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Decaluwé H, De Leyn P, Vansteenkiste J, Dooms C, Van Raemdonck D, Nafteux P, Coosemans W, Lerut T. Surgical multimodality treatment for baseline resectable stage IIIA-N2 non-small cell lung cancer. Degree of mediastinal lymph node involvement and impact on survival. Eur J Cardiothorac Surg 2009; 36:433-9. [PMID: 19502079 DOI: 10.1016/j.ejcts.2009.04.013] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2008] [Revised: 03/23/2009] [Accepted: 04/06/2009] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Analysis of single centre results and identification of prognostic factors of surgical combined modality treatment in pathological proven stage IIIA-N2 non-small cell lung cancer (NSCLC). METHODS Out of a total of 996 resections for NSCLC between 2000 and 2006, 92 patients with radiological response or stable disease after induction chemotherapy for pathologically proven ipsilateral positive lymph nodes (N2-disease) underwent surgical exploration with the aim of complete resection. Adenocarcinoma and squamous cell carcinomas were equally present (48% vs 43%). Median follow-up of surviving patients (n=36) was 51 (10-94) months. RESULTS Complete resection (i.e., tumour with free margins and negative highest mediastinal lymph nodes, R0) was achieved in 68% (n=63), resection was uncertain or incomplete in 24% (n=22), while surgery was explorative in 8% (n=7). Pneumonectomy was performed in 24%, (bi)lobectomy in 62%, and sleeve lobectomy in 13% of patients. In-hospital mortality was 2.3%. Overall need for ICU stay was 18% (30% after pneumonectomy). Median hospital stay was 10 days (6-157). Downstaging of mediastinal lymph nodes (ypN0-1) was found in 43% (n=40). Overall survival at 5 years (5YS) was 33% (n=92), and after complete resection 43% (n=63). Detection of multilevel compared to single level positive nodes at initial mediastinoscopy was related to lower 5YS (17% vs 39%; p<0.005), and this was identified as an independent prognostic factor in a multivariate analysis of the examined presurgical variables. We found a trend for a better 5YS in patients with mediastinal nodal downstaging compared to patients with persistent N2 disease (49% vs 27%; p=0.095). In the subgroup with persistent N2 disease, single level disease has a significantly better survival (37% vs 7% 5YS, p<0.005). Multivariate survival analysis of the examined surgical variables identified completeness of resection and classification of ypN category (ypN0-1 and ypN2-single level vs multilevel-ypN2 and ypN3) as independent prognostic factors. CONCLUSIONS Surgery after induction chemotherapy for stage IIIA-N2 NSCLC can be performed with an acceptable mortality and morbidity. Baseline single level N2 disease is an independent prognostic factor for long-term survival. Patients with mediastinal downstaging, but also a subgroup of patients with single level persistent N2 disease, after induction therapy have a rewarding survival.
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De Vleeschauwer S, Van Raemdonck D, Vanaudenaerde B, Vos R, Meers C, Wauters S, Coosemans W, Decaluwe H, De Leyn P, Nafteux P, Dupont L, Lerut T, Verleden G. Early Outcome After Lung Transplantation From Non–Heart-Beating Donors is Comparable to Heart-Beating Donors. J Heart Lung Transplant 2009; 28:380-7. [DOI: 10.1016/j.healun.2009.01.010] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Revised: 12/17/2008] [Accepted: 01/14/2009] [Indexed: 12/21/2022] Open
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Wauters S, Van Raemdonck D, Meers C, Neyrinck A, Rega F, Van de Wauwer C, Vanhees D, Verleden G, Dupont L, Coosemans W, Decaluwe H, De Leyn P, Nafteux P, Lerut T. 358: Donor Cause of Brain Death Has No Impact on Outcome after Lung Transplantation. J Heart Lung Transplant 2009. [DOI: 10.1016/j.healun.2008.11.365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Lerut T, Coosemans W, Decaluwé H, Decker G, De Leyn P, Nafteux P, Van Raemdonck D. Zenker's diverticulum. Multimed Man Cardiothorac Surg 2009; 2009:mmcts.2007.002881. [PMID: 24412952 DOI: 10.1510/mmcts.2007.002881] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The cricopharyngeal diverticulum or Zenker's diverticulum is the most frequent type of diverticulum of the upper gastrointestinal tract. It occurs mostly in elderly patients. The predominant symptoms are dysphagia and regurgitation which may result in malnutrition and aspiration pneumonia, the latter eventually being life threatening. The underlying cause of Zenker's diverticulum is a dysfunction of the cricopharyngeal muscle and the upper esophageal sphincter, the most common finding being a decreased compliance. The treatment consists in a myotomy of the upper esophageal sphincter and cricopharyngeal muscle combined with a diverticulopexy or diverticulectomy. This procedure is performed via a limited left cervicotomy. Results are excellent to very good in 94% of the patients in our own experience.
