Esophagogastric anastomosis with invagination into stomach: New technique to reduce fistula formation

AIM: To present a new technique of cervical esophagogastric anastomosis to reduce the frequency of fistula formation.

METHODS: A group of 31 patients with thoracic and abdominal esophageal cancer underwent cervical esophagogastric anastomosis with invagination of the proximal esophageal stump into the stomach tube. In the region elected for anastomosis, a transverse myotomy of the esophagus was carried out around the entire circumference of the esophagus. Afterwards, a 4-cm long segment of esophagus was invaginated into the stomach and anastomosed to the anterior and the posterior walls.

RESULTS: Postoperative minor complications occurred in 22 (70.9%) patients. Four (12.9%) patients had serious complications that led to death. The discharge of saliva was at a lower region, while attempting to leave the anastomosis site out of the alimentary transit. Three (9.7%) patients had fistula at the esophagogastric anastomosis, with minimal leakage of air or saliva and with mild clinical repercussions. No patients had esophagogastric fistula with intense saliva leakage from either the cervical incision or the thoracic drain. Fibrotic stenosis of anastomoses occurred in seven (22.6%) patients. All these patients obtained relief from their dysphagia with endoscopic dilatation of the anastomosis.

CONCLUSION: Cervical esophagogastric anastomosis with invagination of the proximal esophageal stump into the stomach tube presented a low rate of esophagogastric fistula with mild clinical repercussions.

Associations of risk factors obesity and occupational airborne exposures with CDKN2A/p16 aberrant DNA methylation in esophageal cancer patients

It is known that obesity and occupational airborne exposure such as dust are among risk factors of esophageal cancer development, in particular squamous cell carcinoma (SCC) of esophagus. Here, we tested whether these factors could also affect aberrant DNA methylation. DNAs from 44 fresh tumor tissues and 19 non-tumor adjacent normal tissues, obtained from 44 patients affected by SCC of esophagus (SCCE), were studied for methylation at the CDKN2A/p16 gene promoter by methylation-specific polymerase chain reaction assay. Statistical methods were used to assess association of promoter methylation with biopathological, clinical, and personal information data, including obesity and airborne exposures. Methylation at the CDKN2A/p16 gene promoter was detected in 12 out of 44 tumor samples. None of the non-tumor tissues exhibited the aberrant methylation. Our results confirmed previously described significant association with low tumor stage (P= 0.002); in addition, we found that obesity (P= 0.001) and occupational exposure (P= 0.008) were both significantly associated with CDKN2A/p16 promoter methylation. This study provides evidence that obesity and occupational exposure increase the risk of developing esophageal cancer through an enhancement of CDKN2A/p16 promoter methylation.

FOXC2 is a novel prognostic factor in human esophageal squamous cell carcinoma

BACKGROUND

FOXC2 has been implicated in cancer progression through its induction of epithelial-to-mesenchymal transition. We analyzed the clinical significance of FOXC2 in esophageal cancer cases, in which early distant metastasis or invasion to nearby organs is an obstacle to treatment.

METHODS

Quantitative reverse transcriptase-polymerase chain reaction was used to evaluate FOXC2 mRNA expression in 70 esophageal cancer cases to determine the clinicopathologic significance of FOXC2 expression. Furthermore, we examined associations between FOXC2 expression and matrix metalloproteinases 2 (MMP2) and matrix metalloproteinases 9 (MMP9). We also performed in vitro invasion and migration assays for FOXC2-suppressed esophageal cancer cells.

RESULTS

In clinicopathologic analysis, the high-FOXC2 expression group showed a higher incidence of advanced tumor stage, lymph node metastasis, and lymphatic invasion than the low-FOXC2 expression group (P < 0.05). In particular, tumor stage exhibited the most remarkable difference (P < 0.0001). Expression of MMP2 and MMP9 was far higher in the high-FOXC2 expression group. Furthermore, the high-FOXC2 expression group had a significantly poorer prognosis than did the low expression group (P = 0.006). Multivariate analysis indicated that high FOXC2 expression was an independent prognostic factor for survival. Suppression of FOXC2 expression altered the invasive and the migratory ability of esophageal cancer cells in vitro.

CONCLUSIONS

Our findings suggest that FOXC2 could be an important prognostic indicator for esophageal cancer patients. FOXC2 is directly involved in cancer progression and is associated with poor prognosis in esophageal cancer cases.

Feasibility study of sentinel lymph node biopsy in esophageal cancer with conservative lymphadenectomy

INTRODUCTION

Lymphoscintigraphy and sentinel node mapping is established in breast cancer and melanoma but not in esophageal cancer, even though many centers have shown that occult tumor deposits in lymph nodes influence prognosis. We report our initial experience with lymphoscintigraphy and sentinel lymph node biopsy in patients undergoing resection for esophageal cancer.

