Making sense of multimodality therapy for esophageal cancer

The results of single modality treatment for esophageal cancer have been poor because of a high rate of local recurrence and distant metastasis. This is probably caused by the prevalence of advanced esophageal cancer at the time of diagnosis; only 3% of patients have Stage I disease, and most of them (80%) are Stage III or IV when they become symptomatic. The most frequently involved metastasis sites are lymph nodes (73%), lung (52%), and liver (47%). Neoadjuvant preoperative chemotherapy, radiotherapy, and combined chemoradiation have been added to the treatment of this disease to enhance local control, increase resectability rate, and improve disease-free survival. The results of recent trials are discussed.

Resection of primary brachial plexus tumor using a modified Dartevelle anterior approach

We treated a patient with a large supraclavicular mass with associated parasthesia of the affected extremity. The mass was removed operatively using a supraclavicular Dartevelle approach.

Accuracy of CT for the detection of pleural adhesions: correlation with video-assisted thoracoscopic surgery

STUDY OBJECTIVE

The presence of pleural adhesions may render video-assisted thoracoscopic surgery (VATS) difficult or impossible. The aim of this study was to assess the value of chest CT in the detection of pleural adhesions prior to VATS.

DESIGN

Prospective study of the accuracy of chest CT in detecting pleural adhesions prior to VATS.

SETTING

Tertiary-referra; teaching hospital and Veterans Administration hospital.

PATIENTS

Between July 1994 and March 1995, 63 consecutive patients undergoing 64 VATS procedures were evaluated with chest CT prior to surgery.

MEASUREMENTS AND RESULTS

Preoperative scans were interpreted by consensus of two pulmonary radiologists prior to surgery. Suspected pleural adhesions and other findings related to the pleura were recorded on a form given to the surgeon prior to VATS. The surgeon confirmed or excluded each suspected adhesion during VATS, and documented any other lesions not identified preoperatively. Patient-by-patient and lesion-by-lesion analyses were performed. Pleural adhesions were correctly identified by CT in 28 of 39 cases (sensitivity, 71%) and excluded in 18 of 25 cases (specificity, 72%). On a lesion-by-lesion basis, 73 adhesions were identified during VATS, of which only 28 were identified prospectively at CT. There were 45 missed adhesions and 20 adhesions that were suggested falsely (sensitivity, 38%; specificity, 46%). Eighteen pleural spaces were correctly identified as being free of pleural adhesions.

CONCLUSIONS

CT is moderately sensitive and specific for preoperative identification of pleural adhesions in patients undergoing VATS but its accuracy is poorer for individual lesions.

The role of video-assisted thoracic surgery in esophageal disease

Numerous applications of video-assisted thoracic surgery (VATS) in the management of diseases of the esophagus for structural, functional, benign, and malignant conditions have been reported. Indications and techniques for the use of VATS in the assessment and treatment of esophageal disease are discussed in this article. The need for careful evaluation of the safety, efficacy, and cost-effectiveness of these techniques is emphasized.

Superior sulcus (Pancoast) tumor: experience with 105 patients

BACKGROUND

The evolution of therapy in 105 patients with superior sulcus (Pancoast) tumor over the past 42 years was reviewed.

METHODS

There were 82 men and 23 women aged 30 to 75 years. Tumor cell types were: squamous, 41 (39%); adenocarcinoma, 23 (21.9%); anaplastic, 14 (13.3%); undetermined, 12 (11.4%); mixed, 9 (8.7%); and large cell 6 (5.7%). Therapy was based on extent of disease and lymph node involvement. There were 5 treatment groups: I, preoperative radiation and operation (n = 28); II, operation and postoperative radiation (n = 16); III, radiation (n = 37); IV, preoperative chemotherapy, radiation, and operation (n = 11); and V, operation (n = 12).