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De Leyn P, Moons J, Vansteenkiste J, Verbeken E, Van Raemdonck D, Nafteux P, Decaluwe H, Lerut T. Survival after resection of synchronous bilateral lung cancer. Eur J Cardiothorac Surg 2008; 34:1215-22. [PMID: 18829338 DOI: 10.1016/j.ejcts.2008.07.069] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Revised: 07/10/2008] [Accepted: 07/14/2008] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Due to recent advances in imaging, the incidence of patients presenting with bilateral lung lesions is increasing. A single contralateral lung lesion can be an isolated metastasis or a synchronous second primary lung cancer. For the revision of the TNM in 2009, the International Association for the Study of Lung Cancer Staging Committee proposes that patients with contralateral lung nodules remain classified as M1 disease. In this retrospective study, the survival after resection of synchronous bilateral lung cancer is evaluated. METHODS From our database of bronchial carcinoma, all patients with bilateral synchronous lung lesions between 1990 and 2007 were retrieved. We analysed 57 patients in which, after functional assessment and thorough staging, the decision was taken to treat the disease with bilateral resection. All these files were retrospectively reviewed. Twenty-one patients were excluded from this analysis because only one side was resected (n=15) or one of the lesions was non-neoplastic on final pathology (n=6). RESULTS Thirty-six patients underwent bilateral resection for synchronous multiple primary lung cancer. All resections were performed as sequential procedures. In 23 patients, one side was anatomically resected (2 pneumonectomies) and the contralateral side was resected by limited resection. In 10 patients a bilateral lobectomy was performed, and 3 patients had bilateral limited resections. Postoperative mortality was 2.8%. Eighteen patients had a tumour with a different histological pattern, confirmed by comparing both specimens by an experienced senior pathologist. The median survival after resection of synchronous bilateral lung cancer in our series was 25.4 months with a 5-year survival rate of 38%. There was no significant difference in survival between patients with different versus same histology. This survival is much higher compared to the survival of assumed stage IV disease. CONCLUSIONS Our study shows that selected patients with bilateral lung cancer may benefit from an aggressive approach, with acceptable morbidity and mortality, and rewarding long-term survival. Patients with a single contralateral lung lesion should not be treated as disseminated disease (stage IV). After extensive searching for metastatic spread, bilateral surgical resection should be considered in fit patients.
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Lerut T, Moons J, Coosemans W, Decaluwé H, Decker G, De Leyn P, Nafteux P, Van Raemdonck D. Multidisciplinary treatment of advanced cancer of the esophagus and gastroesophageal junction: a European center's approach. Surg Oncol Clin N Am 2008; 17:485-502, vii-viii. [PMID: 18486879 DOI: 10.1016/j.soc.2008.02.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Tremendous progress has been made in surgery for cancer of the esophagus and gastroesophageal junction. After primary surgery, overall 5-year survival rates of 35% or more are obtained in high-volume units, and for advanced stage III cancer, 5-year survival reaches 25%. Multimodality therapy, in particular induction chemotherapy with or without radiotherapy, results in a complete response rate in up to 25% of the patients. Approximately 50% of the patients receiving such treatment do not respond, however, and their outcome is dismal. Therefore, further efforts are needed to elaborate more precise algorithms for selecting candidates for induction therapy versus primary surgery.
