Sentinel node biopsy to evaluate the metastatic dissemination of oesophageal adenocarcinoma

Preoperative detection of sentinel lymph nodes with hybrid SPECT/computed tomography imaging may improve the accuracy of sentinel lymph node biopsies in patients with early stages of cancer of the oesophagus or gastro-oesophageal junction

Objectives

The aim of this study was to investigate the sentinel lymph node biopsy (SLNB) method in patients with cancer of the oesophagus or gastro-oesophageal junction (GOJ) guided by preoperative hybrid single-photon emission tomography/computed tomography (SPECT/CT) lymphoscintigraphy.

Methods

Thirty-nine patients with stage T1–T3, any N-stage, M0 cancer of the oesophagus or GOJ planned for curatively intended esophagectomy underwent preoperative SPECT/CT lymphoscintigraphy following endoscopically guided submucosal injection of radiocolloid and intraoperative radio-guided SLNB using a hand-held gamma scintillation device.

Results

The detection rate in preoperative SPECT/CT imaging was 88%. The median number of detected SLN stations in preoperative imaging was 1 (range 0–4). At least one suspected SLN was identified in all intraoperative SLNP procedures. In six cases, no lymph nodes were identified in the SLNB. In six cases, the SLNB was false negative. The sensitivity for successful SLNB procedures was 20%, the specificity was 100% and the accuracy was 75%.

Conclusions

Preoperative SLN mapping using SPECT/CT yields a high number of detected SLN stations compared to previous studies using planar imaging. The accuracy of the SLNB method in patients with predominantly ≥T3-stage tumours and with a history of previous neoadjuvant treatment is poor, and the method is not recommended in these patient groups.

Evolution of Esophagectomy for Cancer Over 30 Years: Changes in Presentation, Management and Outcomes

Background

Esophageal cancer has seen a considerable change in management and outcomes over the last 30 years. Historically, the overall prognosis has been regarded as poor; however, the use of multimodal treatment and the integration of enhanced recovery pathways have improved short- and long-term outcomes.

Objective

The aim of this study was to evaluate the changing trends in presentation, management, and outcomes for patients undergoing surgical treatment for esophageal cancer over 30 years from a single-center, high-volume unit in the UK.

Patients and Methods

Data from consecutive patients undergoing esophagectomy for cancer (adenocarcinoma or squamous cell carcinoma) between 1989 and 2018 from a single-center, high-volume unit were reviewed. Presentation method, management strategies, and outcomes were evaluated. Patients were grouped into successive 5-year cohorts for comparison and evaluation of changing trends.

Results

Between 1989 and 2018, 1486 patients underwent esophagectomy for cancer. Median age was 65 years (interquartile range [IQR] 59–71) and 1105 (75%) patients were male. Adenocarcinoma constituted 1105 (75%) patients, and overall median survival was 29 months (IQR 15–68). Patient presentation changed, with epigastric discomfort now the most common presentation (70%). An improvement in mortality from 5 to 2% (p < 0.001) was seen over the time period, and overall survival improved from 22 to 56 months (p < 0.001); however, morbidity increased from 54 to 68% (p = 0.004).

Conclusions

Long-term outcomes have significantly improved over the 30-year study period. In addition, mortality and length of stay have improved despite an increase in complications. The reasons for this are multifactorial and include the use of perioperative chemo(radio)therapy, the introduction of an enhanced recovery pathway, and improved patient selection.

Near-Infrared Fluorescent Image-Guided Lymphatic Mapping in Esophageal Squamous Cell Carcinoma

BACKGROUND

Recently, the feasibility of near-infrared (NIR) image-guided sentinel lymph node (SLN) mapping has been tested in patients with gastrointestinal cancer. The aim of this study is to investigate whether SLN mapping can be used to identify mediastinal lymph node metastases during minimally invasive esophagectomy and explore the lymphatic drainage pattern of esophageal squamous cell carcinoma (ESCC) using NIR fluorescent imaging.

PATIENTS AND METHODS

A total of 21 patients diagnosed with cT1-3 stage ESCC were enrolled. Patients received submucosal injection of indocyanine green diluted with sodium chloride (0.9%) at the start of the esophagectomy procedure followed by NIR mapping.

RESULTS

Thoracoscopic-assisted McKeown esophagectomy with NIR imaging was successfully performed in all patients. The detection rate and number of NIR+ lymph nodes were 95.2% (20/21) and 4.0 (2.0-6.5), respectively. The accuracy, false-negative rates, and negative predictive value were 100% (10 of 10 cases), 0% (0 of 4), and 100% (6 of 6), respectively, for pT1/T2 diseases; and 80.0% (8 of 10), 40% (2 of 5), and 71.4% (5 of 7), respectively, for pT3 diseases. The NIR+ region was the most commonly detected in the right recurrent laryngeal nerve (80%), and the NIR+ region was identified in the upper mediastinal zone in 20 patients.

CONCLUSIONS

Evaluation of the lymphatic drainage pattern and the application of sentinel lymph node in ESCC with real-time NIR imaging could be effective, especially in pT1/2 disease. NIR imaging-guided SLN navigation appears to be a clinically beneficial less-invasive method for treating ESCC.

Sentinel node navigation surgery in esophageal cancer

Over the last 20 years, the sentinel node (SN) concept has been widely applied to the surgical staging of both breast cancer and melanoma. However, the validity of this concept has been controversial for esophageal cancer, because SN mapping for esophageal cancer is not considered to be technically easy because of the complicated multidirectional lymphatic networks of the esophagus and mediastinum. Nevertheless, studies including meta-analyses indicated that SN mapping may be feasible in early esophageal cancer. Transthoracic esophagectomy with three-field lymphadenectomy was developed as a potential curative procedure for thoracic esophageal cancer. However, this highly invasive procedure might increase morbidity and reduce patients' quality of life (QOL) after esophagectomy. Although further validation based on multicenter trials using the standard protocol of SN mapping for esophageal cancer is required, SN navigation surgery would enable us to carry out personalized and limited lymph node dissection which might reduce morbidity and maintain patients' QOL.

Update on the indications and results of sentinel node mapping in upper GI cancer

The clinical utilization of sentinel node (SN) mapping for early esophageal cancer or gastric cancer has been unclear for a long time. However, previous investigations regarding SN mapping of these cancers have shown relatively good results with regard to the detection rate and diagnostic accuracy for determining the lymph node status. SN mapping helps obtain information about individual metastatic status and allows the modification of the operation in early-stage upper gastrointestinal (GI) disease. Radio-guided methods for identifying SNs in early esophageal cancer have been established via endoscopic injection of technetium-99m tin colloid. Previous studies have reported that the SN concept seems valid, and radio-guided SN mapping can be feasible in cT1N0 esophageal cancer. SN navigation surgery are believed to have potential as strategies for minimally invasive modified surgery for early esophageal cancer. A Japanese study group conducted a prospective multicenter trial of SN mapping for early gastric cancer using a dual tracer method with radioactive colloid and blue dyes; they demonstrated a high detection rate and accuracy for determining the metastatic status based on SN mapping. Subsequently, minimized gastrectomy, including partial gastrectomy and segmental gastrectomy with individualized selective and modified lymphadenectomy for early gastric cancer with a negative SN has been performed to evaluate the long-term survival and postoperative quality of life (QOL) in a multicenter prospective trial. This study verified the SN concept in early-stage upper GI disease with cN0 and found that function-preserving esophagectomy or gastrectomy may help maintain patients' post-surgical QOL.