METHODS

Sixteen of 17 consecutive patients underwent resection for invasive esophageal cancer along with sentinel lymph node retrieval (resection rate, 94%). Peritumoral injection of (99m)Tc antimony colloid was performed by upper endoscopy prior to the operation. A two-surgeon synchronous approach via right thoracotomy and laparotomy was performed with conservative lymphadenectomy. Sentinel lymph nodes were identified using a gamma probe both in vivo and ex vivo. Sentinel lymph nodes were sent off separately for serial sections and immunohistochemistry.

RESULTS

Median patient age was 60.4 years (range, 45-75 years). Fifteen were male, and thirteen had adenocarcinoma. At least one sentinel lymph node (median, 2) was identified in 14 of 16 patients (success rate, 88%). Sentinel nodes were present in more than one nodal station in five patients (31%). In all 14 patients, the sentinel lymph node accurately predicted findings in non-sentinel nodes (accuracy, 100%). Three patients with positive sentinel lymph nodes had metastases identified in non-sentinel nodes (sensitivity, 100%).

CONCLUSIONS

Sentinel lymph node biopsy is feasible in esophageal resection with conservative lymphadenectomy, and initial results suggest it is accurate in predicting overall nodal status. Further study is needed to assess impact on patient management and prognosis.

Outcome following surgery for squamous cell carcinoma of the oesophagus

INTRODUCTION

This study was undertaken to determine the outcomes of patients treated for squamous cell carcinoma (SCC) of the oesophagus.

METHODS

The study group consisted of 61 patients (median age: 64 years) with invasive SCC of the oesophagus who underwent resection between 1987 and 2007 in Adelaide, South Australia. Thirty-two (52%) were female. Survival data were available for all patients. The log rank test was performed to identify prognostic factors for survival.

RESULTS

The 5-year overall survival rate was 33% (median: 24 months). Of 61 patients, 42 (69%) received neoadjuvant therapy prior to surgery. The overall resection rate was 95%. Significant post-operative morbidity occurred in 47%, and the in-hospital mortality was 5% (30-day mortality: 3%). No overall survival benefit was seen in patients undergoing neoadjuvant therapy prior to surgical resection. However, patients who had a complete pathological response to neoadjuvant therapy had a better 5-year survival than patients who did not receive neoadjuvant therapy: 47% versus 30%, respectively.

CONCLUSIONS

Oesophagectomy following neoadjuvant therapy for SCC of the oesophagus can be performed with low perioperative mortality. A complete response to neoadjuvant therapy was followed by an improved survival outcome.

New treatments, new challenges: pathology's perspective on esophageal carcinoma

While frank esophageal carcinoma rarely presents a diagnostic challenge, early lesions are often tricky to assess. This difficulty stems in part from drawbacks in the classification systems designed to stratify early lesions as a guide for deciding treatment. These systems are complex and wrought with specific pathologic challenges brought on by new treatment modalities. Such interventions as endoscopic mucosal resection, photodynamic therapy, and chemotherapy/radiation combinations present the pathologist with new histologic challenges that have a direct impact on patient care. In this article, we discuss staging issues pertinent to early cancers, histologic sequelae of various treatments, and how these factors affect the pathologist's role in evaluating esophageal carcinoma.

Outcome for esophageal cancer following treatment with chemotherapy and radiotherapy but not esophagectomy: Nonsurgical treatment of esophageal cancer

Background:

More than 50% of patients with esophageal cancer are not suitable for surgery. The aim of this study was to analyze the outcome of patients undergoing standard nonsurgical treatment.

Methods:

Data of all patients undergoing nonsurgical treatment for esophageal cancer were identified from a prospective database.

Results:

Seventy-five patients were treated for localized disease, and 52 for metastatic disease at diagnosis. Except for age, which was higher in patients without metastases, there were no significant differences between the patients with vs. without metastatic disease. Kaplan–Meier analysis showed a median survival of 10.8 months for all patients. There was a significant difference in survival (p < 0.001) between the groups with versus without metastases, with median survival in the patients without metastases 13.6 months versus 6.5 months in patients with metastases. Patients undergoing nonsurgical treatment for localized disease had a five-year survival of 12%. No significant difference between adenocarcinoma and squamous cell carcinoma was identified. Subanalysis of patients who received chemoradiotherapy revealed similar results to the overall group of patients.

Conclusion:

In patients with localized disease at diagnosis, long-term survival can be achieved in some patients, whereas five-year survival is rare in patients who present with metastatic disease.