86.7• Observed Pred.Losses Pred.Survivors Correct• Losses 102 4 96.2%• 5-Year Survivors 10 34 77.3%• Total 112 38 90.7%• Classification of Cases by Discriminant Analysis, n=150• Observed Pred.Losses Pred.Survivors Correct• Losses 105 1 99.1%• 5-Year Survivors 5 39 88.6%• Total 110 44 96.0%• Classification of Cases by Neural Networks, n=150, Errors=0.0012• Observed Pred.Losses Pred.Survivors Correct• Losses 106 0 100%• 5-Year Survivors 0 44 100%• Total 106 44 100%

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 29: Kshivets O. Cardioesophageal Cancer Surgery

Ratio of Lymphocytes to Cancer Cells & Glucose Level Ratio of Lymphocytes to Cancer Cells & Glucose Level in Prediction of Cardioesophageal Cancer Patients Survival after Complete

Esophagogastrectomies (n=150)

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 30: Kshivets O. Cardioesophageal Cancer Surgery

Prognostic SEPATH-Model of Cardioesophageal Cancer Patients Survival after Complete Esophagogastrectomies, n=150

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 31: Kshivets O. Cardioesophageal Cancer Surgery

Holling-Tenner Models of Cardioesophageal Holling-Tenner Models of Cardioesophageal Cancer Cell Population and Cytotoxic Cell Cancer Cell Population and Cytotoxic Cell

Population DynamicsPopulation Dynamics

0 2 4 6 8 10

0.1

10

Early CancerInvasive Cancer, Stage IIInvasive Cancer, Stage IIIGeneralization

Model "Early Cancer---Lymphocytes"

Gastroesophageal Cancer Cell Population

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Cardioesophageal Cancer Dynamics

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Conclusions:• 5-year survival and life span of cardioesophageal cancer

patients after complete esophagogastrectomies significantly depended on:

• 1) cell ratio factors: ratio of cancer cell population to blood cell subpopulations in integral patient organism;

• 2) cancer characteristics (cancer cell population number, TNMG-system);

• 3) the data of blood cell circuit, biochemical homeostasis and hemostasis system;

• 4) character of surgical procedure;• 5) anthropometric data.

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 34: Kshivets O. Cardioesophageal Cancer Surgery

Conclusions:• Optimal treatment strategies for cardioesophageal

cancer patients are:• 1) screening and early detection of cardioesophageal

cancer; • 2) availability of very experienced surgeons because of

complexity of radical procedures;• 3) aggressive en block surgery for completeness; • 4) precise prediction; • 5) adjuvant chemioimmunotherapy for patients with • unfavorable prognosis.

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA

Page 35: Kshivets O. Cardioesophageal Cancer Surgery

Address:Oleg Kshivets M.D., Ph.D.,

Consultant Thoracic, Abdominal, General Surgeon & Surgical Oncologist

• Surgery Department, Siauliai Public Hospital & Cancer Center• Tilzes:42-16, LT78206 Siauliai, Lithuania• Tel. 37041-416614• e-mail: [email protected] • http//:myprofile.cos.com/Kshivets

The 60th Annual Meeting of Society of Surgical Oncology March 15-18, 2007, Washington , DC, the USA