RESULTS

The median survival for group I was 21.6 months; group II, 6.9 months; group III, 6 months; and group V, 36.7 months. Median survival for group IV has not yet been reached (estimated at 72% at 5 years). On univariate analysis, mediastinal lymph node involvement, Horner syndrome, TNM classification, and method of therapy affected survival. On multivariate regression analysis, only N2 and N3 disease and method of therapy were significant (p < 0.05).

CONCLUSIONS

The optimal treatment for superior sulcus tumor was preoperative radiation and operation. However, triple modality therapy, although promising, requires longer follow-up.

Acute effects of bilateral lung volume reduction surgery on lung and chest wall mechanical properties

STUDY OBJECTIVES

To characterize acute changes in the dynamic, passive mechanical properties of the lungs and chest wall, elastance (E) and resistance (R), caused by lung volume reduction surgery (LVRS).

DESIGN

Prospective data collection.

PATIENTS

Nine anesthetized/paralyzed patients with severe emphysema.

INTERVENTIONS

Bilateral LVRS.

MEASUREMENTS AND RESULTS

From measurements of airway and esophageal pressures and flow during mechanical ventilation throughout the physiologic range of breathing frequency (f) and tidal volume (VT), E and R of the total respiratory system (Ers and Rrs), lungs (EL and RL), and chest wall (Ecw and Rcw) immediately before and after LVRS were calculated. After surgery, Ers, EL, Rrs, and RL were all greatly increased at each combination off and VT (p<0.05). Ecw and Rcw showed no consistent changes (p>0.05). The increases in EL were greatest in those patients with the lowest residual volumes, highest FEV1 values, and highest maximum voluntary ventilations measured 3 months preoperatively (p<0.05); the increases in RL were greatest in those patients with the lowest preoperative residual volumes (p<0.05). The largest increases in RL were in those patients with the largest decreases in residual volume and total lung capacity, measured 3 months postoperatively, caused by LVRS (p<0.05).

CONCLUSION

Acute effects of LVRS are large increases in lung elastic tension and resistance; these increases need to be considered in immediate postoperative care, and can be predicted roughly from results of preoperative pulmonary function tests.

Multicenter VATS experience with mediastinal tumors

BACKGROUND

The use of video-assisted thoracic surgery for diagnosis and treatment of mediastinal tumors in a multiinstitution patient population is not well understood.

METHODS

We studied 48 cases from Cancer and Leukemia Group B thoracic surgeons. Of 21 men and 27 women, aged 41 +/- 16 years, 22 patients were asymptomatic. In the others, 92% of tumor-related symptoms improved or resolved after treatment. Five tumors involved the anterior compartment, 19 the middle, and 24 the posterior compartment. Diagnoses were typical for each compartment but also included uncommon problems such as superior vena cava hemangioma and a histoplasmosis cyst causing hoarseness. Of the lesions, a biopsy of 12 was done without excision and the rest were excised completely. Fifteen were cystic and 10 were malignant (8 biopsy only). Maximal dimensions were 5.2 +/- 3.3 cm.

RESULTS

Operations were briefer for 24 posterior (93 +/- 41 min) than 5 anterior (195 +/- 46 min, p < 0.01) or 19 middle mediastinal tumors (170 +/- 78 min, p < 0.01). Although 96% had vital mediastinal relations, only six open conversions were performed because of bleeding (n = 3), large size, impaired exposure, or rib attachments, and no patient had morbidity beyond that expected for the thoracotomy. Postoperative stay was shorter for the nonconversion group (3.2 +/- 2.8 versus 5.5 +/- 2.1 days, p = 0.05), as was chest tube duration (1.7 +/- 1.4 days versus 3.2 +/- 1.9 days, p = 0.03). There were no postoperative deaths or major complications, but 7 patients had minor complications. During a mean of 20 months of surveillance (range, 1 to 52 months), one cyst recurred (asymptomatic) as did one sarcoma that was excised.

CONCLUSIONS

Video-assisted thoracic surgery is a safe technique for benign mediastinal tumors, typically those in the middle and posterior mediastinum.

