Surgical therapy of oesophageal carcinoma

Methods of esophagogastric anastomoses following esophagectomy for cancer: A systematic review

Anastomotic complications are responsible for significant morbidity and mortality following esophagectomy for cancer. Conflicting reports exist regarding the superiority of hand-sewn versus stapled techniques. This systematic review identified eight randomized clinical trials examining this issue. None of the studies reported significant differences in leak rate or early mortality. One study demonstrated a difference in stricture rates, with fewer for hand-sewn anastomoses. There is insufficient evidence to recommend one anastomotic technique over the other.

The influence of age on mortality and survival in patients undergoing oesophagogastrectomies. A seven-year experience in a tertiary centre

The aim of this study was to evaluate the effects of advanced age on the outcome and survival of patients undergoing oesophagectomy for oesophageal cancer at a single high-volume centre. We retrospectively reviewed the hospital survival of 326 patients in oesophagogastrectomies (OGs) in a period from May 2001 to April 2008. We divided the patients into two groups. Group A (n=218) consisted of patients younger than 70 years of age, while Group B (n=108) consisted of patients 70 years of age or older. The two groups were comparable. In-hospital mortality for Group A was 11 out of 218 (5%), while in-hospital mortality for Group B was 13 out of 108 (12%). This difference was statistically significant (P=0.024). Multivariate analysis showed that risk factors for in-hospital mortality after OG included age over 70 years [odds ratio (OR)=2.79], reduced % of predicted FEV(1) (OR=0.13) and cardiac co-morbidity (OR=2.53). Despite age over 70 years proving not to be predictive of survival (P=0.21), significant independent predictors were advancing age [hazard ratio (HR)=1.03] and stage of disease (HR=1.84). P-values were 0.0278 and 0.018, respectively. Increasing age is a significant risk factor for mortality and survival after oesophageal resection operations. This mortality is particularly high if associated with a preoperative cardiac or respiratory morbidity.

Respiratory complications after oesophageal surgery

PURPOSE OF REVIEW

The most frequent complications of oesophageal surgery are respiratory and these are associated with increased critical care stay, hospital stay and mortality. This review focuses on the risk factors associated with the development of respiratory complications after oesophageal surgery.

RECENT FINDINGS

An acceptable operative mortality, increased and improved quality of life can be gained in appropriately selected patients. When induction therapy is scheduled, smoking cessation is advised. The preoperative treatment of airway pathogens can reduce postoperative complications and this may be particularly relevant in patients who have received induction chemoradiotherapy. Nonrandomized studies suggest that thoracic epidural analgesia improves outcome. Minimally invasive surgery is increasingly used and appears safe but direct comparisons to open surgery in terms of respiratory complications are awaited. Few randomized studies are available to guide anaesthetic management but anaesthetists should aim to avoid hypoxaemia, hypotension, aspiration and limit blood and fluid administration. Postoperative aspiration is common and steps to reduce it are recommended.

SUMMARY

The multifactorial nature of respiratory complications after oesophageal surgery may mean that a number of interventions are needed to have a detectable influence on outcome, much like a care bundle strategy.

Alcohol drinking, cigarette smoking, and the development of squamous cell carcinoma of the esophagus: epidemiology, clinical findings, and prevention

Both cigarette smoking and alcohol drinking are well-established risk factors for esophageal squamous cell carcinoma (ESCC), and the relationship of dose to cancer risk has already been described. Furthermore, the synergistic effect of these two factors has been reported. Our case-control study revealed the odds ratio of ESCC to be 50.1 for those who were both heavy smokers and heavy drinkers in comparison to people who neither drank nor smoked. In patients with ESCC, head and neck cancers as well as dysplastic lesions are frequently observed. Heavy smoking and heavy drinking are closely related to such multicentric carcinogenesis events in the upper aerodigestive tract (UADT), including the esophagus and head andneck region. Polymorphisms in acetaldehyde dehydrogenase 2 (ALDH2) are reported to be a key event in deciding individual susceptibility to UADT cancer. Patients with inactive ALDH2, in whom facial flushing is usually observed after the drinking of alcohol, are at high risk for ESCC as well as multiple UADT cancers. For the early detection of the disease, effective follow up using endoscopy with Lugol staining or narrow band imaging endoscopy is strongly recommended for high-risk populations, such as smokers, heavy drinkers, people with experience of flushing after the drinking of alcohol, and patients with UADT cancer.

Metachronous adenocarcinoma in a gastric tube after radical surgery for oesophageal cancer

In recent years the prognosis for oesophageal squamous cell carcinoma patients has improved. Together with this improvement, the occurrence of second primary carcinoma, especially gastric carcinoma, in tubes constructed from the stomach after oesophagectomy must be taken into account. We report a case of a patient who had this clinical presentation, which was revealed not in the normal follow-up, but in a consecutive operation carried out because of an anastomotic problem.

Probing the link between oestrogen receptors and oesophageal cancer

BACKGROUND

Human oesophageal carcinoma is considered to be one of the most aggressive malignancies and has a very poor prognosis. The incidence of oesophageal cancer shows a gender bias and is higher in males compared with females, the ratio between males and females varying from 3:1 to 7:1. This sex ratio is not entirely attributable to differences in the prevalence of known risk factors between the sexes. The potential role of oestrogen receptors (ER) in oesophageal cancer has been debated for several years but the significance of the receptors in this cancer remains unknown. Most of the work has been based on immunohistochemistry and has not been validated with other available techniques. The inconsistencies in the published literature on the link between ER expression and oesophageal cancer warrant a thorough evaluation of the potential role of ERs in this malignancy. Even the expression of the two ER isoforms, ERalpha and ERbeta, and its implications for outcome of treatments in histological subtypes of oesophageal tumours is ill defined. The aim of this article is to provide updated information from the available literature on the current status of ER expression in oesophageal cancer and to discuss its potential therapeutic role.

METHODS AND RESULTS

We performed a comprehensive literature search and analysed the results regarding ER expression in oesophageal tumours with special emphasis on expression of different oestrogen receptors and the role of sex hormones in oesophageal cancer. This article also focuses on the significance of the two main ER subtypes and mechanisms underlying the presumed male predominance of this disease.

CONCLUSION

We postulate that differential oestrogen receptor status may be considered a biomarker of poor clinical outcome based on tissue dedifferentiation or advanced stage of the disease. Further, if we can establish the importance of oestrogen and its receptors in the context of oesophageal cancer, then this may lead to a new future direction in the management of this malignancy.

Pathologic response after neoadjuvant therapy is the major determinant of survival in patients with esophageal cancer

BACKGROUND

Esophageal cancer remains a malignancy with high morbidity and mortality despite improvements to diagnosis, staging, chemotherapy, radiation, and surgery. Neoadjuvant therapy (NT) may improve oncologic outcome in many patients, however the degree to which patients benefit remains unclear. We examined the relationship between pathologic response to NT and magnitude of benefit in patients with esophageal cancer.

METHODS

Using a comprehensive esophageal cancer database, we identified patients who underwent esophagectomy between 1994 and 2008. Pathologic response was denoted as complete (pCR), partial (pPR), and nonresponse (NR). Clinical and pathologic data were compared using Fisher's exact and chi-square when appropriate, while Kaplan-Meier estimates were used for survival analysis.