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Internullo E, Moons J, Nafteux P, Coosemans W, Decker G, De Leyn P, Van Raemdonck D, Lerut T. Outcome after esophagectomy for cancer of the esophagus and GEJ in patients aged over 75 years. Eur J Cardiothorac Surg 2008; 33:1096-104. [PMID: 18407509 DOI: 10.1016/j.ejcts.2008.03.004] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 03/03/2008] [Accepted: 03/04/2008] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Though the surgical treatment of esophageal cancer is increasingly accepted for elderly people defined as aged over 70 years, less is reported about the results in patients over 75. This study is a single institution retrospective analysis of outcome after esophagectomy for cancer of the esophagus and GEJ in patients aged over 75 years. METHODS All consecutive patients 76 years old and over undergoing curative esophagectomy for cancer in the period 1991-2006 were analyzed as to comorbidities, outcome and long-term survival. All the data had been prospectively collected in a database. Postoperative mortality risk was assessed by P-POSSUM and O-POSSUM score for in-hospital mortality and by the recently published Steyerberg's score system [Steyerberg EW, Neville BA, Koppert LB, Lemmens VEPP, Tilanus HW, Coebergh JWW, Weeks JC, Earle CC. Surgical mortality in patients with esophageal cancer: development and validation of a simple risk score. J Clin Oncol 2006;24:4277-84.] for 30-day mortality. Five-year survival was compared to the standardized survival in the general population. RESULTS One hundred and eight patients fulfilling the abovementioned criteria were found (76 males and 32 females, mean age 79.5 years, mean standardized life-expectancy: 7.36 years). Among them, 69% had esophageal tumors and 31% GEJ tumors. The predominant histology was adenocarcinoma (74%). Eighty-six (79.6%) presented with one or more major comorbidities or a history of previous major upper-GI surgery, potentially affecting the surgical outcome. All underwent resection with curative intent (R(0) 83.3%, R(1) 12%, R(2) 4.6%). The overall postoperative morbidity rate was 51.9%, pulmonary complications (37%) being the most frequent. Postoperative mortality, mainly due to cardiopulmonary complications, was 7.4%, which was consistent with that predicted by P-POSSUM score (7.2%) and lower than that predicted by O-POSSUM score (15.1%). Thirty-day mortality was 5.5%, being consistent with that predicted by the Steyerberg's score (6.8%). Overall 5-year survival was 35.7%, while R(0) overall survival 42% and cancer specific R(0) survival 51.7%. CONCLUSIONS Patients 76 years old and over with esophageal or GEJ cancer should not be denied surgery solely on the basis of age. Outcome and long-term results in the selected elderly are not differing from those reported for younger patients. However, despite thorough preoperative assessment being applied in the selection of the candidates for surgery, a practical and reliable individual risk-analysis stratification is still lacking.
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Van Raemdonck D, Verleden G, Dupont L, Van Hees D, Coosemans W, Decker G, De Leyn P, Nafteux P, Lerut T. 382: Initial Experience with Lung Transplantation from Non-Heart-Beating Donors. J Heart Lung Transplant 2008. [DOI: 10.1016/j.healun.2007.11.393] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Nafteux P, Coosemans W, De Leyn P, Van Raemdonck D, Decaluwé H, Decker G, Lerut T. Laparoscopic Nissen fundoplication. Multimed Man Cardiothorac Surg 2008; 2008:mmcts.2007.002931. [PMID: 24415720 DOI: 10.1510/mmcts.2007.002931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The dissection is started performing a crural dissection with visualization and preservation of both vagus nerves, followed by circumferential dissection of the esophagus at the gastro-esophageal junction. Adequate intra-mediastinal mobilization of the esophagus is performed to obtain 3-4 cm of intra-abdominal esophagus without undue downward traction on the cardia or stomach. The gastric fundus is then mobilized through adequate short gastric vessel division. The left and right pillars of the right diaphragmatic crus are approximated using interrupted sutures. A short (≪2 cm), floppy 360° fundoplication anchored to the esophagus is created.
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Mathei J, Coosemans W, Nafteux P, Decker G, De Leyn P, Van Raemdonck D, Hoffman I, Deboeck C, Proesmans M, Lerut T. Laparoscopic Nissen fundoplication in infants and children: analysis of 106 consecutive patients with special emphasis in neurologically impaired vs. neurologically normal patients. Surg Endosc 2007; 22:1054-9. [PMID: 17943378 DOI: 10.1007/s00464-007-9578-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2006] [Revised: 04/23/2007] [Accepted: 05/14/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND The laparoscopic Nissen fundoplication has become a frequently performed procedure in infants and children who suffer from gastroesophageal reflux disease (GERD). In this study we describe our 8-year experience with 106 consecutive laparoscopic Nissen fundoplications. METHODS From January 1994 to May 2002, we included 106 consecutive patients (57 neurologically normal (NN) and 49 neurologically impaired (NI)). The indications were symptomatic GERD, pulmonary symptoms or a combination of both. Patient's outcome was assessed by symptom evaluation, technical examinations and a questionnaire. RESULTS Mortality was 0% and conversion rate was 2.8%. Major postoperative complications occurred in 12 patients, mostly neurologically impairment. Dysphagia occurred in 23 patients of which 4 required dilatations and 2 a redo Nissen. Gas bloating occurred in 15 children, with spontaneous regression in all. Recurrent pneumopathies were seen in four children. Documented recurrence of reflux occurred in three symptomatic patients. Redo laparoscopic surgery was performed in six patients. A questionnaire was sent to each patient's parents. This showed that most patients had a normal or clearly improved quality of life (93.1% NN, 90.5% NI). Most patients were satisfied with the result and up to 39.5% gave a maximum satisfaction score. CONCLUSION The laparoscopic Nissen fundoplication can safely be performed with a low conversion rate and no surgical mortality in neurologically normal and neurologically impaired children. Neurologically impaired children are more susceptible to per- and postoperative complications. A good quality of life and a high index of satisfaction could be achieved in most patients.