Thoracoscopic sympathectomy: the U.S. experience

OBJECTIVE

48 patients underwent TSSYM. Charts of patients undergoing thoracoscopy were reviewed to assess the safety and efficacy of thoracoscopic sympathectomy (TSSYM).

DESIGN

A retrospective review was undertaken at four United States medical centers.

RESULTS

TSSYM was performed for reflex sympathetic dystrophy in 27 patients, hyperhydrosis palmaris in 15 patients, and Raynaud's upper extremity ischemia and splanchnic pain in 2 patients each. Anesthesia with one lung ventilation was used. 2.9 ports were used per patient and 0.8 chest tubes were placed per patient. All patients underwent resection of the sympathetic chain, usually with a clip along the bottom of the resected chain. Laser, electro-ablation and electroresection were not used by any of the surgeons in his series. The mean length of hospital stay was 1.8 days.

CONCLUSIONS

TSSYM is a safe and effective technique for treatment of a variety of thoracic disorders.

Incidental lung carcinoma detected at CT in patients selected for lung volume reduction surgery to treat severe pulmonary emphysema

PURPOSE

The authors present their experience with previously unsuspected carcinoma of the lung detected at preoperative computed tomography (CT) in patients with severe pulmonary emphysema who were scheduled to undergo lung volume reduction surgery.

MATERIALS AND METHODS

Preoperative chest CT was performed in 148 patients (84 men, 64 women; mean age, 65 years +/- 8 [standard deviation]) with advanced pulmonary emphysema before lung volume reduction surgery. At surgery, an attempt was made to excise any pulmonary nodule considered suspicious for carcinoma at CT.

RESULTS

Eighteen pulmonary nodules suspicious for lung cancer were found at CT in 17 (11%) of the 148 patients. Sixteen of these 148 nodules were resected at lung volume reduction surgery. Nine non-small cell carcinomas (adenocarcinoma, n = 4, including three with bronchioloalveolar differentiation; poorly differentiated, n = 3; squamous cell carcinoma, n = 2) were found in eight (5%) patients. Eight of the cancers were stage I, and one was unstaged surgically. Maximum diameters of the cancers ranged between 1.0 and 3.8 cm (median, 1.6 cm). The seven (5%) other resected nodules were all benign.

CONCLUSION

A 5% rate of stage I primary lung cancer in patients selected for lung volume reduction surgery suggests that performance of chest CT in candidates for lung volume reduction surgery is appropriate not only to identify patterns of pulmonary parenchymal destruction but also to search for stage I lung cancer.

Esophagopericardial fistula arising from Barrett's esophagus

Esophagopericardial fistula is a rare complication of numerous benign, malignant, and traumatic conditions of the esophagus. Approximately 100 cases of fistulae between the esophagus and heart have been reported. We describe the second reported case of an esophagopericardial fistula secondary to a benign esophageal ulcer within Barrett's mucosa without prior surgery. The radiologic, endoscopic, and surgical management of this case are discussed.

The role of radiologic imaging in diagnosing complications of video-assisted thoracoscopic surgery

STUDY OBJECTIVE

To examine the role of radiologic imaging in evaluating complications of video-assisted thoracoscopic surgery.

DESIGN

Retrospective review of radiographic and clinical data.

SETTING

Tertiary referral hospital.

PATIENTS

All patients who underwent thoracoscopy at the University of Maryland Hospital between July 1990 and June 1994. A total of 260 procedures were performed on 239 patients.

MEASUREMENTS AND RESULTS

Imaging studies performed before, during, and after surgery in cases in which complications occurred were reviewed by two thoracic radiologists. A randomly selected group of 22 CT scans from uncomplicated cases were used as control subjects. Complications occurred in 24 (9.2%) of the 260 thoracoscopic procedures. Intraoperative complications developed in 14 (5.4%) patients. Ten of the 14 patients had an obliterated pleural space that prevented access of the trocars and videoscope. Preoperative imaging showed significant pleural thickening or calcifications in seven of these ten patients. Other intraoperative complications were malposition of the double-lumen endotracheal tube (n=2) and dislodgement of a localizing needle-wire (n=2). In 8 (3.1%) patients, radiographically evident postoperative complications developed; these complications included prolonged air leak, empyema, recurrent pneumothorax, pulmonary edema, and pneumonia.

