Sentinel lymph node mapping in esophageal and gastric cancer

PARP1-targeted fluorescence molecular endoscopy as novel tool for early detection of esophageal dysplasia and adenocarcinoma

BACKGROUND

Esophageal cancer is one of the 10 most common cancers worldwide and its incidence is dramatically increasing. Despite some improvements, the current surveillance protocol with white light endoscopy and random untargeted biopsies collection (Seattle protocol) fails to diagnose dysplastic and cancerous lesions in up to 50% of patients. Therefore, new endoscopic imaging technologies in combination with tumor-specific molecular probes are needed to improve early detection. Herein, we investigated the use of the fluorescent Poly (ADP-ribose) Polymerase 1 (PARP1)-inhibitor PARPi-FL for early detection of dysplastic lesions in patient-derived organoids and transgenic mouse models, which closely mimic the transformation from non-malignant Barrett's Esophagus (BE) to invasive esophageal adenocarcinoma (EAC).

METHODS

We determined PARP1 expression via immunohistochemistry (IHC) in human biospecimens and mouse tissues. We also assessed PARPi-FL uptake in patient- and mouse-derived organoids. Following intravenous injection of 75 nmol PARPi-FL/mouse in L2-IL1B (n = 4) and L2-IL1B/IL8Tg mice (n = 12), we conducted fluorescence molecular endoscopy (FME) and/or imaged whole excised stomachs to assess PARPi-FL accumulation in dysplastic lesions. L2-IL1B/IL8Tg mice (n = 3) and wild-type (WT) mice (n = 2) without PARPi-FL injection served as controls. The imaging results were validated by confocal microscopy and IHC of excised tissues.

RESULTS

IHC on patient and murine tissue revealed similar patterns of increasing PARP1 expression in presence of dysplasia and cancer. In human and murine organoids, PARPi-FL localized to PARP1-expressing epithelial cell nuclei after 10 min of incubation. Injection of PARPi-FL in transgenic mouse models of BE resulted in the successful detection of lesions via FME, with a mean target-to-background ratio > 2 independently from the disease stage. The localization of PARPi-FL in the lesions was confirmed by imaging of the excised stomachs and confocal microscopy. Without PARPi-FL injection, identification of lesions via FME in transgenic mice was not possible.

CONCLUSION

PARPi-FL imaging is a promising approach for clinically needed improved detection of dysplastic and malignant EAC lesions in patients with BE. Since PARPi-FL is currently evaluated in a phase 2 clinical trial for oral cancer detection after topical application, clinical translation for early detection of dysplasia and EAC in BE patients via FME screening appears feasible.

Role of carbon nanotracers in lymph node dissection of advanced gastric cancer and the selection of preoperative labeling time

BACKGROUND

The incidence of gastric cancer is high. The number of dissected lymph nodes was an independent factor affecting prognosis. Although preoperative labeling is helpful in lymph nodes resection, there are no guidelines for when to perform preoperative labeling.

AIM

To investigate the role of nanocarbon in lymph node dissection during gastrectomy, and to discuss the relationship between the timing of preoperative injection of carbon nanoparticles and the extent of lymph node dissection.

METHODS

A prospective analysis was performed on the clinical data of 307 patients with advanced gastric cancer who underwent laparoscopic surgery in the General Surgery Department of Weifang People’s Hospital between June 2018 and February 2021. The patients were randomly divided into experimental group and control group based on whether they received preoperative nanocarbon injection or not. The experimental group was divided into different groups according to the preoperative labeling time. The number of dissected lymph nodes and the number of lymph nodes with black staining were compared in each group after surgery, and the role of nanocarbon in the number of dissected lymph nodes, pathological staging, and the relationship with prognosis were discussed.

RESULTS

The average number of dissected lymph nodes in the experimental group was higher than that in the control group. In the experimental group, the number of lymph node dissections and number of black-staining lymph nodes in the nanocarbon-labeling group at 2 d and 1 d before surgery were higher than in the labeling group on the day before surgery (P < 0.05).

CONCLUSION

Preoperative nanocarbon labeling can safely and effectively guide lymph node dissection. To improve the detection rate of lymph nodes is conducive to subsequent comprehensive anti-tumor therapy.