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Lievens Y, Nafteux P, Vanstraelen B, Nackaerts K. In Regards to Allen et al. (Int J Radiat Oncol Biol Phys 2006;65:640–645). Int J Radiat Oncol Biol Phys 2007; 68:315-6; author reply 316. [PMID: 17448889 DOI: 10.1016/j.ijrobp.2006.12.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2006] [Accepted: 12/27/2006] [Indexed: 10/23/2022]
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Van De Wauwer C, Van Raemdonck D, Verleden GM, Dupont L, De Leyn P, Coosemans W, Nafteux P, Lerut T. Risk factors for airway complications within the first year after lung transplantation. Eur J Cardiothorac Surg 2007; 31:703-10. [PMID: 17306556 DOI: 10.1016/j.ejcts.2007.01.025] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2006] [Revised: 12/29/2006] [Accepted: 01/15/2007] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Lung transplantation (LTx) has enjoyed increasing success with better survival in recent years. Nevertheless, airway anastomotic complications (AC) are still a potential cause of early morbidity and mortality. In this retrospective cohort study we looked at possible predictors of AC within the first year after LTx. METHODS Between July 1991 and December 2004, 232 consecutive single (n=102) and bilateral (n=130) LTx were performed (142 males and 90 females; mean age: 48 years [range 15-66 years]). Indications for LTx were emphysema (n=113), pulmonary fibrosis (n=45), cystic fibrosis (n=35), pulmonary hypertension (n=10), sarcoidosis (n=7) and miscellaneous (n=22). Donor variables (age, gender, PaO(2)/FiO(2), mechanical ventilation, ischemic time and preservation solution) and recipient variables (age, diagnosis, length, gender, pre-operative steroids, smoking, cytomegalovirus matching, LTx type, anastomotic type, wrapping and bypass) were evaluated in an univariate and multivariate model. RESULTS Fifty-seven complications occurred in 362 airway anastomoses (15.7%) of which 55 (15.2%) within the first year after transplantation. Six patients died as a result of AC (mortality 2.6%) during the first year after LTx. In a univariate analysis (321 airway anastomoses at risk), anastomotic type (7/17 [Telescoping] vs 48/304 [End-to-end]; p=0.011), recipient length (p=0.0012), donor ventilation (>50-70h<; p=0.0015) and recipient male gender (43/191 [M] vs 12/130 [F]; p=0.0092) were significant predictors of AC. Three factors remained significant predictors in the multivariate analysis: telescoping technique (p=0.0495), recipient length (p=0.0029) and donor ventilation (p=0.003). CONCLUSIONS Tall recipients and those receiving lungs from donors with prolonged ventilation have an increased risk to develop bronchial anastomotic problems. An end-to-end anastomosis should be preferred. Airway complications remain a matter of concern after lung transplantation.
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Stamenkovic S, Van Raemdonck D, Verleden G, Dupont L, Coosemans W, Decker G, De Leyn P, Nafteux P, Lerut A. Bilateral lobar lung transplantation--the first two cases in Belgium. Acta Chir Belg 2007; 107:201-4. [PMID: 17515271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
In the last twenty years lung transplantation has become an established treatment for end-stage lung failure refractory to medical management. Over this time, better short and long-term results have been achieved due to improvements in organ procurement, perfusion and preservation strategies, newer immunosuppressant regimes and better post-transplant care. The limiting factor for the number of lung transplantation procedures performed is the shortage of available donor organs. This results in longer waiting times for listed patients, with a substantially increased risk of dying prior to transplantation, especially in the paediatric population. Several surgical strategies have evolved to overcome the donor shortage, with lobar transplantation becoming a viable alternative. We describe our initial experience with two young patients with end-stage cystic fibrosis (CF) who required lung transplantation. Given their small size it was not possible to transplant an entire lung from an adult donor in each hemithorax. We describe lobar transplantation as a technique used to overcome this, in the first such operation in Belgium.