Pilot-study on the feasibility of sentinel node navigation surgery in combination with thoracolaparoscopic lymphadenectomy without esophagectomy in early esophageal adenocarcinoma patients

High-risk submucosal esophageal adenocarcinoma's might be treated curatively by means of radical endoscopic resection, followed by thoracolaparoscopic lymphadenectomy without concomitant esophagectomy. A preclinical study has shown the feasibility and safety of this approach; however, no studies are performed in a clinical setting. In addition, sentinel node navigation surgery could be valuable in tailoring the extent of the lymphadenectomy. This study aimed to evaluate the feasibility and safety of thoracolaparoscopic lymphadenectomy without esophagectomy (phase I) and sentinel node navigation surgery (phase II) in patients with early esophageal adenocarcinoma. Patients with T1N0M0 early esophageal adenocarcinoma scheduled for esophagectomy without neoadjuvant therapy were included. Phase I: Two-field, esophagus preserving, thoracolaparoscopic lymphadenectomy was performed, followed by esophagectomy in the same session. Primary outcome parameters were the number of lymph nodes resected, and number of retained lymph nodes in the esophagectomy specimen. Phase II: A radioactive tracer was injected endoscopically the day before surgery. Static imaging was performed 15 and 120 minutes after injection. The day of surgery, sentinel node navigation surgery followed by esophagectomy was performed. Primary outcome parameters were the percentage of patients with a detectable sentinel node, and the concordance between static imaging and probe-based detection of sentinel node. Phase I: Five patients were included, and a median of 30 (IQR: 25-46) lymph nodes was resected. A median of 6 (IQR: 2-9) retained lymph nodes was found in the esophagectomy specimen. No acute adverse events occurred, but near the end of lymphadenectomy esophageal discoloration was observed, possibly indicating ischemia. Phase II: In all five included patients sentinel nodes could be visualized and resected, at a median of 3 (IQR: 2-5) locations. There was a high concordance between imaging and probe-based detection of sentinel nodes. In conclusion, sentinel node navigation surgery followed by lymphadenectomy without concomitant esophagectomy seems feasible in patients with high-risk submucosal early esophageal adenocarcinoma. More evidence is however needed before applying this technique in clinical practice.

Clinical Significance of Sentinel Node Positivity in Patients with Superficial Esophageal Cancer

BACKGROUND

Sentinel node (SN) mapping in esophageal cancer has been reported to be technically feasible with an acceptable detection rate and accuracy. However, the clinical significance and survival analysis findings associated with the metastatic status of SNs in patients with early-stage esophageal cancer have not been clarified. In this study, we investigated the clinical significance and survival impact of SN mapping in early-stage esophageal cancer.

METHODS

Among patients who were diagnosed preoperatively with clinical T1N0M0 or T2N0M0 esophageal cancer and who underwent SN mapping, 70 consecutive patients who were diagnosed with pathological T1 primary thoracic esophageal cancer were enrolled in this study. Sixty-four (91 %) patients were diagnosed with squamous cell carcinoma while 5 (7 %) patients were with adenocarcinoma. Endoscopic injection of technetium-99m tin colloid was performed before surgery, and radioactive SNs were identified by preoperative lymphoscintigraphy and intraoperative gamma probing. Standard esophagectomy with lymphadenectomy was performed in all patients, and all resected nodes were evaluated by routine pathological examination.

RESULTS

SNs were successfully detected in 65 (92.9 %) of 70 patients with pT1 esophageal cancer. The sensitivity to predict lymph node metastasis was 91.7 %, and the diagnostic accuracy based on SN status was 96.9 %. Although there was a wide distribution of SNs from cervical to abdominal areas, 84.5 % of the patients had no lymph node metastasis or had lymph node metastasis only in SN. The disease-specific survival of the patients with metastatic non-SNs was significantly worse relative to that of the patients with no lymph node metastasis or lymph node metastasis only in SN.

CONCLUSIONS

This study demonstrated that radio-guided SN mapping is useful not only as an accurate diagnostic tool for detecting lymph node metastasis but also as a tool for prognostic stratification in patients with cN0 early esophageal cancer.

Sentinel node biopsy during thoracolaparoscopic esophagectomy for advanced esophageal cancer

Background

Omitting extensive lymph node dissection could reduce esophagectomy morbidity in patients without lymph node metastases. Sentinel node biopsy may identify abdominal or thoracic lymph node metastases, thereby differentiating treatment. Feasibility of this approach was investigated in Western European esophageal cancer patients with advanced disease, without lymph node metastases at diagnostic work-up.

Methods

The sentinel node biopsy was performed in eight esophageal cancer patients with cT1-3N0 disease. One day pre-operatively, Tc-99m-labeled nanocolloid was endoscopically injected around the tumor. Lymphoscintigraphy was performed 1 and 3 h after injection. All patients underwent robotic thoracolaparoscopic esophagectomy with two-field lymph node dissection. Intraoperatively, sentinel nodes were detected by gamma probe. The resection specimen was analyzed for remaining activity by scintigraphy and gamma probe.

Results

Visualization rates of lymphoscintigraphy 1 and 3 h after tracer injection were 88 and 100 %, respectively. Intraoperative identification rate was 38 %. Postoperative identification was possible in all patients using the gamma probe to analyze the resection specimen. In 5/8 patients, lymph node metastases were found at histopathology, none of which was detected by the sentinel node biopsy. No adverse events related to the sentinel node biopsy were observed.

Conclusions

In our advanced esophageal cancer patients who underwent thoracolaparoscopic esophagectomy, the sentinel node biopsy did not predict lymph node status. Probably the real sentinel node could not be identified due to localization adjacent to the primary tumor or bypassing due to metastatic tumor involvement. Therefore, we consider the sentinel node biopsy not feasible in advanced esophageal cancer.

Sentinel lymph node in oesophageal cancer-a systematic review and meta-analysis

BACKGROUND

Sentinel lymph nodes (SLNs) have been used to predict regional lymph node metastasis in patients with melanoma and breast cancer. However, the validity of the SLN hypothesis is still controversial for oesophageal cancer. We performed this meta-analysis to evaluate the feasibility and accuracy of radio-guided SLN mapping for oesophageal cancer.

METHODS

A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google scholar, Science Direct, and Web of Science. Original data was abstracted from each study and used to calculate a pooled event rates and 95% confidence interval (95% CI).