CONCLUSION

Pleural calcification or thickening that is found on preoperative studies may help predict difficulty in inserting the thoracoscopic instruments but also can be seen on preoperative CT scans in uncomplicated cases. Thoracic CT scans may fail to predict complete pleural symphysis.

Advances in staging of esophageal carcinoma

Staging criteria for thoracic malignancies are based on survival groupings that allow the stage groups to be used as prognosticators for cancer treatment. Definitive staging of esophageal cancer facilitates allocation of patients to appropriate treatment regimens according to each patient's stage. Existing noninvasive staging methods are imperfect in detecting abdominal and thoracic lymph node metastases in patients with esophageal cancer. Thoracoscopy is an excellent means for staging the chest and mediastinum. We have used thoracoscopic lymph node staging and laparoscopic lymph node staging for esophageal cancer since 1992. Thoracoscopy was performed in 45 patients with biopsy specimen-proved carcinoma of the esophagus. Laparoscopy was done in the last 20 patients. Laparoscopic-assisted feeding jejunostomies were performed in patients with obstructive symptoms. Directed liver biopsies were performed if lesions were present. Thoracoscopy was aborted in three patients because of adhesions. Thoracic lymph node stage was N0 in 40 patients and N1 in 3. Celiac lymph nodes were normal in 14 patients and abnormal in 6. Esophageal resection was performed in 30 patients after thoracoscopic lymph node staging; 18 of these underwent laparoscopic lymph node staging. Thoracoscopic staging showed N0 lymph node status in 28 patients and N1 in 2. Two of these N0 patients (7%) were found at resection to have paraesophageal lymph involvement (N1). Thoracoscopic lymph node staging was accurate in detecting the status of thoracic lymph nodes in 28 of 30 cases (93%). Laparoscopic staging found normal celiac nodes in 13 patients and abnormal lymph nodes in 5. After esophagectomy, final pathologic finding of the 13 N0 patients was N0 in 12 patients and N1 in 1 patient. Thus, laparoscopic lymph node staging was accurate in detecting lymph node status in 17 of 18 patients (94%). Six of 20 patients undergoing laparoscopy had unsuspected celiac axis lymph node involvement missed by standard noninvasive techniques. Three percent of thoracic lymph nodes and 17% of celiac lymph nodes were downstaged after preoperative chemoradiotherapy. Thoracoscopic and laparoscopic lymph node staging are more accurate than existing staging methods.

Minimally invasive staging for esophageal cancer

Thoracoscopy is an excellent means for staging esophageal cancer. Staging of esophageal carcinoma facilitates prognostication and allocation of patients to appropriate treatment regimens. Thoracoscopy is also useful in biopsies of direct mediastinal invasion. Routine thoracoscopic and laparoscopic lymph node staging has been used in patients with esophageal carcinoma with excellent results. Thoracoscopy can allocate patients for neoadjuvant therapy and help avoid an unnecessary thoracotomy in patients found to have gross spread of locoregional disease.

Search for a primary lung neoplasm in patients with brain metastasis: is the chest radiograph sufficient?

OBJECTIVE

We assessed whether chest CT provided an advantage over chest radiography when diagnosing a primary lung neoplasm in a selected group of patients.

MATERIALS AND METHODS

From a retrospective evaluation of 925 patients who had a discharge diagnosis of brain metastasis, we identified 32 patients who presented without a known primary tumor site and who were investigated subsequently with both chest radiography and CT. Reports of chest radiographs were classified as showing a primary lung neoplasm (positive), as abnormal but nonspecific, or as negative. Patients were categorized as having negative chest radiograph, negative CT; positive chest radiograph, positive CT; nonspecific chest radiograph, positive CT; or negative chest radiograph, positive CT. Radiographic technique and clinical and lesion characteristics were compared among these categories.