RESULTS

We identified 347 patients who underwent esophagectomy, and 262 (75.5%) were treated with NT. The median age was 66 years (28-86 years) with median follow-up of 20 months (1-177 months). There were 106 (40.5%) patients exhibiting pCR, 95 (36.3%) with pPR, and 61 (23.3%) with NR. The rate of R0 resections was higher amongst pCR (100%) compared with 94.7% in pPR (P = 0.02) and 87.5% in NR (P = 0.0007). There were 15 (14.2%) recurrences in pCR, 22 (23.7%) in pPR, and 17 (28.8%) in NR (P = 0.04). Patients achieving pCR had 5-year disease-free survival (DFS) and overall survival (OS) of 52% and 52%, respectively, compared with 36% and 38% in pPR and 22% and 19% in NR (P < 0.0001, P < 0.0001).

CONCLUSIONS

Esophageal cancer patients frequently succumb to their disease. However, patients treated with neoadjuvant therapy who achieve pCR have a higher rate of R0 resections, fewer recurrences, and improved 5-year OS and DFS.

Lgr5, an intestinal stem cell marker, is abnormally expressed in Barrett's esophagus and esophageal adenocarcinoma

Lgr5 (leucine-rich-repeat-containing G-protein-coupled receptor 5), a recently discovered intestinal stem cell marker, is expressed in premalignant lesions including Barrett's esophagus (BE) and cancers including colon cancer, ovarian cancer, and hepatocellular carcinoma. It was also recently found to be expressed in tumor spheres prepared from colon cancer, suggesting that it will likely serve as a cancer stem cell marker. We sought to examine Lgr5 as a biomarker in BE-associated neoplasia. Using standard immunohistochemistry, we performed immunostaining on 81 esophageal specimens (53 biopsy specimens and 28 surgical resections) representing BE, BE-associated dysplasia, and esophageal adenocarcinoma (EAC). Each immunostain was scored based on intensity of immunostaining and percentage of positive cells. For 24 EAC cases, survival analysis was performed with expression scores and other clinicopathological variables. We found that Lgr5 expression was detected in 70% of BE cases and between 90 and 100% of advanced dysplastic lesions and EAC. The intensity of expression was significantly higher in high-grade dysplasia and EAC than BE. In EAC, high Lgr5 expression scores (> or = 5) were associated with worse survival, independent of stage, age, and neoadjuvant/adjuvant therapy (P = 0.03). Our findings suggest that Lgr5 has potential utility as a biomarker for BE-associated dysplasia and EAC.

The use of self-expandable metallic stents for palliative treatment of inoperable esophageal cancer

Most patients with esophageal carcinoma present in the advanced stage die from tumor invasion and widespread metastases. Because radical regimens are not appropriate for the majority of patients, and their expected survivals are as short as to be measured by months, the main aim of therapy is palliation with minimum morbidity and mortality. Among the palliative modalities are surgery, external radiotherapy or brachytherapy, dilatation, laser, photodynamic therapy, bipolar electrocoagulation tumor probe, and chemical ablation. The placement of self-expandable metallic stents is another method that improves dysphagia for these patients. In this study, the aim was to evaluate retrospectively the effectiveness of metallic stents deployed because of inoperable malignant esophageal stenosis and esophagotracheal fistulas. The results of 170 patients with 202 stents administered because of inoperable malignant esophageal stenosis and esophagorespiratory fistula between January 2000 and October 2008 at the Ataturk University, Department of Thoracic Surgery, were investigated. Despite epidemiological and clinical data, information regarding relief of dysphagia and quality of life were also examined. One hundred seventy patients with stents were between 28 and 91 years old (mean age 63.7 years+/-11.4 years). Ninety-seven were male and 73 were female. Stent indications were advanced tumors with distant metastasis (82 cases, 48.2%), unresectable tumors (51 cases, 30%), patients who cannot tolerate surgery or chemoradiotherapy (18 cases, 10.5%), local recurrence after primary therapy (1 case, 0.5%), esophagorespiratory fistulas from tumor or therapy (14 cases, 8.2%), and refusal of surgery (4 cases, 2.3%). Dysphagia scores evaluated by a modified Takita's grading system improved from 3.4 before the procedure to 2.6 afterward. The overall complication rate without chest pain was 31.7% (occurring in 64 cases). Mean survival was 177.7 days+/-59.3 days (2-993 days). Quality-of-life scores (The European Organization of Research and Treatment of Cancer QLQ C30) improved from 73+/-10.3 (57-85) to 112+/-12.6 (90-125). In therapy of malignant esophageal obstructions, metallic stents provide a significant improvement in dysphagia and require less frequent re-intervention according to other methods of dysphagia palliation such as dilatation, laser, and photodynamic therapy, nearly completely relieve esophagotracheal fistulas and improve quality of life to an important degree.

Clinical utility of postchemoradiation endoscopic brush cytology and biopsy in predicting residual esophageal adenocarcinoma

BACKGROUND

Esophageal adenocarcinoma generally carries a poor prognosis. Treatment with combination chemoradiation (CRT) followed by esophagectomy is becoming common. A pathologic complete response is uncommon but predicts improved survival. Identifying the subset of patients with residual carcinoma has potential management implications. Post-CRT endoscopic brush cytology and biopsy may detect residual tumor; however, the accuracy and clinical value of these methods remain unclear.

METHODS

Sixty-seven patients with esophageal adenocarcinoma who underwent preoperative CRT and post-CRT endoscopic brush cytology and biopsy followed by esophagectomy were identified. By using esophagectomy histology as the gold standard, the performance of cytology and biopsy was evaluated in diagnosing residual carcinoma. Two pathologists independently reviewed all false-negative and false-positive cases and resolved disagreements by consensus.

RESULTS

The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of cytology for diagnosing residual carcinoma were 26%, 95%, 92%, 35%, and 45%, respectively. For biopsy, these rates were 13%, 90%, 75%, 31%, and 36%, respectively. Sampling error accounted for false-negative diagnoses in approximately 66% of cytology analyses and 98% of biopsy analyses. Approximately 33% of false-negative cytology analyses and 1 false-negative biopsy analysis were caused by the under-recognition of tumor cells. Major diagnostic pitfalls included obscuring acute inflammation, necrosis, tumor cells that mimicked benign cells with radiation/reactive atypia, and the under recognition of mucin-containing adenocarcinoma cells.

CONCLUSIONS

Brush cytology and biopsy were specific but not sensitive methods for predicting residual cancer after CRT. However, cytology was superior. The current results indicated that brush cytology can be used alone to diagnose residual esophageal carcinoma, and awareness of specific diagnostic pitfalls will help pathologists improve its accuracy.

Management of oesophageal cancer

Oesophageal cancer is a disease of dismal prognosis. There are variations of epidemiology among different ethnic groups and geographic regions. India is a country with high incidence. This can be attributed to the interplay between environmental, dietary factors and life-style of the population of the country. Optimal therapeutic strategy for patients with oesophageal cancer demands individual consideration.Majority of oesophageal cancer patients present at an advanced stage of disease. Screening programmes or strategies aiming at early diagnosis can improve the prognosis; unfortunately this is not cost-effective except in very high incidence areas. Accurate staging can help select the most appropriate treatments, such as excluding those patients with metastatic disease who are unlikely to benefit from surgery, and treating very early lesions with endoscopic means. When surgery is indicated, treating patient in a high-volume centre can improve the outcome and minimise complications. Although surgical resection remains the main treatment modality, long-term prognosis after surgical resection alone has been suboptimal except in those with early disease. Multidisciplinary approaches including chemotherapy and radiotherapy with or without surgery are increasingly employed for patients with advanced disease. Collaboration among surgeons, clinical oncologists, radiologists and physicians is of utmost importance to achieve the best results. Treatment for patients should be individualised to enhance outcome.