RESULTS

The search identified 23 relevant articles. The overall detection rate was 0.93 (95% CI: 0.894-0.950), sensitivity 0.87 (95% CI: 0.811-0.908), negative predictive value 0.77 (95% CI: 0.568-0.890) and the accuracy was 0.88 (95% CI: 0.817-0.921). In the adenocarcinoma cohort, detection rate was 0.98 (95% CI: 0.923-0.992), sensitivity 0.84 (95% CI: 0.743-0.911) and the accuracy was 0.87(95% CI: 0.796-0.913). In the squamous cell carcinoma group, detection rate was 0.89 (95% CI: 00.792-0.943), sensitivity 0.91 (95% CI: 0.754-0.972) and the accuracy was 0.84 (95% CI: 0.732-0.914).

CONCLUSIONS

It is possible to identify and obtain a SLN before neoadjuvant therapy in oesophageal cancer. However, further work is needed to optimize radiocolloid type, refine the technique and develop a quick and accurate way to determine SLN status intraoperatively. This technique has to be further evaluated before it can be applied widely.

Minimally invasive surgery for esophageal cancer: a review on sentinel node concept

BACKGROUND

Lymphoadenectomy is a cornerstone of esophageal cancer treatment, and sentinel node (SN) biopsy (SNB) might provide surgeons with an extra tool to limit unnecessarily extended lymphadenectomy and to implement a minimally invasive approach. The aim of our study was to review all the available literature on the use of SNB in esophageal surgery for malignancy.

METHODS

The review was conducted according to the PRISMA guidelines. A systematic search was performed in PubMed, EMBASE, and the Cochrane database to identify all original articles on the role of SNB in esophageal cancer. Data on methodologies, tumor stage and localization, and results were summarized and used to address relevant clinical questions related to the application of the SNB technique in esophageal cancer.

RESULTS

Twelve studies were included, with a total of 492 patients. Different methods for SN identification were used (radionuclide, blue dye, computed tomography [CT] lymphography). The pooled values estimated using the random-effects model were, respectively: technetium-99 m overall detection rate (DR) 0.970 (95 % CI 0.814-0.996), accuracy (ACC) 0.902 (95 % CI 0.736-0.968); blue-dye DR 0.971 (95 % CI 0.890-0.993), ACC 0.790 (95 % CI 0.681-0.870); and CT lymphoscintigraphy DR 0.970 (95 % CI 0.814-0.996), ACC 0.902 (95 % CI 0.736-0.968).

CONCLUSION

Based on these results, the concept of SN in esophageal cancer is technically feasible with an acceptable DR and ACC, and it might be applicable in the event of early-stage adenocarcinoma of the gastroesophageal junction in patients with a high surgical risk or in a patient where an endoscopic resection is taken into consideration. Further studies focused on a single tumor type and localizations are needed in order to predict the correct utilization of this concept in minimally invasive treatment of esophageal cancer.

Accuracy of sentinel node biopsy in esophageal carcinoma: a systematic review and meta-analysis of the pertinent literature

The use of sentinel node surgery for esophageal carcinoma is still under investigation. We evaluated the data available in the literature on this topic, and herein present the results in a systematic review format. PUBMED, SCOPUS, the ISI web of knowledge and the information from the annual meetings of the Japan Esophageal Society were searched using the search terms: "(esophagus OR esophageal) AND sentinel". The outcomes of interest were the detection rate and sensitivity. Overall, 18 studies were included. The pooled detection rate was 89.2% [82.6-93.5]. Patients with T1 and two tumors had a 17% higher detection rate compared to those with T3 and four tumors. The pooled sensitivity was 84% [78-88%]. The sensitivity was higher for adenocarcinoma compared to squamous cell carcinoma (SCC) (91 vs. 81%). In the SCC patients, there was a trend toward decreased sensitivity associated with an increasing tumor depth (T1:88%, T2:76%, T3:50%). Our analysis indicated that sentinel node biopsy is useful in adenocarcinoma patients. For SCC patients, including only cN0 patients (preferably T1 and 2) would increase the detection rate and sensitivity. Due to the limited number of high-quality studies, drawing any more definite conclusions is impossible. Large cohort studies with a standardized and consistent design will be needed in the future.

Hybrid SPECT/CT imaging of sentinel nodes in esophageal cancer: first results

BACKGROUND

Sentinel node (SN) biopsy in esophageal cancer has the potential of becoming an important tool for ruling out the presence of lymph node metastases in patients opted for less extensive surgery without neoadjuvant treatment.

PURPOSE

To investigate preoperative SN imaging in esophageal cancer using hybrid single photon emission computed tomography (SPECT)/CT.

MATERIAL AND METHODS

Eight patients with esophageal cancer scheduled for thoracoabdominal esophagectomy after neoadjuvant treatment, underwent endoscopic submucosal injection of (99m)Tc-nanocoll the day before surgery, followed by imaging with SPECT/CT for preoperative detection. Intraoperative detection of SNs was performed with a gamma probe.

RESULTS

SNs were identified by SPECT/CT in 7/8 cases (88%) and by gamma probe in all cases. The median number of identified lymph node stations with SN in the operating field was 1 (range 0-2) for SPECT/CT and 1 (range 1-3) for gamma probe. The median distance between the perceived location of the respective SN according to SPECT/CT and the location identified with the gamma probe was <5 mm (range <5-15 mm). In one patient who had a complete histologic response to neoadjuvant treatment in the primary tumor, there was one single metastasis that was not contained in one of the SNs.

CONCLUSION

Preoperative identification of sentinel nodes with hybrid SPECT/CT after endoscopic injection of radiocolloid is a technique with obvious potential for SN mapping in esophageal cancer.

Sentinel lymph node in thyroid tumors - own experience

AIM OF THE STUDY

To determine the feasibility of sentinel lymph node biopsy (SLNB) for the evaluation of the cervical lymph node status in patients with thyroid tumors.

MATERIAL AND METHODS

Twenty-three patients with suspected thyroid cancer were enrolled in the study. 0.5-1.0 ml of 1% Patent Blue dye was injected intratumorally. After SLNB, thyroidectomy and proper lymphadenectomy were performed.

RESULTS

Sentinel lymph node was detected in 20 (86.9%) patients. Thirty-one SLNs were found - 21 (67.7%) were located in the central neck compartment, 4 (12.9%) in the lateral neck compartment, 6 (19.4%) in the upper mediastinum. The number of SLNs ranged from 1 to 3 (mean 1.6). Sentinel lymph node was positive in 5 (25%) patients, negative in 15 (75%) in the final histopathology. Sentinel lymph nodes were located only in the central neck compartment in 13 patients, and in both the central and lateral neck compartments in 2 patients. In one patient, SLNs were located only in the central neck compartment and upper mediastinum. Three patients had SLNs only in the upper mediastinum, while one had them only in the lateral neck compartment. In one patient a node regarded as SLN was negative, while there were metastases in removed non-sentinel lymph nodes (NSLNs). In two patients, histopathology of SLNs showed that they were actually parathyroid glands.