RESULTS

We found negative chest radiograph and negative CT in one patient who ultimately proved to have breast cancer. The remaining 31 patients (97%) had primary lung carcinoma. In 19 (59%) of the 32 patients, chest radiographs and CT were positive. Twelve patients (38%) had a nonspecific or negative chest radiograph and positive CT. In the 31 patients with lung carcinoma, the mean diameter of lesions in patients with positive chest radiographs was 4.2 cm, compared with 2.5 cm in patients with normal or nonspecific radiographs (p < .01).

CONCLUSION

Lung cancer is by far the most common cause of a de novo presentation with brain metastasis. Chest CT is valuable to supplement chest radiography in patients with metastatic brain disease in whom a primary lesion is sought. Lesion size appears to be the most important determinant of detectability of a primary tumor on chest radiographs.

Esophagogastrectomy for carcinoma of the esophagus and cardia: a comparison of findings and results after standard resection in three consecutive eight-year intervals with improved staging criteria

OBJECTIVE

A review of findings and results after standard resection for carcinoma of the esophagus and cardia without neoadjuvant therapy was done to provide a basis for comparison with current reports of radical resection and neoadjuvant therapy.

METHODS

A 24-year experience on one surgical service with 454 operations for carcinoma of the esophagus and cardia was reviewed. A comparison of findings and results in three consecutive 8-year intervals was analyzed, and new staging criteria were developed and compared with those currently favored by the American Joint Committee on Cancer.

RESULTS

From January 1, 1970, to January 1, 1994, 454 patients with carcinoma of the esophagus or cardia underwent operation, of whom 408 (90%) had esophagogastrectomy with a 30-day mortality rate of 2.5% and an additional hospital mortality rate of 1.2%. Of the 121 complications (30.7%), 71 (18%) were major and 50 (12.7%) were minor. Cardiovascular complications predominated. The overall 5-year survival was 24.7%, with a 33.7% survival after complete resections in the most recent interval under study. Palliation of dysphagia was achieved in nearly 80% of patients who survived the operation. During the three intervals under review, resectability, mortality, and complication rates remained constant. The percentages of left thoracotomies and transhiatal resections increased, and there was a decrease in thoracoabdominal incisions. The percentages of patients with Barrett's esophagus and stage 0 and I tumors increased. The percentage of complete resections (R0) increased, whereas that for resections with residual microscopic tumor (R1) decreased, and there was no change in the percentage of patients with residual gross tumor after resection (R2). Modified WNM staging criteria are proposed that provide better prognostic stratification of the disease than those currently favored by The American Joint Committee on Cancer.

CONCLUSIONS

Standard esophagogastrectomy is applicable in 90% of patients with operable carcinoma of the esophagus or cardia, with consistently low mortality and morbidity rates and satisfactory palliation of dysphagia. The 5-year survival (24.7% overall) remains suboptimal, but the current figure for complete resections (33.7%) is encouraging. There is a need for revision of the current American Joint Committee on Cancer staging criteria.

The management of malignant pleural and pericardial effusions

Malignant pleural and pericardial effusions are debilitating complications of metastatic malignancy. Improper management may lead to multiple hospital admissions and loss of quality of life for patients with a short life expectancy. The majority of malignant pleural effusions are diagnosed and controlled by thoracentesis and sclerosis. Those with pericardial malignancy are best diagnosed and treated with pericardiocentesis and pericardial window. Strategies for the management of more difficult cases are also discussed in this article.

Endoscopic knot

A new technique for a simplified endoscopic knot with careful attention to knot formation is presented. This knot has been shown to be strong and reliable without the need for intracorporeal knot tying or knot pushers.