Current status and challenges in sentinel node navigation surgery for early gastric cancer

As an optimal surgical procedure to accurately evaluate lymph node (LN) metastasis during surgery with minimal surgical resection, we have been developing sentinel node (SN) biopsy for early gastric cancer since the 1990s. Twelve institutions from the Japanese Society of Sentinel Node Navigation Surgery (SNNS), including Keio University Hospital, conducted a multicenter prospective trial to validate the SN concept using the dual-tracer method with blue dye and a radioisotope. According to the results, 397 patients were included in the final analysis, and the overall accuracy in detecting LN metastasis using SN biopsy was 99% (383 of 387). Based on the validation study, we are targeting cT1N0 with a primary tumor of ≤4 cm in diameter as an indication for SN biopsy for gastric cancer. We are currently running a multicenter nonrandomized phase III trial to assess the safety and efficacy of SN navigation surgery. The Korean group has reported the result of a multicenter randomized phase III trial. Since meticulous gastric cancer in the remnant stomach was rescued by subsequent gastrectomy, the disease-specific survival was comparable between the two techniques, implying that SN navigation surgery can be an alternative to standard gastrectomy. With the development of SN biopsy procedure and treatment modalities, the application of SN biopsy will be expanded to achieve an individualized minimally invasive surgery.

Lymph Node Mapping in Gastric Cancer Surgery: Current Status and New Horizons

Gastric cancer (GC) remains one of the most important malignant diseases with significant geographical, ethnic, and socioeconomic differences in distribution. Sentinel lymph node (SLN) mapping is an accepted way to assess lymphatic spread in several solid tumors; however, the complexity of gastric lymphatic drainage may discourage use of this procedure, and the estimated accuracy rate is, in general, reasonably good. This study aimed at reviewing the current status of SLN mapping and navigation surgery in GC. SLN mapping should be limited to tumors clinically T1 and less than 4 cm in diameter. Combination SLN mapping with radioactive colloid and blue dye is used as the standard. Despite its notable limitations, SLN mapping and SLN navigation surgery present a novelty individualizing the extent of lymphadenectomy.

Numerous lymph node metastases in early gastric cancer without preoperatively enlarged lymph nodes: a case report

BACKGROUND

According to the 2018 Japanese gastric cancer treatment guidelines (ver. 5), a reduced extent of lymphadenectomy (D1 or D1+) is indicated for cT1 N0 tumors that do not meet the criteria for endoscopic resection. However, early gastric cancer with multiple lymph node metastases is not unknown, and cases have been reported. We report a case of a patient with early gastric cancer and numerous nodal metastases who underwent laparoscopic proximal gastrectomy based on a preoperative diagnosis of T1 N0.

CASE PRESENTATION

A 69-year-old woman underwent emergent endoscopic hemostasis for massive hematemesis of the stomach, and endoscopic examination showed ulceration with a visible vessel. Pathological biopsy examination of the ulcer identified poorly differentiated adenocarcinoma with signet ring cells. The patient was diagnosed with early gastric cancer that was not indicated for endoscopic resection because of the ulceration and histological type. Endoscopic ultrasound showed that the third layer was poorly demarcated at the ulcer scar, indicating invasion to the submucosal layer. Computed tomography did not reveal enlarged lymph nodes or distant metastasis. The preoperative diagnosis was early gastric cancer of the fundus without nodal metastasis, and laparoscopic proximal gastrectomy with D1+ lymphadenectomy was performed. The initial postoperative pathological diagnosis was intramucosal carcinoma without lymphovascular invasion; however, the presence of 26 lymph node metastases was revealed unexpectedly. Additional pathological examination of more resected specimens transected every 2-3 mm revealed that only one lesion contained a small number of cancer cells in the lymphatic duct below the muscularis mucosa.

CONCLUSIONS

We report a case of early gastric cancer with 26 nodal metastases in which lymph node involvement was not identified prior to surgery. These findings indicate that the extent of lymphadenectomy and the surgical procedure should be carefully decided even in cT1 N0 early gastric cancer when several risk factors for lymph node metastasis are present.

Tumor differentiation as related to sentinel lymph node status in gastric cancer

AIM: To investigate the influence of tumor grade on sentinel lymph node (SLN) status in patients with gastric cancer (GC).

METHODS: We retrospectively studied 71 patients with GC who underwent SLN mapping during gastric surgery to evaluate the relationship between SLN status and tumor grade.

RESULTS: Poorly differentiated tumors were detected in 50/71 patients, while the other 21 patients had moderately differentiated tumors. SLNs were identified in 58/71 patients (82%). In 41 of the 58 patients that were found to have stained nodes (70.7%), the tumor was of the poorly differentiated type (group I), while in the remaining patients with stained nodes 17/58 (29.3%), the tumor was of the moderately differentiated type (group II). Positive SLNs were found in 22/41 patients in group I (53.7%) and in 7/17 patients in group II (41.2%) (P = 0.325). The rate of positivity for the SLNs in the two groups (53.7% vs 41.2%) was not statistically significant (P = 0.514).