A retrospective comparison of clinical outcomes and quality of life measures between definitive chemoradiation alone and radical surgery for clinical stage II-III esophageal carcinoma

BACKGROUND

This retrospective study was conducted to compare the treatment and quality of life (QOL) results between radical surgery and definitive chemoradiotherapy (CRT) for stage II-III carcinoma of the esophagus.

METHODS

Between 2000 and 2009, 128 consecutive patients were selected for this study in which 72 were treated with definitive CRT and 56 with radical surgery. QOL was assessed using Functional Assessment of Cancer Therapy-Esophagus for 51 patients who were free of disease at the time of survey.

RESULTS

With a median follow-up period of 37.8 months with 66 survivors, the 4y-DFS in the surgery group were 36% in the CRT group and 51% in the surgery group (P = 0.0028). In the CRT group, the number of cases of the advanced age, T4 stage, and stage III was significantly larger than the surgery group. QOL assessments were completed at rates of 100% in the CRT group and 88% in the surgery group. Overall E Total score had a significant difference between arms (CRT > surgery, P = 0.045).

CONCLUSIONS

CRT was inferior to surgery in survival but superior in QOL measures, although the CRT group had a larger number of patients with poorer prognostic factors.

Salvage esophagectomy after definitive chemoradiotherapy for thoracic esophageal cancer

BACKGROUND AND OBJECTIVES

Although locoregional failure frequently occurs after definitive chemoradiotherapy (CRT), the role of salvage esophagectomy has not been fully evaluated. The aim of this study was to compare the outcome of salvage esophagectomy after high-dose definitive CRT with neoadjuvant CRT.

METHODS

From 1994 to 2007, 33 patients with thoracic esophageal cancer underwent salvage esophagectomy after definitive CRT, and 115 patients underwent neoadjuvant CRT followed by surgery.

RESULTS

The postoperative mortality rate in the salvage group (12%) was higher than in the neoadjuvant group (3.6%, P = 0.059). The rates of postoperative complications were significantly higher in the salvage group than in neoadjuvant group: Anastomotic leakage (39% vs. 22%, respectively, P = 0.049), bleeding (15% vs. 1.7%, respectively, P = 0.002), cardiovascular complications (24% vs. 5.4%, respectively, P = 0.001). Univariate analysis showed that pretherapy T stage, pretherapy lymph node status, pathological T stage, and operative curability were significant prognostic factors affecting survival of patients who underwent salvage esophagectomy. In particular, patients with cT3-T4 tumors or cN1 tumors before definitive CRT showed worse prognosis after salvage esophagectomy.

CONCLUSIONS

Salvage esophagectomy after high-dose definitive CRT was associated with higher postoperative mortality and morbidity rates compared with neoadjuvant CRT. Only selected patients can be rescued by salvage esophagectomy.

National trends in esophageal surgery--are outcomes as good as we believe?

INTRODUCTION

Positive volume-outcome relationships in esophagectomy have prompted support for regionalization of care; however, outcomes have not recently been analyzed. This study examines national trends in provision of esophagectomy and reassesses the volume-outcome relationship in light of changing practice patterns and training paradigms.

METHODS

The Nationwide Inpatient Sample was queried from 1998 to 2006. Quantification of patients' comorbidities was made using the Charlson Index. Using logistic regression modeling, institutions' annual case volumes were correlated with risk-adjusted outcomes over time, as well as presence or absence of fellowship and residency training programs.

RESULTS

A nationwide total of 57,676 esophagectomies were recorded. In-hospital unadjusted mortality fell from 12% to 7%. Adjusting for comorbidities, greater esophagectomy volume was associated with improvements in the incidence of most measured complications, though mortality increased once greater than 100 cases were performed. Hospitals supporting fellowship training or a surgical residency program did not have higher rates of mortality or total complications.

CONCLUSIONS

The current national mortality rate of 7% following esophagectomy is higher than is reported in most contemporary case series. A greater annual esophagectomy volume improves outcomes, but only up to a point. Current training paradigms are safe.

Impact on outcome of the route of conduit transposition after transhiatal oesophagectomy: A randomized controlled trial

AIM

To assess the influence of the route of conduit transposition after transhiatal oesophagectomy on the postoperative morbidity and mortality and late outcome at 6 months.

METHODS

Patients with oesophageal carcinoma, undergoing transhiatal oesophagectomy (gastric conduit), were randomized to either anterior or posterior route of conduit transposition. Patients with advanced tumour, distant metastasis, extensive invasion of the stomach, previous gastric surgery, any anterior mediastinal abnormality detected on preoperative imaging, ASA grade III/IV and poor preoperative pulmonary function were excluded. Intraoperative complications, postoperative morbidity and mortality and late outcomes were compared.

RESULTS

Of the 49 patients (34 men), 24 patients were randomized to the anterior mediastinal route and 25 to the posterior. The mean duration of the operative procedure (anterior: 235min; posterior: 225min) and the mean blood loss (anterior: 531ml; posterior: 538ml) were not statistically different. The most common complications were pulmonary and cardiac and comparable in both groups. Four patients died postoperatively. At 6-month follow-up the incidence of dysphagia, anastomotic stricture, anastomotic recurrence, aspiration and reflux symptoms and weight gain were similar.

CONCLUSIONS

The route of conduit transposition did not affect the outcome. However, an individualized approach depending upon the operative findings, radicality of the procedure, and perceived need for postoperative adjuvant therapy may be useful.

A suspected [18F]fluorodeoxyglucose positron emission tomography-negative metastatic lymph node successfully diagnosed by laparoscopic staging in esophageal cancer: report of two cases

An accurate preoperative staging is important for selecting an appropriate therapy for esophageal cancer. In particular, diagnosis of lymph node metastases influences the indication for radical surgery. [18F]Fluorodeoxyglucose positron emission tomography (FDG-PET) has been widely applied primarily as a useful tool for initial staging of esophageal cancer. However, false-negative cases sometimes make it difficult to select the appropriate treatment. We report two patients with esophageal cancer and PET-negative enlarged lymph node successfully diagnosed by laparoscopic sampling. This procedure did not only allow accurate histopathological staging, but also helped to select the optimal minimally invasive management. This technique can be recommended for patients with esophageal cancer in whom the diagnosis of enlarged lymph node cannot be confirmed by preoperative imaging.

Current trends in extended lymph node dissection for esophageal carcinoma

Extended lymph node dissection helps increase the curativeness of resection, the accuracy of surgical-pathological staging, and the prognosis of thoracic esophageal carcinoma. However, it is also associated with significantly increased surgical morbidity and has noticeable negative effects on the quality of life after surgery. Current trends for selective lymph node dissection based on clinical evidence may be helpful in reducing surgical risks while assuring the completeness of resection.

Tumor budding in tumor invasive front predicts prognosis and survival of patients with esophageal squamous cell carcinomas receiving neoadjuvant chemotherapy

BACKGROUND

In neoadjuvant chemotherapy for advanced esophageal cancers, complete tumor regression has been difficult to achieve, and tumor often remained after chemotherapy. However, the best method for evaluating the response to chemotherapy based on histopathologic examination of residual tumors has not been established.

METHODS

Studied were 74 patients who received neoadjuvant chemotherapy (5-fluorouracil, cisplatin, and doxorubicin), followed by surgery for advanced esophageal squamous cell carcinoma. The correlation between various histopathologic factors and clinical response with survival was examined, including the importance of tumor budding in the invasive front of tumors on clinical response and survival.