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De Leyn P, Stroobants S, De Wever W, Lerut T, Coosemans W, Decker G, Nafteux P, Van Raemdonck D, Mortelmans L, Nackaerts K, Vansteenkiste J. Prospective comparative study of integrated positron emission tomography-computed tomography scan compared with remediastinoscopy in the assessment of residual mediastinal lymph node disease after induction chemotherapy for mediastinoscopy-proven stage IIIA-N2 Non-small-cell lung cancer: a Leuven Lung Cancer Group Study. J Clin Oncol 2006; 24:3333-9. [PMID: 16849747 DOI: 10.1200/jco.2006.05.6341] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Mediastinal restaging after induction therapy for non-small-cell lung cancer remains a difficult and controversial issue. The goal of this prospective study was to compare the performance of integrated positron emission tomography (PET)--computed tomography (CT) and remediastinoscopy in the evaluation of mediastinal lymph node metastasis after induction chemotherapy. PATIENTS AND METHODS Thirty consecutive stage IIIA-N2 non-small-cell lung cancer patients surgically treated at our institution were entered onto this prospective study. N2 disease was proven by cervical mediastinoscopy, at which a mean number of 3.8 lymph node levels were biopsied. After completion of induction chemotherapy, the mediastinum was reassessed by integrated PET-CT and remediastinoscopy. All patients underwent thoracotomy with attempted complete resection and systematic nodal dissection. RESULTS PET-CT showed no evidence of nodal disease (N0) in 13 patients, Hilar nodal disease (N1) disease in three patients, and residual mediastinal disease (N2) in 14 patients. Remediastinoscopy was positive in only five patients. The preinduction involved lymph node level could be accurately re-evaluated in 18 patients. This was not the case in the other 12 because of extensive fibrosis and adhesions. In 17 patients, persistent N2 disease was found at thoracotomy. The sensitivity, specificity, and accuracy of PET-CT were 77%, 92%, and 83%, respectively. These parameters for remediastinoscopy were 29%, 100%, and 60%, respectively. Sensitivity (P < .0001) and accuracy (P = .012) were significantly better for PET-CT. CONCLUSION After a thorough staging mediastinoscopy, postinduction remediastinoscopy had a disappointing sensitivity because of adhesions and fibrosis. Integrated PET-CT yielded a better result than that obtained in previous studies with side-by-side PET and CT images.
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Lerut T, Coosemans W, Decker G, De Leyn P, Moons J, Nafteux P, Van Raemdonck D. Diagnosis and therapy in advanced cancer of the esophagus and the gastroesophageal junction. Curr Opin Gastroenterol 2006; 22:437-41. [PMID: 16760764 DOI: 10.1097/01.mog.0000231822.48890.3d] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The aim of this article is to discuss recent developments in the diagnosis and treatment with curative option of advanced cancer of the esophagus and gastroesophageal junction. RECENT FINDINGS Recent data indicate improvement of clinical staging accuracy by multi-slice computer tomography, endoscopic ultrasound with fine needle aspiration and positron emission tomography, the latter gaining growing impact as a prognostic indicator. When combined with extended lymphadenectomy primary surgery offers 5-year survivals between 25 and 35% for stage III disease. Results of induction therapy remain conflicting. While the most recent meta-analysis favored induction chemoradiotherapy, a subsequent randomized trial failed to confirm this conclusion. A growing interest in adjuvant chemoradiotherapy is stimulated by promising results from a recent pilot study. Trials investigating definitive chemoradiotherapy indicate a high incidence of locoregional recurrence. The emerging understanding of the molecular pathways that govern neoplastic events are under intense investigation. Results of pilot clinical studies on targeted therapy are expected shortly. SUMMARY Refinements in staging offer incremental increase of accuracy, the impact of positron emission tomography becoming increasingly important. In locally advanced disease, the debate on the added value of multimodality therapy remains unsolved as primary surgery combined with extended lymphadenectomy offers equal results. New drugs in particular in combination with targeted therapy may offer better perspectives in the near future.
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Driessen A, Landuyt W, Pastorekova S, Moons J, Goethals L, Haustermans K, Nafteux P, Penninckx F, Geboes K, Lerut T, Ectors N. Expression of carbonic anhydrase IX (CA IX), a hypoxia-related protein, rather than vascular-endothelial growth factor (VEGF), a pro-angiogenic factor, correlates with an extremely poor prognosis in esophageal and gastric adenocarcinomas. Ann Surg 2006; 243:334-40. [PMID: 16495697 PMCID: PMC1448952 DOI: 10.1097/01.sla.0000201452.09591.f3] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate the expression of carbonic anhydrase IX (CA IX) and vascular-endothelial growth factor (VEGF) in esophageal and gastric adenocarcinomas and in turn with the histologic subtype. SUMMARY BACKGROUND DATA Tumor hypoxia is an important factor in therapy resistance. A low oxygen concentration in tumors stimulates a.o. the expression of CA IX, a marker of hypoxia, and VEGF, a pro-angiogenic factor. METHODS We evaluated the immunohistochemical expression of CA IX and VEGF on paraffin-embedded material of 154 resection specimens: 39 esophageal, 73 cardiac, and 42 distal gastric adenocarcinomas (UICC classification). The adenocarcinomas were subtyped according to the Lauren classification (intestinal- and diffuse-type). STATISTICAL ANALYSIS chi test, Kaplan-Meier survival analysis, log-rank test, and Cox proportional hazards model. RESULTS CA IX and VEGF expression were independent of the localization of the tumor. However, intestinal-type adenocarcinomas showed a significantly higher expression of CA IX as well as VEGF than diffuse-type tumors. VEGF expression was associated with a high microvessel density. Although survival analysis showed that CA IX expression (P = 0.008) as well as the coexpression of CA IX and VEGF (P = 0.008) correlate with a poor outcome, only CA IX expression is an independent prognostic factor for overall survival and metastasis-free survival. CONCLUSION The difference in expression of CA IX and VEGF between intestinal- and diffuse-type adenocarcinomas may possibly explain the different clinical behavior of these tumors. CA IX expression, rather than VEGF positivity in tumors, enables the identification of a subpopulation, characterized by a more aggressive behavior and a poorer prognosis.