CONCLUSION: Most of our patients were found to have poorly differentiated adenocarcinoma of the stomach and there was no correlation between tumor grade and SLN involvement.

Clinical relevance of novel imaging technologies for sentinel lymph node identification and staging

The sentinel lymph node (SLN) concept has become a standard of care for patients with breast cancer and melanoma, yet its clinical application to other cancer types has been somewhat limited. This is mainly due to the reduced accuracy of conventional SLN mapping techniques (using blue dye and/or radiocolloids as lymphatic tracers) in cancer types where lymphatic drainage is more complex, and SLNs are within close proximity to other nodes or the tumour site. In recent years, many novel techniques for SLN mapping have been developed including fluorescence, x-ray, and magnetic resonant detection. Whilst each technique has its own advantages/disadvantages, the role of targeted contrast agents (for enhanced retention in the SLN, or for immunostaging) is increasing, and may represent the new standard for mapping the SLN in many solid organ tumours. This review article discusses current limitations of conventional techniques, limiting factors of nanoparticulate based contrast agents, and efforts to circumvent these limitations with modern tracer architecture.

Sentinel node and mechanism of lymphatic metastasis

The validity and clinical usefulness of the sentinel node (SN) concept for breast cancer has been confirmed, and individualized limited surgery based on diagnosis of SN metastasis is presently performed. In the future, SN navigation surgery (SNNS) will be actively applied to the treatment of early gastric cancer, and an intraoperative real-time reverse transcription-polymerase chain reaction (RT-PCR) assay to detect SN micrometastasis of gastric cancer is under development. Not only anatomical factors, but also many other factors such as local immunosuppression in the SN and lymphoangiogenesis may be involved in development of SN micrometastasis, and clarification of the mechanisms of metastasis and development of treatment methods are awaited. (*English Translation of J Jpn Col Angiol 2008; 48: 137-142.).

Sentinel lymph node mapping and biopsy using radioactive tracer in gastric cancer

BACKGROUND

Lymph node metastasis is one of the most important prognostic factors in gastric cancer survival. Sentinel lymph node (SLN) mapping and biopsy may reduce the extension of lymph node dissection by determination of lymph node involvement. The current study prospectively evaluates the feasibility and reliability of SLN biopsy in gastric cancer.

METHODS

A total of 30 patients with gastric cancer with a preoperative imaging stage of T1-T2 or T3, N0 and M0 were enrolled in the study. Furthermore, 2-16 h prior to each operation, (99m) Tc-sulphur colloid solution (0.5 mL, 2 mCi/mL) was endoscopically injected into the submucosal layer around the primary lesion. Lymph nodes were examined using a hand-held gamma probe. Subsequently, a total or subtotal gastrectomy and D2 lymphadenectomy was performed in each patient.

RESULTS

The success rate of SLN biopsy was 100%. Sensitivity, specificity, positive predictive value and negative predictive value were 91.7%, 100%, 100% and 75%, respectively. Both of the two false-negative cases were in the T3 group. In cases of T2 tumours, the sensitivity was 100%.

DISCUSSION

SLN biopsy using a gamma probe in early stage gastric cancer seems to be a safe, feasible and accurate procedure with high sensitivity in predicting regional lymph node involvement.

The extent of lymph node dissection for gastric cancer: a critical appraisal

The extent of lymphadenectomy during therapeutic gastrectomy for gastric cancer remains a protracted and controversial issue. While traditionally extended lymphadenectomy is performed in Eastern Asia, limited lymphadenectomy is advocated by most western surgeons. Two large western randomized trials, meta-analyses and a recent systematic review were unable to demonstrate overall benefit from extended lymphadenectomy. In this review, the currently available data on this topic are critically evaluated, while ongoing studies and future perspective are discussed.

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.

Surgical strategies for adenocarcinoma of the esophagogastric junction

This chapter summarizes the surgical strategies for adenocarcinomas of the distal esophagus, gastric cardia, and subcardial gastric cancer invading the cardia+/-distal esophagus known as adenocarcinomas of the esophagogastric junction (AEG). The different surgical approaches according to the tumor origin, localization, and tumor stage are addressed with particular attention to the extent and type of resection and appropriate lymphadenectomy (LAD). The classification of AEG according to Siewert is helpful for the selection of the surgical strategy. While type I tumors benefit from a transthoracic en bloc esophagectomy including a two-field LAD, type II and III tumors can be treated by an extended total gastrectomy with a transhiatal resection of the distal esophagus and LAD of the lower mediastinum and the abdominal D2 compartment. Limited resections appear to be -possible for early tumor stages in selected cases of type I-III tumors.