CONCLUSIONS

Our results confirm that thyroid cancer SLNB is rather easy to carry out. Its performance along with intraoperative examination can help to avoid unnecessary lymphadenectomy. However, it should be kept in mind that parathyroid glands can be stained and removed by mistake during SLNB.

Number of metastasis-positive lymph node stations is a simple and reliable prognostic factor following surgery in patients with esophageal cancer

The aim of this study was to evaluate the utility of lymph node metastasis classification based on the number of positive stations in patients undergoing surgical management of esophageal cancer. Of 257 patients who underwent curative esophagectomy, 126 patients with lymph node involvement underwent assessment of nodal metastasis mode according to the 7th edition of the TNM classification (UICC), and the Japanese Guidelines for the Clinical and Pathological Studies on Carcinoma of the Esophagus. Lymph node metastasis mode was divided into single station (S) and multi-station (M) groups. The S group was subclassified into single-node-single-station (SS) or multi-node-single-station (MS), and the M group was subclassified into multi-station in pN1 (2 metastasis positive nodes; MM-pN1) or multi-station in pN2 or 3 (MM-pN2,3) by TNM classification, multi-station-single-area (MMS) or multi-station-multi-areas (MMM). The correlation between prognosis and lymph node metastasis mode was assessed. A total of 47 patients were classified as S (MS, n=11; SS, n=36), and 79 patients were classified as M (MM-pN1, n=12; MM-pN2,3, n=67; MMM, n=55; MMS, n=24). Prognosis was poorer among the M- than in the S-classified patients (p=0.0035), whereas prognosis was not significantly different between the subgroups. In conclusion, lymph node metastasis classification based on the number of metastasis-positive stations is a useful predictor of prognosis in patients undergoing surgical management of esophageal cancer. This system relies on a simple classification method that combines the Japanese classification based on lymphatic spread and the TNM classification based on the number of positive lymph nodes.

Sentinel node navigation surgery in early-stage esophageal cancer

The sentinel node (SN) concept has revolutionized the surgical staging of both melanoma and breast cancer over the past two decades. However, the validity of the SN hypothesis has been controversial for esophageal cancer, because SN mapping for esophageal cancer is technically complicated, and the number of early-stage esophageal cancer is very limited. Nevertheless previous studies nicely demonstrated that SN mapping may be feasible in patients with early-stage esophageal cancer. Transthoracic extended esophagectomy with three-field radical lymph node dissection has been recognized as a curative procedure for thoracic esophageal cancer in Japan. However, uniform application of this highly invasive procedure might increase the morbidity and markedly reduce the quality of life (QOL) after surgery. Although further accumulation of evidence based on multicenter clinical trials using a standard protocol is needed, SN mapping and SN navigation surgery would provide significant information to perform individualized selective lymphadenectomy which might reduce the morbidity and retain the patients' QOL. In addition, technical innovation including the development of new tracers is expected to confirm the accuracy and reliability of SN mapping in esophageal cancer.

Barrett's esophagus: treatments of adenocarcinomas I

The following on the treatments of adenocarcinomas in Barrett's esophagus contains commentaries on endo mucosal resection; choice between other ablative therapies; the remaining genetic abnormalities following stepwise endoscopic mucosal resection and possible recurrences; the Fotelo-Fotesi PDT; the CT TNM classification of early stages of Barrett's carcinoma; the indications of lymphadenectomy in intramucosal cancer; the differences in lymph node yield in transthoracic versus transhiatal dissection; video-assisted lymphadenectomy; and the importance of the length of proximal esophageal resectipon; and indications of sentinel node dissection.

Sentinel lymph node biopsy in esophageal cancer: should it be standard of care?

INTRODUCTION

Sentinel node mapping is established in some superficial cancers but remains controversial in harder-to-access solid tumors. There are an increasing number of recent studies suggesting that isolated tumor cells have prognostic significance in predicting poor survival, in breast cancer, esophageal cancer, and others. It is for this reason that we have persevered with the sentinel lymph node concept in our esophagectomy cancer patients, and we report our results since 2008.

METHODS

Thirty-one of 32 consecutive patients underwent resection for invasive esophageal cancer along with sentinel lymph node retrieval (resection rate, 97%). Peritumoral injection of (99m)Tc antimony colloid was performed by upper endoscopy prior to the operation. A two-surgeon synchronous approach via a right thoracotomy and laparotomy was performed with a conservative lymphadenectomy. Sentinel lymph nodes were identified with a gamma probe both in and ex vivo, and sent off separately for three serial sections and immunohistochemistry with AE1/AE3.

RESULTS

The median patient age was 63.4 years (range, 45-75 years). Most patients (81%) had an adenocarcinoma, and 61% had received neoadjuvant therapy. At least one sentinel lymph node (median, 3) was identified in 29 of 31 patients (success rate, 94%). Sentinel nodes were present in more than one nodal station in 16 patients (55%). One false negative case led to a sensitivity of 90%. In 28 of 29 patients, the sentinel lymph node accurately predicted findings in non-sentinel nodes (accuracy, 96%).

CONCLUSIONS

Sentinel lymph node biopsy is both feasible and accurate in esophageal resections with conservative lymphadenectomy. It allows targeted serial sectioning and immunohistochemical studies of those nodes and should become standard of care in patients undergoing esophagectomy for esophageal cancer.

Barrett's esophagus: treatments of adenocarcinomas II

The following topics are explored in this collection of commentaries on treatments of adenocarcinomas related to Barrett's esophagus: the importance of intraoperative frozen sections of the margins for the detection of high dysplasia; the preferable way for sentinel node dissection; the current role of robotic surgery and of video-endoscopic approach; the value of the Siewert's classification of adenocarcinomas; the indications of two-step esophagectomy; the evaluation of pathological complete response; the role of PET scan in staging and response assessment; the role of p53 in the selection of adenocarcinomas patients; chemotherapy regimens for adenocarcinomas; the use of monoclonal antibodies in the control of cell proliferation; he attempt to define a stage-specific strategy, and the possible indications of selective therapy; and changes in mortality rates from esophageal cancer.

The prevalence of lymph node metastases in patients with T1 esophageal adenocarcinoma a retrospective review of esophagectomy specimens

Knowledge of the risk of lymph node metastases is critical to planning therapy for T1 esophageal adenocarcinoma. This study retrospectively reviews 75 T1a and 51 T1b tumors and correlates lymph node metastases with depth of tumor invasion, tumor size, presence of lymphovascular invasion, and tumor grade.

OBJECTIVES

Increasingly, patients with superficial esophageal adenocarcinoma are being treated endoscopically or with limited surgical resection techniques. Since no lymph nodes are removed with these therapies, it is critical to have a clear understanding of the risk of lymph node metastases in these patients. The aim of this study was to define the risk of lymph node metastases for intramucosal and submucosal (T1) esophageal adenocarcinoma and to analyze factors potentially associated with an increased risk of lymph node involvement.