A transforming growth factor beta 1 receptor type II mutation in ulcerative colitis-associated neoplasms

BACKGROUND & AIMS

Numerous gastrointestinal tumors, notably sporadic and ulcerative colitis (UC)-associated colorectal carcinomas and dysplasias, gastric cancers, and esophageal carcinomas, manifest microsatellite instability. Recently, a transforming growth factor beta 1 type II receptor (TGF-beta 1RII) mutation in a coding microsatellite was described in colorectal carcinomas showing instability. One hundred thirty-eight human neoplasms (61 UC-associated, 35 gastric, 26 esophageal, and 16 sporadic colorectal) were evaluated for this TGF-beta 1RII mutation.

METHODS

Whether instability was present at other chromosomal loci in these lesions was determined. In lesions manifesting or lacking instability, the TGF-beta 1RII coding region polydeoxyadenine (poly A) microsatellite tract was polymerase chain reaction amplified with 32P-labeled deoxycytidine triphosphate. Polymerase chain reaction products were electrophoresed on denaturing gels and exposed to radiographic film.

RESULTS

Three of 18 UC specimens with instability at other chromosomal loci (17%) showed TGF-beta 1RII poly A tract mutation, including 2 cancers and 1 dysplasia; moreover, 2% of UC specimens without instability (1 of 43) (1 cancer), 81% of unstable sporadic colorectal cancers (13 of 16), and none of the 61 stable or unstable gastric or esophageal cancers contained TGF-beta 1RII mutations.

CONCLUSIONS

Mutational inactivation of the poly A microsatellite tract within TGF-beta 1RII occurs early and in a subset of unstable UC neoplasms and commonly in sporadic colorectal cancers but may be rare in unstable gastric and esophageal tumors.

The role of thoracoscopic lymph node staging in esophageal cancer

BACKGROUND

Unlike mediastinoscopy in lung cancer, there exists no standard minimally invasive test to stage esophageal cancer. If it were possible to obtain exact preoperative staging in esophageal cancer, patients could be separated prospectively to receive adjuvant therapy appropriately.

METHODS

We studied the feasibility and efficacy of thoracoscopic lymph node staging (TSLN) and laparoscopic lymph node staging (LSLN) in esophageal cancer.

RESULTS

TSLN was performed in 45 patients with biopsy proven carcinoma of the esophagus. LSLN was done in the last 19 patients. TSLN was aborted in 3 pts due to adhesions. Thoracic LN stage was N0 in 39 patients and N1 in 3; celiac LN were negative in 13 and positive in 6 patients. Esophageal resection was performed in 30 patients after TSLN; 17 of these underwent LSLN. TSLN staging showed N0 lymph node status in 28 patients and N1 in 2 patients. Two of the 28 N0 patients (7%) were found at resection to have paraesophageal lymph node involvement (N1) and were thus understaged by TSLN. Thus TSLN was accurate in detecting the presence of thoracic LN in 28/30 cases (93%). LSLN staging found negative celiac nodes in 12 patients and positive LN in 5 patients. After esophagectomy, final pathology of the 12 N0 patients was N0 in 11 and positive LN in one patient. Thus, LSLN was accurate in detecting lymph node metastases in 16/17 patients (94%).

Video assisted thoracoscopic biopsy for interstitial lung disease

At the University of Maryland Medical Systems, 356 consecutive thoracoscopic procedures were performed including 147 lung resections for various indications. Forty-nine patients underwent thoracoscopy for the diagnosis of interstitial lung disease. Two patients underwent bilateral procedures after a gap of more than six months for suspected malignancy. There were 28 females and 21 males. Age ranged from 23 to 75 years. The mean length of operation was 45 minutes and the mean length of chest tube duration 1.3 days. There were no deaths, no re-explorations or need to convert to an open thoracotomy. Staphylococcal pneumonia developed in one patient postoperatively requiring admission and intravenous antibiotics. One patient with systemic pulmonary hypertension was ventilator dependent for 48 hours. All patients, except two ventilator dependent patients, were intubated with a double lumen tube. CO2 insufflation at the rate of 2 L/min and pressure of 10 mmHg was used in all patients. Biopsy of at least two lobes was performed in all patients with resection of grossly abnormal lung. A single chest tube was left at the end of the procedure. The tissue diagnosis was interstitial fibrosis in 19 patients. Bronchiolitis obliterans with organizing pneumonitis (BOOP) was seen in 7 patients. Foreign body granulomas were seen in 8 patients. Allergic alveolitis was diagnosed in 4 patients. Emphysematous changes with pneumonitis was observed in 3, nonspecific pneumonitis in 2. Anthracosis, connective tissue disorder, leukemic infiltrate with interstitial fibrosis and CMV pneumonitis were observed in one patient each. The clinical diagnosis correlated with pathological diagnosis and intraoperative findings. Thoracoscopy is a safe and effective method for diagnosis of interstitial lung disease.