RESULTS

Among 74 patients, 3 achieved a pathologic complete response, and 29 (41%) of 71 residual tumors demonstrated high-grade budding in the invasive front. The 5-year survival rate of patients with low-grade budding tumors was 49%, compared with 17% for those with high-grade budding (P < .001). Budding correlated inversely with good response, which was observed in 44 (60%) of 74 patients. Univariate analysis showed that pathologic tumor depth, number of lymph node metastases, pathologic stage, lymphatic invasion, budding and clinical response were significant prognostic factors. Multivariate analysis identified budding as the most important prognostic factor followed by number of lymph node metastases.

CONCLUSIONS

The results of the current study indicated that tumor budding in the invasive front of tumors correlated significantly with clinical response and prognosis of patients with esophageal squamous cell carcinomas who received neoadjuvant chemotherapy. However, the mechanism of tumor budding in the invasion front of esophageal squamous cell carcinomas treated with chemotherapy was not clarified.

Influence of irradiated lung volumes on perioperative morbidity and mortality in patients after neoadjuvant radiochemotherapy for esophageal cancer

PURPOSE

In some randomized trials, the treatment outcome of locally advanced esophageal cancer has been significantly improved by neoadjuvant radiochemotherapy (RCT). However, increased perioperative pulmonary toxicity in terms of acute respiratory distress syndrome (ARDS) has been linked to radiation exposure of the lungs. In our study we evaluated perioperative morbidity and mortality in patients with cancer Stages IIA-IVA treated with curative intent either with surgery alone (S) or with neoadjuvant RCT followed by surgery (RCTS).

PATIENTS AND METHODS

Between 1996 and 2003, 55 patients received S, and 98 received RCTS. In the RCTS group, most patients received two cycles of 5-fluorouracil plus cisplatinum simultaneously with normofractionated radiotherapy (40Gy). Four weeks later they underwent surgery. Endpoints were the incidence of acute lung injury (ALI), ARDS, other postoperative complications, and mortality within 31 days.

RESULTS

Between both groups there were no significant differences between the incidence and severity of ALI and ARDS (RCTS: 42.9%, 42.9%; S: 45.5%, 38.2%). Furthermore, there were no significant differences in the incidences of pneumonia, pleural effusion, and pneumothorax (RCTS 29.6% vs. S 16.4%, p = 0.07). Perioperative complication rates and mortality did not vary significantly (mortality after RCTS 5.1% vs. S 3.6%). A detailed analysis of 54 RCTS patients according to lung dose-volume histograms did not show any correlation between ARDS and pulmonary exposure. In univariate analysis, only respiratory comorbidity correlated with ARDS.

CONCLUSION

Neoadjuvant cisplatinum and 5-fluorouracil-based RCT apparently has no detrimental impact on the postoperative course.

Endoscopic surveillance for Barrett's oesophagus: the patients' perspective

OBJECTIVE

Barrett's oesophagus (BO) is associated with the development of oesophageal adenocarcinoma and endoscopic surveillance is commonly practised. In view of the clinical, psychological and economic implications of BO, we have studied patients' attitudes towards surveillance, their levels of anxiety and quality of life.

METHODS

Patients with BO undergoing endoscopic surveillance were asked to complete a questionnaire,including seven questions on their experience of surveillance, the Hospital Anxiety and Depression Scale,the Trust in Physician Scale (TIPS) and the Short Form-36 quality of life questionnaire.

RESULTS

Of the 250 patients invited, 178 responded (71%).One hundred and fifty-one (60%) completed the questionnaire sufficiently for analysis [median age 66 (range 41-79) years, 101 male]. Twenty-nine percent of patients had received too little information concerning surveillance of BO and 22% no information at all. Information was deemed difficult to understand by 24%. Hospital Anxiety and Depression Scale anxiety score: 14%abnormal, 25% borderline. Quality of life was lower than the general population in seven of eight Short Form-36 parameters. Increasing TIPS score correlated with having received (r= 0.33, P <0.001) and understood (r = 0.2, P= 0.037) BO information, and negatively with the belief that endoscopic surveillance reduced oesophageal adenocarcinoma risk (r= - 0.19, P =0.025). Increasing TIPS score was associated with less anxiety (P= 0.015) and depression (P =0.001), and better quality of life.

CONCLUSION

Patients undergoing endoscopic surveillance for BO suffer anxiety and have impaired quality of life. As trust in their physicians is correlated with receiving sufficient BO information, we surmise that ensuring BO patients understand their condition is likely to improve quality of life, anxiety and depression.

Minimally invasive oesophageal resection for distal oesophageal cancer: A review of the literature

Oesophagus resection is adequate treatment for some benign oesophageal diseases, especially caustic and peptic stenosis and end-stage motility dysfunction. However, the most frequent indications for oesophageal resection are the high-grade dysplasia of Barrett oesophagus and non-metastasized oesophageal cancer. Different procedures have been developed for performing oesophageal resection given the 5-year survival rate of only 18% among patients operated on. A disadvantage of the conventional approach is the high morbidity rate, especially with pulmonary complications. Minimally invasive oesophageal resections, which were first performed in 1991, may reduce this important morbidity and preserve the oncologic outcome. The first reports of morbidity and respiratory complications with this approach were disappointing and it seemed likely that the procedure would have to be abandoned. However, in the past 5 years, Japanese groups and the group of Luketich in Pittsburgh have given these techniques an important impetus. The outcomes of the new series are different from those in the beginning period, and are leading to an enormous expansion worldwide. Important factors behind the change are standardization of the operative technique, the experience of many surgeons with more advanced laparoscopic procedures, important improvements in instruments for dissection and division of tissues, a better technique in use of anaesthesia, and a better selection of patients for operation. Two minimally invasive techniques are being perfected: the three-stage operation by right thoracoscopy and laparoscopy, and the transhiatal laparoscopic approach. The former may be applied successfully for any tumour in the oesophagus, whereas the latter seems ideal for distal oesophageal and oesophagogastric junction tumours. This review article discusses all these aspects, giving special attention to indications and operative technique.

Esophageal cancer in Stockholm county 1978-1995

BACKGROUND

Most studies regarding esophageal cancer are based on a selection of patients, influencing the prognosis as well as other variables measured. Sweden may be unique in that it has registries that cover the whole population, permitting population based studies regarding diseases such as esophageal cancer. This also makes it possible to study the true nature of a population of patients and to describe changes in that population over time.

METHOD

Retrospective analysis of the files of all 1284 patients diagnosed with esophageal cancer in Stockholm County 1978-1995. The study period was divided into three six-year intervals (periods I, II and III).

RESULTS

A total of 201 patients were diagnosed at autopsy. They were only analyzed regarding histopathological and demographic parameters. A statistically significant increased survival for the whole group of patients was found, but this improvement in survival was not found among resected patients. No survival benefit was noted for patients operated on at large centers compared to patients operated on at surgical clinics with few yearly resections performed. The well-known increase in the incidence of adenocarcinoma in the esophagus among men was documented. A tendency (non-significant) of an increase in the incidence of adenocarcinoma among women was also noted.

CONCLUSIONS

Survival seems to have increased among esophageal cancer patients, but this survival benefit is not dependent on improved surgery. The number of yearly operations in a clinic did not correlate to long-term survival in this study.