METHODS

We reanalyzed the pathology specimens of all patients that had primary esophagectomy for T1 adenocarcinoma of the distal esophagus or gastroesophageal junction from January 1985 to December 2008. The prevalence of lymph node metastases was correlated with tumor size, depth of invasion, presence of lymphovascular invasion, and degree of tumor differentiation.

RESULTS

There were 126 patients, 102 men (81%) and 24 women (19%), with a mean age of 64 (± 10) years. Tumor invasion was limited to the mucosa (T1a) in 75 patients (60%), whereas submucosal invasion (T1b) was present in 51 patients (40%). Tumors that had poor differentiation, lymphovascular invasion, and size ≥2 cm were significantly more likely to be invasive into the submucosa. Lymph node metastases were rare (1.3%) with intramucosal tumors but increased significantly with submucosal tumor invasion (22%)[P = 0.0003]. Lymph node metastases were also significantly associated with poor differentiation (P = 0.0015), lymphovascular invasion (P < 0.0001), and tumor size ≥2 cm (P = 0.01). Division of the submucosa into thirds did not show a layer with a significantly decreased prevalence of node metastases.

CONCLUSIONS

Adenocarcinoma invasive deeper than the muscularis mucosa is associated with a significant increase in the prevalence of lymph node metastases,and there is no "safe" level of invasion into the submucosa. Lymphovascular invasion, tumor size ≥2 cm, and poor differentiation are associated with an increased risk of submucosal invasion and lymph node metastases and should be factored into the decision for endoscopic therapy or esophagectomy

Nodal metastasis from locally advanced esophageal cancer: how neoadjuvant therapy modifies their frequency and distribution

BACKGROUND

Neoadjuvant chemoradiotherapy (CT-RT) before esophagectomy seems to affect the number of nodal metastasis and to alter the distribution of those that remain. The aim of this study was to define how neoadjuvant chemoradiotherapy changes nodal metastasis patterns in locally advanced esophageal cancer.

METHODS

A total of 402 consecutive patients with cancer of the esophagus or esophagogastric junction (181 adenocarcinoma [AC] and 221 squamous cell carcinoma [SCC]) (evaluated at clinical stage T1N1, T2N1, T3N0, or T3N1 and pathological stage M0) presenting in our Department between 1992 and 2007 and who underwent complete resection (R0) were included in this retrospective study on a prospectively collected database. All dissected lymph nodes were retrieved and microscopically analyzed. Nodal metastasis patterns in patients who underwent chemotherapy (CT) or chemoradiotherapy (CT-RT) neoadjuvant therapy were compared with those in patients who underwent surgery alone.

RESULTS

Almost 30% of the adenocarcinoma patients and approximately 40% of the SCC patients showed effective tumor downstaging after neoadjuvant therapy. There were fewer paracardial node metastases (P = .002) in the AC patients who underwent CT-RT neoadjuvant therapy. There were, likewise, significantly fewer paraesophageal, paracardial, and subcarinal node metastases in the SCC patients in whom the perigastric nodes became the second-most frequent site of metastasis.

CONCLUSION

Not only was frequency of lymph node metastases decreased after neoadjuvant therapy, but nodal localization and pattern were also significantly modified.

Sentinel node navigation surgery is acceptable for clinical T1 and N0 esophageal cancer

BACKGROUND

If the sentinel node (SN) concept is established for esophageal cancer, it will be possible to reduce safely the extent of lymphadenectomy. Our objective was to perform SN mapping in esophageal cancer to assess distribution of lymph node metastases with the goal to reduce the need for extensive lymphadenectomy.

METHODS

A total of 134 patients who underwent esophagectomy with lymph node dissection were enrolled. The number of patients with clinical T1, T2, and T3 tumors was 60, 31, and 32, respectively. Eleven patients also received neoadjuvant chemoradiation therapy (CRT). (99m)Tc-Tin colloid was injected endoscopically into the esophageal wall around the tumor 1 day before surgery. SNs were identified by using radioisotope (RI) uptake. RI uptake of all dissected lymph nodes was measured during and after surgery. Lymph node metastases, including micrometastases, were confirmed by hematoxylin eosin and immunohistochemical staining.

RESULTS

Detection rates of SNs were 93.3% in cT1, 100% in cT2, 87.5% in cT3, and 45.5% in CRT patients. In the 120 cases where SNs were identified, lymph node metastases were found in 12 patients with cT1, 18 with cT2, 24 with cT3 tumors, and 3 with CRT. Accuracy rate of SN mapping was 98.2% in cT1, 80.6% in cT2, 60.7% in cT3, and 40% in CRT patients. Although one false-negative case had cT1 tumor, the lymph node metastasis was detected preoperatively.

CONCLUSIONS

SN mapping can be applied to patients with cT1 and cN0 esophageal cancer. SN concept might enable to perform less invasive surgery with reduction of lymphadenectomy.

Differential pathologic variables and outcomes across the spectrum of adenocarcinoma of the esophagogastric junction

BACKGROUND

Adenocarcinoma of the esophagogastric junction (AEG) as described by Siewert et al. is classified as one entity in the latest (7th Edition) American Joint Cancer Committee/International Union Against Cancer (AJCC/UICC) manual, compared with the previous mix of esophageal and gastric staging systems. The origin of AEG tumors, esophageal or gastric, and their biology remain controversial, particularly for AEG type II (cardia) tumors.

METHODS

We adapted a large prospective database (n = 520: 180 type I, 182 type II, 158 type III) to compare AEG tumors under the new TNM system Pathological variables associated with prognosis were compared (pT, pN, stage, differentiation, R status, lymphovascular invasion, perineural involvement, number of positive nodes, percent of positive nodes, and tumor length), as well as overall survival.

RESULTS

Compared with AEG type I tumors, type II and type III tumors had significantly (p < 0.05) more advanced pN stages, greater number and percentage of positive nodes, poorer differentiation, more radial margin involvement, and more perineural invasion. In AEG type I, 14/180 patients (8%) had >6 involved nodes (pN3), compared with 16 and 30% of patients classified type II and III, respectively. Median survival was significantly (p = 0.03) improved for type I patients (38 months) compared with those with tumors classified as type II (28 months) and type III (24 months). In multivariate analysis node positivity and pN staging but not AEG site had an impact on survival.

CONCLUSIONS

In this series AEG type I is associated with more favorable pathologic features and improved outcomes compared with AEG type II and III. This may reflect earlier diagnosis, but an alternative possibility, that type I may be a unique paradigm with more favorable biology, requires further study.

Sentinel node identification using technetium-99m neomannosyl human serum albumin in esophageal cancer

BACKGROUND

This study is a clinical trial designed to test the reliability and feasibility of sentinel node detection using a new mannose receptor radioactive binding agent in patients with esophageal squamous cell carcinoma.