Alterations of transforming growth factor-beta 1 receptor type II occur in ulcerative colitis-associated carcinomas, sporadic colorectal neoplasms, and esophageal carcinomas, but not in gastric neoplasms

BACKGROUND & AIMS

Gastric cancers, sporadic colorectal cancers, and ulcerative colitis (UC)-associated colorectal carcinomas and dysplasias manifest microsatellite instability (MI); however, esophageal carcinomas rarely exhibit MI. Recently, a transforming growth factor-beta 1 type II receptor (TGF-beta 1RII) mutation in a coding microsatellite was described in primary colorectal carcinomas demonstrating MI. No previous studies of TGF-beta 1RII have addressed mechanisms of inactivation other than MI in human tumors; furthermore, MI-negative tumors have not been examined for TGF-beta 1RII mutation. We evaluated 138 primary human neoplasms for mutation in the poly-A microsatellite tract of TGF-beta 1RII. Additionally, a group of esophageal tumors was evaluated for the expression of TGF-beta 1RII messenger RNA (mRNA).

METHODS

First, we determined whether MI was present at other chromosomal loci in these lesions. The poly-deoxyadenine (poly-A) microsatellite tract within the TGF-beta 1RII coding region was then PCR-amplified. In a group of MI-negative esophageal tumors, RT-PCR was performed to determine the expression of TGF-beta 1RII mRNA.

RESULTS

Among 17 MI+ UC specimens, 3 (18%) demonstrated TGF-beta 1RII poly-A tract mutation (2 cancers and 1 dysplasia), while 2 (4%) of 44 MI-negative UC specimens (1 dysplasia and 1 tumor), and 13 (81%) of 16 MI+ sporadic colorectal cancers, contained TGF-beta 1RII poly-A mutation. No gastric or esophageal tumors contained TGF-beta 1RII mutation. Among 21 MI-negative esophageal carcinomas. 6 cases (28.5%) had TGF-beta 1RII transcripts that were low or undetectable by RT-PCR.

CONCLUSIONS

Mutation within the poly-A microsatellite tract of TGF-beta 1RII occurs early in a subset of UC-neoplasms and commonly in sporadic colorectal cancers, but may be rare in MI+ gastric tumors. Diminished expression of TGF-beta 1RII mRNA in esophageal tumors suggests that mechanisms of inactivation in this gene other than MI play a role in esophageal carcinogenesis.

Role of thoracoscopic lymph node staging for lung and esophageal cancer

Staging is extremely important in determining the proper treatment of patients with thoracic malignancies. Staging groups can be used to predict outcome after cancer treatment and allocate patients to appropriate treatment regimens. Thoracoscopy is an excellent means of staging intrathoracic malignancies. It is a good tool for biopsy of mediastinal lymph nodes and evaluation of the pleural cavity. Routine thoracoscopic and laparoscopic lymph node staging have been used in patients with esophageal carcinoma with excellent results. For patients with lung cancer, thoracoscopy augments other noninvasive and minimally invasive staging procedures. It is used as a complement to standard cervical mediastinoscopy in assessing mediastinal and hilar lymph nodes. It can thus help avoid an unnecessary thoracotomy for attempted resection in a patient who is found to have gross spread of locoregional disease.