The role of minimally invasive treatments in surgical oncology

This article reviews the use of minimally invasive surgical and endoscopic techniques in the field of surgical oncology. It reviews the indications and techniques of the use of minimally invasive surgery for several oncologic indications in general surgery. In particular, it reviews the currently published literature discussing the oncologic outcomes of these techniques.

The triangulating stapling technique for cervical esophagogastric anastomosis after esophagectomy

PURPOSE

To evaluate the safety and feasibility of the triangulating stapling technique (TST) for cervical esophagogastric anastomosis after esophagectomy (CEGA).

METHODS

The subjects were 123 patients who underwent transthoracic esophagectomy with three-field lymph node dissection and reconstruction with a 3.5-cm wide gastric tube, for thoracic esophageal cancer. We performed the TST for CEGA in 33 patients operated on after December, 2006 (TST group) and hand-sewn anastomosis in 90 patients operated on between 2002 and 2006 (HSA group).

RESULTS

In the TST group, CEGA was performed in an end-to-end fashion using three linear staplers. The first anastomosis was applied to the posterior walls of the remnant esophagus and gastric tube in an inverted fashion. The second and the third anastomoses were done in an everted fashion to make the anterior wall. The end-to-end HSA was performed with interrupted sutures using 4-0 absorbable material. Anastomotic leakage occurred in only 1 (3.0%) of the 33 TST patients, but in 13 (14.4%) of the 90 HSA patients (P = 0.07). The frequency of anastomotic stenosis was 9.1% and 25.6% in the TST and HSA groups, respectively (P < 0.05).

CONCLUSIONS

Cervical esophagogastric anastomosis using TST may reduce the frequency of anastomotic leakage and stenosis. This technique is a safe and reliable alternative for CEGA after esophagectomy.

Preoperative therapy for esophageal cancer

This article examines the role of combined-modality therapy for treating locally advanced esophageal cancer. Although surgery remains a cornerstone of treatment, recent studies have demonstrated that pre- or perioperative chemotherapy is associated with improved survival for patients who have adenocarcinoma histology. Primary chemoradiotherapy is the accepted standard of care for medically inoperable patients. Recent studies also suggest that definitive chemoradiotherapy is acceptable for patients who have squamous histology, while subsequent surgery improves local control without conferring a clear survival benefit. Neoadjuvant chemoradiotherapy continues to be investigated but is associated with several advantages over neoadjuvant chemotherapy alone, including an improvement in the pathologic complete response rate and resectability. Patients who achieve a pathologic complete response also appear to have improved survival. Adjuvant chemoradiotherapy may be considered for patients who undergo primary resection of lower esophageal/gastroesophageal junction adenocarcinoma.

[Perioperative fluid management: an analysis of the present situation]

Optimal perioperative fluid management is still controversial. Besides well known perioperative hypovolaemia, hypervolaemia has an influence on perioperative morbidity and mortality, particularly with regard to the patient's medical history, a reduced cardiac and pulmonal function and the operation itself. The concepts of preoperative, intraoperative and postoperative fluid administration are neither adequately validated, nor sufficiently integrated into a perioperative concept. At the present, moderate fluid administration to improve preoperative and postoperative outcome is safe in minor or medium surgical procedures. High-risk surgical patients benefit from a time-oriented or/and goal-oriented monitored fluid therapy. In the past only little attention has been concentrated on postoperative fluid management, but may be stimulated by the new concepts of fast track surgery.

Self-expanding plastic stents for inoperable malignant strictures of the cervical esophagus

Dysphagia and respiratory complications are the major problems in patients suffering from malignant strictures of the cervical esophagus. In inoperable cases, interventional palliation is the cornerstone of treatment. The aim of this study was to evaluate the use of self-expanding plastic stents (SEPS) in this group of patients. In a retrospective study, 23 patients suffering from various malignant obstructive diseases of the cervical esophagus, including squamous cell carcinoma (n = 10), laryngeal cancer (n = 7), lung cancer with esophageal invasion (n = 5), and metastatic breast cancer (n = 1), underwent SEPS placement, under endoscopic and fluoroscopic guidance. Tracheoesophageal fistula was documented in five patients. Technical success rate, improvement of dysphagia grade, and stent-related complications were evaluated after stent placement. Stent insertion was successfully achieved in all cases, namely in 20 patients at the first stent placement attempt and in three patients after a second attempt. Dysphagia grade was notably improved after 24 h. In two cases, major complications occurred. These were successfully treated without the need of stent extraction. Barium swallowing studies demonstrated complete sealing of all fistulas. Foreign-body sensation that gradually disappeared within the first week after stent placement was observed in eight patients. Recurrence of dysphagia occurred in three patients, due to hyperplastic tissue proliferation (n = 2) and tumor overgrowth (n = 1). Late migration of the stent was detected in one case after 67 days. SEPS placement is an effective and safe palliative treatment for malignant strictures of the cervical esophagus. Main advantages include easy retrievability and reduced rates of reinterventions.

Economic analysis of esophageal stenting for management of malignant dysphagia

Over half of patients diagnosed with esophageal cancer are unsuitable for curative resection. A significant proportion of these patients will subsequently require palliative stenting to alleviate dysphagia. There is growing consensus in the literature that the deployment of a Self-Expanding Metal Stent is the optimum stenting strategy; however, it remains unclear whether covered or uncovered metal stents are more cost-effective. In order to determine which type of prosthesis is more cost-effective, we compared the different stenting strategies in terms of 1-year stent-related mortality, health-related quality of life, and cost. A decision analytical model was constructed to compare the 1-year stent-related mortality, health-related quality of life, and cost between covered and uncovered stents. Probabilistic sensitivity analysis was performed to quantify the uncertainty associated with our results. Value of Information analysis was performed to assess the value of further research. In order to fully characterize the uncertainty associated with this decision, plastic stents were included in our analysis. Stent-related mortality was slightly lower following covered stent deployment compared with uncovered stent deployment (1.00% vs. 1.26%). Covered stents were more effective by 0.0013 Quality-Adjusted Life Years (Standard Deviation [SD] 0.0013 Quality-Adjusted Life Years). They were also less expensive by $729.58 (SD $390.63). Probabilistic sensitivity analysis suggested that these results were not sensitive to model parameter uncertainty. Plastic stents deployment was $2832.64 (SD $1182.72) more expensive than uncovered metal stent deployment. Value of Information analysis suggests that the maximum value of further research in the UK is $61,124.30. The results of this study represent strong evidence for the cost-effectiveness of covered compared with uncovered self-expanding metal stents for the palliation of patients with malignant dysphagia. The findings support previously published literature asserting the dominance of self-expanding metal stents over plastic stents. Value of Information analysis suggests that further research may not be cost-effective. These findings have significant implication for both current clinical practice and future clinical research.

Response to chemoradiatiotherapy in squamous cell carcinoma of the esophagus: evaluation of some prognostic factors

Objective:

To evaluate the predictive values of the expression of factor VIII, CD-34, p53, bcl-2, and DNA ploidy regarding the response to chemoradiation of squamous cell carcinoma of the esophagus.

Design:

Retrospective analysis of pretreatment biopsies with immunohistochemistry and flow cytometry. The results were correlated to tumor response (complete vs. noncomplete) following chemoradiation with three cycles of 5-FU and cisplatin combined with 40–64 Gy of radiation.

Subjects:

44 consecutive patients with squamous cell carcinoma of the esophagus treated with chemoradiation with a curative intent from 1992–2000.

Main outcome measures:

Treatment response.