METHODS

Twenty-three patients (21 men, 2 women; mean age 61.0±8.60 years) who were candidates for esophagectomy with conventional lymph node dissection for thoracic esophageal cancer were enrolled. A total dose of 1 mCi of 99mTc-MSA [technetium-99m neomannosyl human serum albumin] in 0.2 mL was administered at 4 quadrants into the submucosal layer around the primary tumor under esophagoscopic guidance approximately 1 hour before surgery. Intraoperative sentinel node sampling was subsequently followed by esophagectomy. All harvested lymph nodes were cut into 2-mm slices and ultimately diagnosed using formalin-fixed and paraffin-embedded sections with hematoxylin and eosin staining.

RESULTS

The number of dissected lymph nodes per patient was 30.5±9.18 (15-47). Among 23 patients, the sentinel lymph nodes could be identified in 21 patients (91.3%). The sentinel nodes could be identified in all 21 patients with cT1 or T2N0M0 (100%) disease; these patients were candidates for sentinel lymph node navigation surgery for the esophageal cancer. The mean number of sentinel nodes identified was 2.6±1.35 (range, 1-5) per patient. No false-negative sentinel lymph nodes were detected in any of the 8 patients with node-positive disease (0%).

CONCLUSIONS

Intraoperative sentinel lymph node identification using 99mTc-MSA was feasible and reliable in patients with esophageal squamous cell carcinoma.

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.

Role of intraoperative sentinel lymph node mapping in the management of carcinoma of the esophagus

BACKGROUND/AIM

Precise evaluation of lymph node status is one of the most important factors in determining clinical outcome in treating gastro-intestinal (GI) cancer. Sentinel lymph node (SLN) mapping clearly has become highly feasible and accurate in staging GI cancer. This study aims to investigate the feasibility and accuracy of detection of SLN using methylene blue dye in patients with carcinoma of the esophagus and assess its potential role in determining the rational extent of lymphadenectomy in esophageal cancer surgery.

MATERIALS AND METHODS

Thirty-two patients of esophageal cancer diagnosed on endoscopic biopsy were enrolled in this prospective study. After laparotomy, patent methylene blue was injected into the subserosal layer adjacent to the tumor. SLNs were defined as blue stained nodes within a period of 5 min. Standard radical esophagogastrectomy with lymphadenectomy was performed in all the patients. All the resected nodes were examined postoperatively by routine hematoxylin and eosin stain for elucidating the presence of metastasis, and the negative SLNs were examined further with cytokeratin immunohistochemical staining.

RESULTS

SLNs were detected in 26 (81.25%) patients out of 32 patients who were studied. The number of SLNs ranged from 1 to 4 with a mean value of 1.7 per case. The SLNs of esophageal cancer were only found in N1 area in 21 (80.77%) cases, and in N2 or N3 area in only 19.33%. The overall accuracy of the procedure was 75% in predicting nodal metastasis. SLN had a sensitivity of 85.71% in mid esophageal tumors and 93.33% in lower esophageal tumors. The SLN biopsy had sensitivity of 87.5% in the case of squamous cell carcinoma and 92.86% in the cases of adenocarcinoma of the esophagus. The accuracy of the procedure for squamous cell carcinoma and adenocarcinoma was 60% and 76.47%, respectively.

CONCLUSION

SLN mapping is an accurate diagnostic procedure for detecting lymph node metastasis in patients with esophageal cancer and may indicate rational extent of lymphadenectomy in these patients. SLN mapping provides "right nodes" to the pathologists for detailed analysis and appropriate staging, thereby helping in individualizing the multi-modal treatment for esophageal cancer.

Impact of lymph-node metastasis site in patients with thoracic esophageal cancer

BACKGROUND AND OBJECTIVES

We retrospectively compared surgical outcomes between patients with intra-thoracic and extra-thoracic (cervical and abdominal) lymph-node metastasis.

METHODS

The study population comprised 96 patients with lymph-node metastasis who had undergone curative esophagectomy for thoracic esophageal cancer. The patients were grouped according to whether the site of lymph-node metastasis was intra-thoracic, extra-thoracic, or both intra-thoracic and extra-thoracic. The patient characteristics, survival time, and prognostic factors were compared.

RESULTS

The most significant difference in disease-specific survival was detected at a threshold value of four metastatic lymph nodes. Lymph-node metastasis was observed at intra-thoracic sites in 41 patients, at extra-thoracic sites in 20 patients, and at both intra-thoracic and extra-thoracic sites in 35 patients. Intra-thoracic lymph-node metastasis was frequently observed in patients with middle and upper thoracic esophageal cancer. There was no difference in the number of metastatic lymph nodes between patients with intra-thoracic and extra-thoracic lymph-node metastasis. Multivariate analysis revealed that the number of metastatic lymph nodes was an independent prognostic factor, whereas the site of metastatic lymph nodes was not.

CONCLUSIONS

These findings suggest that the surgical outcomes in patients with thoracic esophageal cancer depend on the number, but not the site, of metastatic lymph nodes after curative esophagectomy.

The role of lymphadenectomy in esophageal cancer

OBJECTIVE

To address the role of lymphadenectomy in the treatment of esophageal cancer.

BACKGROUND

The role of lymphadenectomy in esophageal cancer surgery is controversial, and there is a lack of uniformity as to what the term means.

METHODS

The published data was reviewed to evaluate the evidence base for, and the terminology associated with, lymphadenectomy for esophageal cancer.

RESULTS

Recommendations are given for a standardization of terminology for radical and nonradical lymphadenectomy procedures. Although there is no doubt that the presence of lymph node metastases worsens prognosis for a patient, there is a lack of high-level evidence to support lymphadenectomy. Logically, the best procedure, from a staging and perhaps theoretical oncologic point of view, is a 3-field lymphadenectomy but it is not clear which patients, if any, are most likely to benefit.

CONCLUSIONS

Well-designed randomized controlled trials are required to test, in a scientific manner, which of these procedures we should be offering our patients.

Validation study of radio-guided sentinel lymph node navigation in esophageal cancer

BACKGROUND

Radio-guided detection of sentinel lymph nodes (SLN) has been used to predict regional lymph node metastasis in patients with melanoma and breast cancer. However, the validity of the SLN hypothesis is still controversial for esophageal cancer. The aim of this study is to evaluate the feasibility and accuracy of radio-guided SLN mapping for esophageal cancer.

METHODS

Seventy-five consecutive patients who were diagnosed preoperatively with T1N0M0 or T2N0M0 primary esophageal cancer were enrolled. Endoscopic injection of technetium-99m tin colloid was performed before surgery and radioactive SLNs were identified with preoperative lymphoscintigraphy and gamma probe. Standard radical esophagectomy with lymphadenectomy was performed in all patients and all resected nodes were evaluated by routine pathologic examination.

RESULTS

SLNs were identified successfully in 71 (95%) of 75 patients. The mean number of identified SLNs per case was 4.7. Twenty-nine (88%) of 33 cases with lymph node metastasis showed positive SLNs. The diagnostic accuracy based on SLN status was 94% (67/71). Distribution of identified SLNs was widely spread from the cervical to abdominal areas.