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Van De Wauwer C, Dupont L, De Leyn P, Coosemans W, Nafteux P, Decker G, Lerut T, Verleden G, Van Raemdonck D. 413. J Heart Lung Transplant 2006. [DOI: 10.1016/j.healun.2005.11.428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Lerut T, Coosemans W, Decker G, De Leyn P, Moons J, Nafteux P, Van Raemdonck D. Surgical techniques. J Surg Oncol 2005; 92:218-29. [PMID: 16299783 DOI: 10.1002/jso.20363] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Adenocarcinoma of the esophagus and gastroesophageal junction (GEJ) has shown a remarkable increase during recent decades. Most patients are present with advanced stage disease, reflecting transmural growth and metastasis to lymph nodes at the time of diagnosis. Moreover, the pattern of lymph node dissemination is chaotic and difficult to predict, and despite the use of modern technology (e.g., spiral CT, EUS, FDG-PET), clinical staging remains suboptimal. These shortcomings in staging, as well as in different attitudes toward extent of resection and lymphadenectomy, are reflected by a great variation in surgical techniques, which are discussed in this review. As to the results, primary surgery can currently be performed with low mortality, below 5% in high volume centers. Hospital mortality and morbidity are mainly related to pulmonary complications and anastomotic leaks, the latter mostly resolving under conservative treatment. Overall 5-year survival varies between 10% and 59%. As expected the most important prognostic determinants are completeness of resection (R0 vs. R1-R2) and lymph node status (N0, N1). R0 resection currently offers 5-year survival rates of over 40%. Five-year survival figures for node-negative (N0) patients exceed 70%, and even for node-positive (N1), patients reach 25%. It is not known whether performing a three-field lymph node dissection is beneficial for patients with adenocarcinoma of the distal esophagus. With overall 5-year survival currently exceeding 30%-40%, these figures should be the gold standard against which all other therapeutic modalities are compared.
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Van Raemdonck D, Klepetko W, Verleden GM, Daenen W, Coosemans W, Decker G, De Leyn P, Nafteux P, Lerut T. [Surgical aspects of (cardio) pulmonary transplantation]. Rev Mal Respir 2005; 22:785-95. [PMID: 16272981 DOI: 10.1016/s0761-8425(05)85636-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
UNLABELLED INTRODUCTION AND STATE OF THE ART: Both short and long-term outcomes following lung transplantation have improved substantially in recent years as a result of advances in the selection and management of donors, organ preservation, immunosuppressive therapy, and the treatment of infectious and malignant complications. In addition surgical techniques have evolved over time and have contributed to this increase in success rates. PERSPECTIVES AND CONCLUSIONS This review outlines surgical aspects of lung transplantation including a historical note, techniques of lung harvesting, some anaesthetic considerations, the different transplant types and incisions, as well as anastomotic techniques and their pitfalls.