Results:

No correlations were found between the expressions of p53, bcl-2, or DNA ploidy and tumor response to chemoradiation. A positive correlation was found between factor VIII expression and a complete tumor response (p = 0.0357). However the other marker for angiogenesis, CD-34, showed a negative correlation (p = 0.0493). Both markers indicate blood vessel density meaning that, in this study, many vessels indicated a favorable response if measured with factor VIII, but a poor response if measured with CD-34.

Conclusion:

It is not possible to predict tumor response to our chemoradiation protocol through the analysis of pretreatment expression of p53, bcl-2 or DNA ploidy in biopsy specimens. In spite of significant correlations between complete tumor responses and the expressions of the markers for angiogenesis this significance may be questionable since one of the two markers, factor VIII had a positive and the other,CD-34, a negative correlation to tumor response.

Esofagogastrectomia com linfadenectomia em dois campos no câncer do esôfago torácico

OBJETIVO: Avaliar as indicações, sobrevida e fatores prognósticos da esofagogastrectomia com linfadenectomia em dois campos no câncer do esôfago torácico. MÉTODOS: Foram avaliados 111 pacientes retrospectivamente no período de janeiro de 1990 a dezembro de 2001 sendo 83 homens e 29 mulheres. A idade média dos pacientes foi 55,1 anos (variando entre 35-79). A linfadenectomia em dois campos foi parcial (Standard) em 34 pacientes(30,6%) e ampliada em 77(69,4%). RESULTADOS: A média de linfonodos dissecados foi de 22,6(variando entre 4 e 50). A doença R0 ocorreu em 53 pacientes(47,7%) a doença residual microscópica (R1) em 57 (52,3%) e a doença residual R2 em um paciente(0,9%). A recidiva ocorreu em 32 pacientes (28,8%) sendo em sete (6,3%) cervical, 17 (15,3%) locorregional e 19 (17,1%) sistêmica. A morbidade e mortalidade pós-operatória foram de 31,5% e 9% respectivamente, sem diferença significativa em relação á extensão da linfadenectomia mediastinal. A sobrevida global dos 111 pacientes em cinco anos foi de 48,4%, sem diferença significativa na sobrevida em relação á extensão da linfadenectomia, porém, houve aumento significativo na sobrevida livre de doença a favor dos paciente submetidos a linfadenectomia mediastinal ampliada(p=0,01). A ausência de doença residual (R0), comprometimento linfonodal (pN0) e o número de linfonodos comprometidos inferior a quatro, indicaram bom prognóstico. CONCLUSÃO: A esofagogastrectomia com linfadenectomia em dois campos apresentou um impacto positivo na taxa de sobrevida em cinco anos nos pacientes com câncer do esôfago torácico, particularmente em relação aos pacientes com ECIII. A linfadenectomia mediastinal ampliada aumentou significativamente a sobrevida livre de doença.

Differential responses of cellular immunity in patients undergoing neoadjuvant therapy followed by surgery for carcinoma of the oesophagus

BACKGROUND

To compare immune responses following neoadjuvant chemoradiation therapy in combination with hyperthermia plus surgery to those induced by surgery alone in patients with oesophageal cancer.

METHODS

Thirty-two patients with histopathologically proven oesophageal cancer, scheduled for potentially curative transhiatal or transthoracic oesophagectomy with (neo, n = 20) or without (control, n = 12) neoadjuvant thermochemoradiation therapy (ThCR) were included. Peripheral blood samples were obtained before ThCR, after 2 weeks of ThCR, 1 day before surgery, on postoperative days 1, 3, 7, and 6 weeks after surgery, for white blood cell counts, lymphocyte subsets and T helper type 1 (Th1) and type 2 (Th2) lymphocyte responses.

RESULTS

Neo patients showed a significant decrease in granulocytes and lymphocyte subsets, and T cell cytokines after 2 weeks of ThCR. Only CD8+ (cytotoxic) T cells recovered after ThCR to reach normal levels prior to surgery. In contrast, CD4+ T (helper) cells, and NK- and B cells in neo patients did not recover prior to surgery (all P < 0.05). Oesophagectomy induced a significant increase in granulocytes and a decrease in lymphocytes (and subsets). Only those subsets that had not recovered after ThCR (CD4+ T cells, NK and B cells but not CD8+ T cells), were significantly lower (all P < 0.05) during the entire postoperative study period. Postoperatively, the stimulated cytokine production capacity of Th1 and Th2 cells, corrected for number of T cells, was not significantly different between the groups.

CONCLUSION

Neoadjuvant thermochemoradiation for oesophageal cancer caused significant disturbances of host cellular immunity with reduced T, NK and B cell counts, and differential recovery of cytotoxic and helper T cells leading to prolonged T cell imbalance that extends beyond the time of surgery. The functional and anti-tumour consequences of this immunodisturbance need further investigation, as recovery of T helper cytokine production towards surgery was less impaired than T helper cell counts.

Esofagogastrectomia com linfadenectomia em dois campos no câncer do esôfago torácico

OBJETIVO: Avaliar as indicações, sobrevida e fatores prognósticos da esofagogastrectomia com linfadenectomia em dois campos no câncer do esôfago torácico. MÉTODOS: Foram avaliados 111 pacientes retrospectivamente no período de janeiro de 1990 a dezembro de 2001 sendo 83 homens e 29 mulheres. A idade média dos pacientes foi 55,1 anos (variando entre 35-79). A linfadenectomia em dois campos foi parcial (Standard) em 34 pacientes(30,6%) e ampliada em 77(69,4%). RESULTADOS: A média de linfonodos dissecados foi de 22,6(variando entre 4 e 50). A doença R0 ocorreu em 53 pacientes(47,7%) a doença residual microscópica (R1) em 57 (52,3%) e a doença residual R2 em um paciente(0,9%). A recidiva ocorreu em 32 pacientes (28,8%) sendo em sete (6,3%) cervical, 17 (15,3%) locorregional e 19 (17,1%) sistêmica. A morbidade e mortalidade pós-operatória foram de 31,5% e 9% respectivamente, sem diferença significativa em relação á extensão da linfadenectomia mediastinal. A sobrevida global dos 111 pacientes em cinco anos foi de 48,4%, sem diferença significativa na sobrevida em relação á extensão da linfadenectomia, porém, houve aumento significativo na sobrevida livre de doença a favor dos paciente submetidos a linfadenectomia mediastinal ampliada(p=0,01). A ausência de doença residual (R0), comprometimento linfonodal (pN0) e o número de linfonodos comprometidos inferior a quatro, indicaram bom prognóstico. CONCLUSÃO: A esofagogastrectomia com linfadenectomia em dois campos apresentou um impacto positivo na taxa de sobrevida em cinco anos nos pacientes com câncer do esôfago torácico, particularmente em relação aos pacientes com ECIII. A linfadenectomia mediastinal ampliada aumentou significativamente a sobrevida livre de doença.

Scoring system for predicting response to chemoradiotherapy, including 5-Fluorouracil and platinum, for patients with esophageal cancer

We have retrospectively evaluated clinical data before therapy to enable reliable prediction of the response of esophageal cancer to chemoradiotherapy (CRT). We analyzed 108 patients who received 5-fluorouracil and platinum combined with 60 Gy radiation for esophageal cancer. Factors significantly related to response were extracted by use of logistic regression analysis, and a response score (RS) was prepared by combining these factors. By multivariate analysis, nutritional status, T stage, M stage, and alkaline phosphatase were selected as significant factors that contributed independently to the response of esophageal cancer to CRT (P < 0.05). The odds ratios of the four selected factors was approximated and scored. The group with a high RS was found to include patients with complete response with a significantly higher frequency than the group with a low score (72.7% vs. 14.8%, P < 0.001). The RS is suggested to be an appropriate scoring system with which to predict response for these patients.