CONCLUSIONS

This study reveals that radio-guided SLN mapping is an accurate diagnostic procedure for detecting lymph node metastasis in patients with early-stage esophageal cancer.

[Surgical treatment for early Barrett cancer]

Adenocarcinomas in Barrett's oesophagus are more commonly diagnosed at an early stage due to effective surveillance programmes. Subtotal oesophagectomy with extended lymphadenectomy is considered the best curative treatment for patients with early adenocarcinoma of the oesophagus. However, such treatment carries substantial morbidity and compromises quality of life. Limited resection, minimal invasive surgical procedures or endoscopic mucosal ablation have been proposed as less invasive alternatives. A comparison of treatment associated morbidity, recurrence rate, long-term survival and functional outcome suggests that none of these alternative methods can be universally recommended. An individualized strategy should be employed based on staging (tumour penetration into the mucosa/submucosa, presence of lymph node metastasis), multicentricity, length of the underlying Barrett mucosa and risk factors of the patient. Surgical resection (radical or limited) remains the treatment of choice for tumours invading the submucosa, or multicentric and recurrent tumours after endoscopic mucosectomy.

The sentinel node concept in adenocarcinomas of the distal esophagus and gastroesophageal junction

OBJECTIVE

The sentinel node concept is of great value in the treatment of various malignancies. In this study we investigated whether the application of the sentinel node procedure is feasible in esophageal adenocarcinoma and whether it can tailor surgical treatment of the individual patient.

METHODS

In 40 patients with an adenocarcinoma of the distal esophagus or gastroesophageal junction, blue dye was injected around the tumor intraoperatively. Sentinel nodes (blue-stained) and nonsentinel nodes were identified and dissected during transhiatal esophagectomy. In sentinel nodes negative for tumor cells on routine hematoxylin-eosin examination, multilevel sectioning and immunohistochemical staining were performed to search for micrometastases.

RESULTS

The sentinel node procedure was technically successful in 39 of 40 patients (98%). The median number of sentinel nodes identified was 4. Sentinel nodes were present in more than 1 nodal station in 8 patients (21%). In 6 patients in whom the sentinel node was negative for metastasis, nonsentinel nodes were positive for tumor cells (false-negative rate 6/39 = 15%). Micrometastases and isolated tumor cells were detected in 7 of 19 patients (37%) with sentinel nodes, but this finding did not affect the false-negative rate.

CONCLUSION

Detection of sentinel nodes is technically feasible during esophagectomy for cancer. However, given the relatively high false-negative rate of 15% and the high frequency of sentinel nodes in more than 1 nodal station, the clinical relevance of the sentinel node concept (through application of the blue dye technique) in the current treatment of patients with an adenocarcinoma of the distal esophagus or gastroesophageal junction seems limited.

A comprehensive overview of radioguided surgery using gamma detection probe technology

The concept of radioguided surgery, which was first developed some 60 years ago, involves the use of a radiation detection probe system for the intraoperative detection of radionuclides. The use of gamma detection probe technology in radioguided surgery has tremendously expanded and has evolved into what is now considered an established discipline within the practice of surgery, revolutionizing the surgical management of many malignancies, including breast cancer, melanoma, and colorectal cancer, as well as the surgical management of parathyroid disease. The impact of radioguided surgery on the surgical management of cancer patients includes providing vital and real-time information to the surgeon regarding the location and extent of disease, as well as regarding the assessment of surgical resection margins. Additionally, it has allowed the surgeon to minimize the surgical invasiveness of many diagnostic and therapeutic procedures, while still maintaining maximum benefit to the cancer patient. In the current review, we have attempted to comprehensively evaluate the history, technical aspects, and clinical applications of radioguided surgery using gamma detection probe technology.

Detection of lymph node metastases in oesophageal cancer

Background

The importance of lymph node status in oesophageal cancer cannot be disputed. It is therefore surprising that no standardization exists in either terminology or methodology in lymph node analysis.

Methods

All online databases were searched to identify articles published from 1970 onwards. This was supplemented by hand searching references of retrieved articles.

Results and conclusion

Without accurate identification of lymph node metastases, patients cannot be staged properly, nor can best practice for the treatment of oesophageal cancer be determined. This review outlines the problem and proposes recommendations for standardization in terminology and methodology for the detection of lymph node metastases in oesophageal cancer.

Analysis of micrometastatic disease in histologically negative lymph nodes of patients with adenocarcinoma of the distal esophagus or gastric cardia

Lymphatic dissemination is the most important prognostic factor in patients with esophageal carcinoma. However, the clinical significance of lymph node micrometastases is still debated due to contradictory results. The aim of the present study was to identify the incidence of potentially relevant micrometastatic disease in patients with histologically node-negative esophageal adenocarcinoma and to analyze the sensitivity and specificity of three different immunohistochemical assays. From a consecutive series of 79 patients who underwent a transthoracic resection with extended 2-field lymphadenectomy, all 20 patients with pN0 esophageal adenocarcinoma were included in this study. A total of 578 lymph nodes were examined for the presence of micrometastases by immunohistochemical analysis with the antibodies Ber-EP4, AE1/AE3 and CAM 5.2. Lymph node micrometastases were detected in five of the 20 patients (25%). They were identified in 16 of the 578 lymph nodes examined (2.8%) and most frequently detected with the Ber-EP4 and AE1/AE3 antibody (sensitivity 95% and 79% respectively). In 114 of the 559 negative lymph nodes (20.4%), positive single cells were found that did not demonstrate malignant characteristics. These false-positive cells were more frequently found with the AE1/AE3 staining (specificity of the Ber-Ep4 and AE1/AE3 antibody 94% and 84% respectively). The presence of nodal micrometastases was associated with the development of locoregional recurrences (P=0.01), distant metastases (P=0.01), and a reduced overall survival (log rank test, P=0.009). For the detection of clinically relevant micrometastatic disease in patients operated upon for adenocarcinoma of the distal esophagus or gastric cardia, Ber-EP4 is the antibody of first choice because of its high sensitivity and specificity. Immunohistochemically detected micrometastases in histologically negative lymph nodes have potential prognostic significance and are associated with a high incidence of both locoregional and systemic recurrence. Therefore, this technique has the potential to refine the staging system for esophageal cancer and to help identify patients who will not be cured by surgery alone.

Management of early esophageal cancer

In early esophageal cancer, squamous cell cancer and early adenocarcinoma must be managed differently because they have different origins, pathogenesis. and clinical characteristics. The current treatment options vary widely, from extended resection with lymphadenectomy to endoscopic mucosectomy or ablation. None of these treatment options can be recommended universally. Instead, an individualized strategy should be based on the depth of tumor infiltration into the mucosa or submucosa, the presence or absence of lymph node metastases, the multicentricity of tumor growth, the length of the segment of intestinal metaplasia, and comorbidities of the patient. Endoscopic mucosectomy may be sufficient in a subset of patients who have m1 or m2 squamous cell carcinoma and in patients who have isolated foci of high-grade intraepithelial neoplasia or mucosal cancer. Surgical resection is the treatment of choice for carcinomas invading the submucosal and multicentric tumors. Limited resection with jejunal interposition provides an effective treatment option for patients who have early esophageal adenocarcinoma. The onset of lymph node involvement is later in patients who have early adenocarcinoma than in patients who have squamous cell cancer, probably because chronic injury and repair mechanisms obliterate the otherwise abundant lymph vessels.