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Dooms C, Nackaerts K, Vansteenkiste J, Nafteux P, Schmitt H. P-396 Treatment of malignant pleural mesothelioma with platinum-pemetrexed chemotherapy: The Leuven Lung Cancer Group experience. Lung Cancer 2005. [DOI: 10.1016/s0169-5002(05)80889-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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146
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Lerut T, Nafteux P, Moons J, Coosemans W, Decker G, De Leyn P, Van Raemdonck D, Ectors N. Three-field lymphadenectomy for carcinoma of the esophagus and gastroesophageal junction in 174 R0 resections: impact on staging, disease-free survival, and outcome: a plea for adaptation of TNM classification in upper-half esophageal carcinoma. Ann Surg 2004; 240:962-72; discussion 972-4. [PMID: 15570202 PMCID: PMC1356512 DOI: 10.1097/01.sla.0000145925.70409.d7] [Citation(s) in RCA: 311] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine the impact of esophagectomy with 3-field lymphadenectomy on staging, disease-free survival, and 5-year survival in patients with carcinoma of the esophagus and gastroesophageal junction (GEJ). BACKGROUND Esophagectomy with 3-field lymphadenectomy is mainly performed in Japan. Data from Western experience with 3-field lymphadenectomy are scarce and dealing with relatively small numbers. As a result, its role in the surgical practice of cancer of the esophagus and GEJ remains controversial. METHODS Between 1991 and 1999, primary surgery with 3-field lymphadenectomy was performed in 192 patients, of whom a cohort of 174 R0 resections was used for further analysis. RESULTS Hospital mortality of the whole series was 1.2%. Overall morbidity was 58%. Pulmonary complications occurred in 32.8%, cardiac dysrhythmias in 10.9%, and persistent recurrent nerve problems in 2.6%. pTNM staging was as follows: stage 0, 0.6%; stage I, 9.2%; stage II, 27.6%; stage III, 28.7%; and stage IV, 33.9%. Overall 3- and 5-year survival was 51% and 41.9%, respectively. The 3- and 5-year disease-free survival was 51.4% and 46.3%, respectively. Locoregional lymph node recurrence was 5.2%; no patient developed an isolated cervical lymph node recurrence. Five-year survival for node-negative patients was 80.2% versus 24.5% for node-positive patients. Five-year survival by stage was 100% in stages 0 and I, 59.1% in stage II, 36.8% in stage III, and 13.3% in stage IV. Twenty-three percent of the patients with adenocarcinoma (25.8% distal third and 17.6% GEJ) and 25% of the patients with squamous cell carcinoma (26.2% middle third) had positive cervical nodes resulting in a change of pTNM staging specifically related to the unforeseen cervical lymph node involvement in 12%. Cervical lymph node involvement was unforeseen in 75.6% of patients with cervical nodes at pathologic examinations. Five-year survival for patients with positive cervical nodes was 27.7% for middle third squamous cell carcinoma. For distal third adenocarcinomas, 4-year survival was 35.7% and 5-year survival 11.9%. No GEJ adenocarcinoma with positive cervical nodes survived for 5 years. CONCLUSIONS Esophagectomy with 3-field lymph node dissection can be performed with low mortality and acceptable morbidity. The prevalence of involved cervical nodes is high, regardless of the type and location of tumor resulting in a change of final staging specifically related to the cervical field in 12% of this series. Overall 5-year and disease-free survival after R0 resection of 41.9% and 46.3%, respectively, may indicate a real survival benefit. A 5-year survival of 27.2% in patients with positive cervical nodes in middle third carcinomas indicates that these nodes should be considered as regional (N1) rather than distant metastasis (M1b) in middle third carcinomas. These patients seem to benefit from a 3-field lymphadenectomy. The role of 3-field lymphadenectomy in distal third adenocarcinoma remains investigational.
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Driessen A, Alaerts H, Van Riet J, Flamen P, Plessers L, Nafteux P, Haustermans K, Lerut T, Mortelmans L, Ectors N. Correlation of positron emission tomography (PET)-avidity in esophageal and cardiac adenocarcinomas with hypoxia-related biomarkers. J Clin Oncol 2004. [DOI: 10.1200/jco.2004.22.90140.4045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Lerut T, Coosemans W, Decker G, De Leyn P, Moons J, Nafteux P, Van Raemdonck D. Extended surgery for cancer of the esophagus and gastroesophageal junction. J Surg Res 2004; 117:58-63. [PMID: 15013715 DOI: 10.1016/j.jss.2003.12.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2003] [Indexed: 10/26/2022]
Abstract
The overall prognosis of patients with carcinoma of the esophagus and gastroesophageal junction (GEJ) remains poor mainly because of the advanced stage of the disease at the time of presentation. As a result, controversy persists over the appropriate extent of surgery. This article reviews the impact of aggressive surgery on staging, disease-free survival, and cure rate. Despite recent advances in staging including positron emission tomography (PET), the findings after aggressive surgery indicate that the overall accuracy, sensitivity, and specificity of clinical staging are still too low. These shortcomings in clinical staging therefore question the value of the indications, results, and interpretation of outcomes in multimodality treatment regimens. Extended surgery increases the R(0) resection rate, which seems to have an undeniable beneficial effect on the incidence of locoregional recurrence and which should be considered as a parameter of surgical quality, especially within the context of multimodality trials. As to the effect on cure rate, the only randomized trial with published results did not indicate a significant difference between extended and more limited resections for adenocarcinoma of the esophagus and GEJ, albeit that a subsequent subanalysis did show a significant survival benefit favoring more extended surgery in distal third adenocarcinomas. However, the bulk of current literature suggests that better survival is achieved by more aggressive surgery. For three-field lymphadenectomy the available data suggest a potential survival benefit. It appears that positive cervical lymph nodes in patients with middle or proximal third carcinoma should no longer be considered as M(1a/b) distant lymph node metastasis but rather as N(1) regional disease.