Multidisciplinary treatment of advanced cancer of the esophagus and gastroesophageal junction: a European center's approach

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.

A single institutional non-randomized retrospective comparison between definitive chemoradiotherapy and radical surgery in 82 Japanese patients with resectable esophageal squamous cell carcinoma

This retrospective study was conducted to compare the treatment results between radical surgery and definitive chemoradiotherapy for resectable squamous cell carcinoma of the esophagus. Between June 2000 and May 2005, 82 consecutive patients were selected for this study in which 33 were treated with chemoradiotherapy and 49 with surgery. The patients in the chemoradiotherapy (CRT) group received 2-4 cycles of 5-fluorouracil (1000 mg/m(2)/day, day 1-4, continuous) combined with cisplatin (75 mg/m(2), day 1, bolus) plus 50.4 Gy of radiation, while those in the surgery group were treated by an esophagectomy with radical node dissection. Eighteen surgical patients received postoperative chemotherapy. The baseline clinical TNM stage was similar between the two groups. With a median follow-up period of 36 months (range: 23-84 months) with 47 survivors (57%), the 3-year overall survival rates (P = 0.22) and disease-free survival rates (P = 0.16) were 48% and 44% in the chemoradiotherapy group versus 65% and 59% in the surgery group, and lacked statistical significance. This non-randomized study on patients with resectable squamous cell carcinoma of the esophagus showed that chemoradiotherapy could result in survival comparable with conventional surgery in spite of selection bias of patients. There is a trend toward improved survival with surgery versus definitive CRT.

Clinical application of layered anastomosis during esophagogastrostomy

The aim of this study was to compare the operative results in regard to reducing anastomotic leakage and stricture formation using a newly designed layered manual esophagogastric anastomosis versus a stapler esophagogastrostomy versus the conventional hand-sewn whole-layer anastomosis after resection for esophageal or gastric cardiac carcinoma. From January 2004 to September 2006, a total of 1024 patients with esophageal or gastric cardia carcinoma underwent a layered esophagogastric anastomosis with the assistance of a three-leaf clipper in a single university medical center. The mucosal layers of the esophagus and stomach were sutured continuously with 4/0 Vicryl plus antibacterial suture (polyglyconate). From May 2002 to December 2003, there were also 170 patients and 69 patients who underwent stapler and conventional whole-layer anastomosis, respectively; they served as control groups. The results were analyzed retrospectively. The operative mortality rate was 0.7% in the layered group compared to 5.9% and 7.2% for the stapler group and the whole-layer group (p < 0.01), The anastomotic leakage rates were 0%, 3.5%, and 5.8% for the layered group, stapler group, and whole-layer group, respectively (p < 0.01). All patients were followed postoperatively. Six patients in the layered group (0.6%) developed mild stricture formation compared to 16 patients in stapled group (9.9%) and 5 patients in the conventional whole-layer group (7.8%) (p < 0.01). The application of layered esophagogastric anastomosis could reduce the incidence of anastomotic leakage and stricture after esophagectomy compared with the stapler and whole-layer manual anastomoses. It is easy to apply and could be used as an alternative for esophagogastric anastomosis after resection for esophageal or cardiac carcinoma.

Laparoscopic partial gastric transection and devascularization in order to enhance its flow

Background

Esophagogastric fistula following an esophagectomy for cancer is very common. One of the most important factors that leads to its development is gastric isquemia. We hypothesize that laparoscopic gastric devascularization and partial transection is a safe operation that will enhance the vascular flow of the fundus of the stomach.

Method

Our study included eight pigs. Each animal had two operations. In the first one, a laparoscopic gastric devascularization and mobilization took place. Vascular flow was measured previous to the procedure and immediately after it with a laser doppler (endoscopic probe). After three weeks, a second operation took place. We re-measured the vascular flow and sent a sample of gastric fundus for histopathologic evaluation.

Results

The gastric fundus showed signs of neovascularization after both macroscopic and microscopic evaluation. These findings correlated with laser doppler measurements.

Conclusion

Laparoscopic gastric devascularization and partial transection is a safe procedure that increases the vascular flow of the stomach in a three week period. This finding can have a positive impact in terms of decreasing fistula formation.

Role of PET/PET CT in the staging and restaging of thoracic oesophageal cancer and gastro-oesophageal cancer: a literature review

BACKGROUND

Current evidence for the use of FDG PET/PET-CT in staging thoracic oesophageal and GOJ cancer is reviewed.

METHODS

PubMed, Medline, Embase (1988-November 2006) and the Cochrane database identified studies in which FDG PET and PET CT were used for the assessment of thoracic and GOJ cancer.

RESULTS

Conventional assessment remains the mainstay for evaluating the primary site. EUS is used for assessing the primary site, but when EUS is incomplete or not tolerated FDG PET CT is invaluable. The major of advantage of FDG PET CT lies in the ability to detect metastatic disease beyond the celiac axis. There is growing evidence to show that FDG PET CT is useful for assessment of treatment response. FDG PET CT will also detect other occult primary cancers.

CONCLUSIONS

The contribution of FDG PET CT to the investigation of patients with primary thoracic oesophageal and GOJ cancer has resulted in improved staging, so providing the ability to optimise treatment.

Long-term outcome of esophageal mucosal squamous cell carcinoma without lymphovascular involvement after endoscopic resection

BACKGROUND

Esophageal cancer is an aggressive cancer with a reported 3-year survival of 20%. However, early-stage esophageal cancer can be cured by endoscopic resection (ER). The long-term survival of esophageal mucosal squamous cell carcinoma after ER was investigated by calculating the standard mortality rate (SMR).

METHODS

From January 1995 to December 2004, 110 patients with 138 esophageal mucosal squamous cell carcinomas without lymphovascular involvement were treated by ER. Long-term survival after ER was compared with that in the general population by calculating SMR. Subgroup analysis of patients without second primary cancer diagnosed within 1 year before ER (subgroup A) was also performed.

RESULTS

A total of 108 patients (98.2%) were followed-up completely, with a mean observation period of 4.7 (0.4-11.3) years. The cumulative 5-year survival rate of all patients and subgroup A was 79.5% and 86.6%, respectively. Overall mortality (SMR, 1.68; 95% confidence interval [CI], 1.05-2.55) and mortality from malignant tumor (SMR, 3.14; 95% CI, 1.79-5.09) was significantly higher than that in the general population. SMR of esophageal cancer was high, although it was not significantly different from that in the general population (SMR, 4.82; 95% CI, 0.06-26.81). In subgroup A overall mortality (SMR, 0.86; 95% CI, 0.41-1.57) was similar to that in the general population.

CONCLUSIONS

High overall mortality in patients with esophageal mucosal cancer after ER was mainly due to elevated mortality from second primary cancer. Favorable mortality in subgroup A indicates the efficiency of ER as a curative treatment for esophageal mucosal cancer.