Sentinel lymph node biopsy for gastrointestinal cancers

Sentinel lymph node biopsy (SLNB) in gastrointestinal-(GI)-tract cancer is not yet of clinical relevance. Nevertheless, the results in the upper GI-tract promise to be helpful to individualize the indication for surgical therapy. SLNB in colon cancer still fails to show high validity to predict the nodal status, but may be helpful to clarify the prognostic role of micrometastases/isolated tumor cells. In anal cancer SLNB is able to guide the indication for groin irradiation.

Extramural lymphatic drainage from the thoracic esophagus based on minute cadaveric dissections: fundamentals for the sentinel node navigation surgery for the thoracic esophageal cancers

In order to elucidate the lymphatic pathways from the thoracic esophagus, minute dissection of five adult cadavers, from the neck through the diaphragm, was performed. Peri-esophageal lymphatics were dissected from both the anterior and posterior aspects. The topographical differences between the right and left lymphatic drainage were revealed. The right lymphatic drainage system (RDS) was basically longitudinal and multi-stationed. Longitudinal lymphatics were relatively poorly developed in the left lymphatic drainage system (LDS), and direct drainage to the thoracic duct from the left wall of the thoracic esophagus, was frequently observed. The right uppermost thoracic paratracheal node received almost all levels of the right esophageal wall, and this node was thought to be the key node in the RDS. A contralateral lymphatic pathway was relatively frequently observed in the middle and lower thoracic esophagus. These results seemed to be in agreement with the anatomical and clinicopathological data in the literature, and might serve as a basis for sentinel node navigation surgery for the thoracic esophageal cancers.

Limited surgical resection and jejunal interposition for early adenocarcinoma of the distal esophagus

The need for radical resection and extensive lymphadenectomy for early adenocarcinoma of the distal esophagus has recently been challenged. Limited surgical resection and endoscopic mucosal ablation techniques are increasingly proposed and used as less invasive alternatives. Available data indicate that a limited resection of the distal esophagus and esophagogastric junction with jejunal interposition is associated with less morbidity and mortality, provides similar oncologic results, and offers a better quality of life as compared with radical esophagectomy. In contrast, endoscopic ablation and mucosectomy techniques are still plagued by high tumor recurrence rates, particularly in patients with incomplete removal of the underlying Barrett's mucosa, multicentric tumors, or tumors invading into the submucosa. Attention to technical details of limited resection and jejunal interposition is, however, required to avoid complications, poor functional results, and the need for reintervention.

Impact of solitary involved lymph node on outcome in localized cancer of the esophagus and esophagogastric junction

Node-positive esophageal cancer is associated with a dismal prognosis. The impact of a solitary involved node, however, is unclear, and this study examined the implications of a solitary node compared with greater nodal involvement and node-negative disease. The clinical and pathologic details of 604 patients were entered prospectively into a database from1993 and 2005. Four pathologic groups were analyzed: node-negative, one lymph node positive, two or three lymph nodes positive, and greater than three lymph nodes positive. Three hundred and fifteen patients (52%) were node-positive and 289 were node-negative. The median survival was 26 months in the node-negative group. Patients (n=84) who had one node positive had a median survival of 16 months (p=0.03 vs node-negative). Eighty-four patients who had two or three nodes positive had a median survival of 11 months compared with a median survival of 8 months in the 146 patients who had greater than three nodes positive (p=0.01). The survival of patients with one node positive [number of nodes (N)=1] was also significantly greater than the survival of patients with 2-3 nodes positive (N=2-3) (p=0.049) and greater than three nodes positive (p<0001). The presence of a solitary involved lymph node has a negative impact on survival compared with node-negative disease, but it is associated with significantly improved overall survival compared with all other nodal groups.

Immunobiology of the sentinel lymph node and its potential role for antitumour immunity

The sentinel lymph node (SLN) is thought to be an important lymphoid organ for protecting against metastasis and is thought to play a crucial part in provoking antitumour immunity. Because SLN biopsy is undertaken for various types of cancers, such as malignant melanoma and breast cancer, SLN mapping has become a standard procedure, thereby eliminating unnecessary lymph-node resection in patients who do not have affected nodes. The immune surveillance activities of the SLN in melanoma and breast cancer are thought to be suppressed, whereas in cancers of gastrointestinal-tract, the presence of T cells in the SLN has not been shown to suppress the host's immune function. Furthermore, cell death after primary systemic chemotherapy for solid tumours can provoke an antigen-specific immunity in the tumour, which affects tumour response to treatment and, therefore, survival in patients. This review discusses the immunobiology of the SLN and potential strategies for activation of antitumour immunity by primary systemic chemotherapy and other modalities, in terms of tumour-size reduction and survival benefit.

Gastroesophageal carcinoma: individualized surgical therapy

During the twentieth century, surgical management of gastroesophageal carcinoma was developed by an establishment of standard procedures with lymph node dissection according to the metastatic distribution. The "fear" of invisible micrometastasis caused surgeons to perform more aggressive resection with lymphadenectomy to control the disease locally. Although several promising results of extensive lymph node dissection have been reported, the prognostic benefits of extensive surgery have not been proven by prospective randomized trials. A novel technology to detect micrometastasis without extensive surgical resection is required to gastroesophageal carcinoma. The lymphatic mapping technique is one of the attractive candidates for a novel tool to approach this issue.

Emerging aspects of oesophageal and gastro-oesophageal junction cancer histopathology - an update for the surgical oncologist

Adenocarcinoma of the oesophagus and gastro-oesophageal junction are rapidly increasing in incidence and have a well described sequence of carcinogenesis: the Barrett's metaplasia-dysplasia-adenocarcinoma sequence. During recent years there have been changes in the knowledge surrounding disease progression, cancer management and histopathology specimen reporting. Tumours around the gastro-oesophageal junction (GOJ) pose several specific challenges. Numerous difficulties arise when the existing TNM staging systems for gastric and oesophageal cancers are applied to GOJ tumours. The issues facing the current TNM staging and GOJ tumour classification systems are reviewed in this article. Recent evidence regarding the importance of several histopathologically derived prognostic factors, such as circumferential resection margin status and lymph node metastases, have implications for specimen reporting. With the rising use of multimodal treatments for oesophageal cancer it is important that the response of the tumour to this therapy is carefully documented pathologically. In addition, several controversial and novel areas such as endoscopic mucosal resection, lymph node micrometastases and the sentinel node concept are being studied. We aim to review these aspects, with special relevance to oesophageal and gastro-oesophageal cancer specimen reporting, to update the surgical oncologist with an interest in upper gastrointestinal cancer.