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149
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Driessen A, Nafteux P, Lerut T, Van Raemdonck D, De Leyn P, Filez L, Penninckx F, Geboes K, Ectors N. Identical cytokeratin expression pattern CK7+/CK20- in esophageal and cardiac cancer: etiopathological and clinical implications. Mod Pathol 2004; 17:49-55. [PMID: 14631371 DOI: 10.1038/modpathol.3800011] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Surgical treatment and prognosis is different in esophageal, cardiac and distal gastric adenocarcinomas. Determination of the origin, in particular of adenocarcinomas situated at the gastroesophageal junction, may be difficult. It has been suggested that esophageal adenocarcinomas are characterized by a specific cytokeratin pattern, namely the CK7+/CK20- pattern. According to the same authors, this cytokeratin pattern is absent in gastric adenocarcinomas. The aim of our study is to evaluate if this cytokeratin pattern CK7+/CK20- is absent in cardiac and distal gastric adenocarcinomas. Therefore, we evaluated the combined immunohistochemical expression of CK7 and CK20 on paraffin-embedded material of 214 resection specimens for adenocarcinoma, comprising 66 esophageal, 73 cardiac and 75 distal gastric adenocarcinomas (UICC-classification). The adenocarcinomas were subtyped into intestinal- and diffuse-type according to the Lauren classification. The immunohistochemical staining was considered as positive if 50% or more of the tumor cells were stained. Statistical analysis has been performed applying the chi2-test. The tumors situated at the gastroesophageal junction, esophageal as well as cardiac adenocarcinomas, showed predominantly a CK7+/CK20- expression pattern (67 vs 68%), whereas this cytokeratin pattern is rather uncommon in distal gastric adenocarcinomas (31%, P<4 x 10(-5)). Independent of their localization, intestinal- as well as diffuse-type adenocarcinomas have a similar cytokeratin pattern. Our data show that the combined expression of CK7 and CK20 is different for the adenocarcinomas situated on both sides of the gastroesophageal junction compared to the distal gastric adenocarcinomas. However, in contrast to data in the literature, the combined expression of CK7 and CK20 has a low specificity in the distinction between esophageal and cardiac adenocarcinomas. This may suggest a similar origin (cell lineage) and thus may have an impact on therapeutic strategies.
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Lerut T, Coosemans W, Decker G, De Leyn P, Ectors N, Fieuws S, Moons J, Nafteux P, Van Raemdonck D. Extracapsular lymph node involvement is a negative prognostic factor in T3 adenocarcinoma of the distal esophagus and gastroesophageal junction. J Thorac Cardiovasc Surg 2003; 126:1121-8. [PMID: 14566257 DOI: 10.1016/s0022-5223(03)00941-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess prognosis according to whether lymph node involvement is intracapsular or with extracapsular breakthrough in adenocarcinoma of the distal esophagus and gastroesophageal junction. Materials and methods One hundred ninety-five consecutive patients with T3 adenocarcinoma of the distal esophagus and gastroesophageal junction between 1990 and 1999 were studied. All patients underwent primary R0 esophagectomy. The mean number of resected nodes per patient was 36.9. Survival was analyzed according to intracapsular and extracapsular involvement. RESULTS In N0 patients 5-year survival was 57% and 9-year survival was 38.7%. In patients with positive nodes these figures were 26.2% and 18.1%, respectively (P =.0069). Intracapsular and extracapsular node involvement showed 5- and 10-year survival of 40.9% and 21.7% versus 18% and 15.7%, respectively. There was no significant difference in 5- and 10-year survival between N0 and intracapsular node involvement (P =.43). However, there was a significant difference in survival between N0 and extracapsular node involvement (P =.002) and between intracapsular and extracapsular node involvement (P =.0001). CONCLUSIONS This study shows a significant difference in survival according to whether lymph node involvement was intracapsular or extracapsular. Patients with intracapsular lymph node involvement have similar survival rates as N0 patients. Extracapsular lymph node involvement is a bad prognostic factor, independent of the number of involved lymph nodes. The number of involved lymph nodes has an additive negative effect. These data may have an impact on treatment strategies.
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