Concurrent chemoradiotherapy with S-1 and cisplatin in advanced esophageal cancer

How best to manage advanced esophageal cancer remains unresolved, especially in palliative care. Here, in a pilot study, we evaluated the efficacy and safety of concurrent chemoradiotherapy with S-1 and cisplatin in advanced esophageal cancer. Patients with locally advanced or metastatic squamous cell carcinoma of the esophagus received S-1 and cisplatin at doses of 70 mg/m(2)/day for 14 days and 70 mg/m(2) on day 1, respectively, every 3 weeks. Concurrently, radiotherapy was started at a dose of 200 cGy/day, up to a total of 5400 cGy. After concurrent chemoradiotherapy, additive chemotherapy was repeated up to six cycles. Thirty patients were enrolled in this study; of the 27 in whom efficacy could be evaluated, an objective response rate was seen in 20 (74.1%), including five (18.5%) complete pathologic responses in primary lesions. Improvement of dysphagia was seen in 21 (76%) patients. In patients with stage II or III esophageal cancer, the median progression-free survival and overall survival were 10.6 +/- 0.6 months (95% CI: 9.4-11.8) and 23.0 +/- 5.1 months (95% CI: 13.0-32.9), respectively. In patients with stage IV esophageal cancer, the median progression-free survival and overall survival were 5.4 +/- 1.6 months (95% CI: 2.2-8.6) and 11.6 +/- 1.6 months (95% CI: 8.4-14.8), respectively. The main hematological toxicity was neutropenia, but no neutropenic fever was observed. The major non-hematological toxicities were asthenia and vomiting, mostly of grades 1 and 2. Thus, concurrent chemoradiotherapy with S-1 and cisplatin may be a promising nonsurgical treatment in advanced esophageal cancer.

Atelectasis induced by thoracotomy causes lung injury during mechanical ventilation in endotoxemic rats

Atelectasis can impair arterial oxygenation and decrease lung compliance. However, the effects of atelectasis on endotoxemic lungs during ventilation have not been well studied. We hypothesized that ventilation at low volumes below functional residual capacity (FRC) would accentuate lung injury in lipopolysaccharide (LPS)-pretreated rats. LPS-pretreated rats were ventilated with room air at 85 breaths/min for 2 hr at a tidal volume of 10 mL/kg with or without thoracotomy. Positive end-expiratory pressure (PEEP) was applied to restore FRC in the thoracotomy group. While LPS or thoracotomy alone did not cause significant injury, the combination of endotoxemia and thoracotomy caused significant hypoxemia and hypercapnia. The injury was observed along with a marked accumulation of inflammatory cells in the interstitium of the lungs, predominantly comprising neutrophils and mononuclear cells. Immunohistochemistry showed increased inducible nitric oxide synthase (iNOS) expression in mononuclear cells accumulated in the interstitium in the injury group. Pretreatment with PEEP or an iNOS inhibitor (1400 W) attenuated hypoxemia, hypercapnia, and the accumulation of inflammatory cells in the lung. In conclusion, the data suggest that atelectasis induced by thoracotomy causes lung injury during mechanical ventilation in endotoxemic rats through iNOS expression.

Endoscopic submucosal dissection used for treating early neoplasia of the foregut using a combination of knives

BACKGROUND

Endoscopic submucosal dissection (ESD) has emerged as a novel technique for achieving en bloc resection for early esophageal or gastric carcinoma limited to the mucosa. The authors report their experience with a combination of various devices to treat early neoplasia of the foregut using the ESD technique.

METHODS

In this prospective case series, ESD was performed for early esophageal or gastric carcinoma limited to the mucosa. These lesions were staged by endoscopic ultrasonography before resection. Magnifying endoscopy and chromoendoscopy were used to locate the tumor and define the margin. The resection was accomplished with submucosal dissection using the insulated tip knife, the hook knife, and the triangular tip knife. The resected specimen was examined systematically for the lateral and deep margins.

RESULTS

From January 2004 to March 2006, ESD was performed to manage 30 cases of early gastric or esophageal carcinoma. For 29 of these patients, R0 resection was successfully achieved. The mean operating time was 84.6 min. One patient experienced reactionary hemorrhage 12 h after resection, which was controlled endoscopically. There was no perforation. Most of the circumferential mucosal incisions were performed using the insulated tip knife (76.6%), whereas submucosal dissection was accomplished with a combination of various knives. One of the specimens showed involvement of the lateral margin, whereas another patient had two areas of new early gastric cancer 6 months after the initial procedure. These patients received salvage laparoscopically assisted gastrectomy.

CONCLUSIONS

Endoscopic submucosal dissection to manage early neoplasia of the foregut can be achieved safely and effectively with a combination of knives.

Positron emission tomography and pathological evidence of response to neoadjuvant therapy in adenocarcinoma of the esophagus

Our aim was to determine if fluorodeoxyglucose positron emission tomography (FDG-PET) could be correlated with a pathological response in patients with esophageal adenocarcinoma receiving neoadjuvant chemotherapy and/or chemoradiation therapy. Patients with resectable, histologically proven adenocarcinoma of the esophagus were entered in the study. Preoperative chemotherapy comprised two cycles of cisplatin and 5-fluorouracil. Radiation therapy commenced with the second cycle on day 22. FDG-PET images were obtained pre-treatment and on completion of intended neo-adjuvant treatment. Quantification was achieved by the calculation of both standardized uptake values (SUV) and tumor/liver ratios (TLR). Evidence of histopathological response was identified according to the Mandard tumor regression scoring system. There were 45 patients, 22 receiving neoadjuvant chemotherapy and 23 chemoradiation therapy. Forty patients underwent surgical resection. Seven patients (16%) had a histopathological response. The mean percentage change in SUV in the histological responders group was -56.8% (SD 29) and in the non-responders -27.8% (SD 32.1) (P = 0.035). The mean percentage change in TLR was -49.1% (SD 44.8) in the responders and in the non-responders -27.3% (SD 31.3) (P = 0.128). There was no difference between the two methods of assessment, however there was less variation with SUV. There was no correlation between the FDG-PET response and the histopathological response. Presently an FDG-PET scan performed 3-6 weeks after neoadjuvant therapy for adenocarcinoma of the esophagus should not be used as a marker of the potential result of the treatment. The optimal timing of a second FDG-PET remains unclear.

Advances in esophageal cancer surgery in Japan: an analysis of 1000 consecutive patients treated at a single institute

BACKGROUND

In Japan, most esophageal cancers are squamous cell carcinomas, and the results of esophagectomy have improved remarkably in recent years. The object of this study was to evaluate advances in operative therapy for esophageal cancer in Japan.

METHOD

We evaluated mortality, morbidity, and prognosis in 1000 consecutive patients who underwent esophagectomy for esophageal cancer at a single institution in Japan. The patients were divided into 3 groups according to the period when esophagectomy was performed: Group I (n = 197), 1964-1980; group II (n = 432), 1981-1993; and group III (n = 371), 1993-2006.

RESULTS

The incidence of squamous cell carcinoma was 94%. The morbidity rates were 62%, 38%, and 33 %, in groups I, II, and III, respectively (P < 0.01, groups I vs II and III), and the in-hospital mortality rates were 14.2%, 5.1%, and 2.4%, respectively (P < 0.01, between each group). The 5-year overall survival rate was 30% (14%, 27%, and 46% in groups I, II, and III, respectively; P < 0.0001). Multivariate analysis revealed age, gender, depth of invasion, node metastasis, distant metastasis, curability, extent of lymphadenectomy, resectability, and the period when the operation was performed as independent prognostic factors.

CONCLUSION

Generally, esophagectomy has been performed safely without critical complications; however, the prognosis has improved remarkably with advances in surgical techniques and treatment modalities.