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.

[Not Available]

M. Pocard, J.-C. Sabourin In theory, the concept of sentinel lymph node (SLN) biopsy can be applied to cancer surgery for all solid cancers. Yet sentinel lymph node biopsy has not become a standard part of gastrointestinal cancer surgery. It has been of value in the assessment of small early-stage gastric cancers, but has only achieved widespread practice in Japan. Studies of SLN biopsy in colon cancer have not shown it to be a reliable predictor of N+ status and therefore don't permit the omission of lymph node dissection in selected cases. On the other hand, as a form of intra-operative lymph node mapping, dye injection of the SLN may demonstrate aberrant lymphatic drainage and could occasionally permit the sparing of a middle colic artery whose sacrifice would otherwise be dictated by standard drainage patterns. SLN biopsy may have prognostic usefulness by demonstrating micrometastases; careful serial sectioning focussed on the SLN may detect nests of metastatic cells on HE staining, thereby converting a tumor from Stage I (TxN0M0) to Stage II (TxN1M0). This finding has been noted in 10-15% of cases. However, the prognostic value of micrometastases detected only by immunohistochemical staining or PCR has not been demonstrated. For cancers of the anal canal, SLN biopsy of inguinal nodes has been tested as a means of establishing the indications for inguinal lymph node dissection.

The current management of esophageal cancer

The divergence in epidemiology between the East and West has made interpretation of data in the literature more difficult and has affected the choice of the most appropriate surgical technique and treatment strategies. The management of esophageal cancer certainly has evolved, and many more options are available. Stage-directed strategies and individualization of treatment are important considerations. Surgeons play a central role in directing management of this disease by advising how best to integrate surgical therapy with nonoperative programs. Surgeons should aim at improving their results further, so that the best results of surgery are compared with seemingly "safer" nonsurgical therapies. Low death rates have been achieved in specialized centers, but there still is much room for improvement in morbidity rates. Even with the best surgical resection and chemoradiation therapy, distant failure remains a barrier to improved survival rates. Therapeutic improvements will require more effective systemic drugs and a better ability to predict responders with precision. Management strategies will evolve further, with improvements in molecular techniques, imaging methods, and introduction of more novel tumoricidal agents. The challenge for the future is to test strategies critically in a scientific, unbiased manner and to explore other innovative treatments.

Current status of sentinel lymph node navigation surgery in breast and gastrointestinal tract

Sentinel lymph node biopsy (SLNB) has been developed as a new diagnostic and therapeutic modality in melanoma and breast cancer surgery. The purpose of the SLNB include preventing the operative morbidity and improving the pathologic stage by focusing on fewer lymph nodes using immunocytochemic and molecular technology has almost achieved in breast cancer surgery. The prognostic meaning of immunocytochemically detected micrometastases is also evaluating in the SLN and bone marrow aspirates of women with early-stage breast cancer. SLNB using available techniques have suggested that the lymphatic drainage of the gastrointestinal tract is much more complicated than other sites, skip metastasis being rather frequent because of an aberrant lymphatic drainage outside of the basin exist. At the moment, the available data does not justify reduced extent of lymphadenectomy, but provides strong evidence for an improvement in tumor staging on the basis of SLNB. Two large scale prospective multi-center trials concerning feasibility of gamma-probe and dye detection for gastric cancer are ongoing in Japan. Recent studies have shown favorable results for identification of SLN in esophageal cancer. CT lymphography with endoscopic mucosal injection of iopamidol was applicable for SLN navigation of superficial esophageal cancer. The aim of surgical treatment is complete resection of the tumor-infiltrated organ including the regional lymph nodes. Accurate detection of SLN can achieve a selection of a more sophisticated tailor made approach. The patient can make a individualized choice from a broader spectrum of therapeutic options including endoscopic, laparoscopic or laparoscopy-assisted surgery, modified radical surgery, and typical radical surgery with lymph node dissection. Ultrastaging by detecting micrometastasis at the molecular level and the choice of an adequate treatment improve the postoperative quality of life and survival. However these issues require further investigation.

Lymph node dissection in surgical treatment of esophageal neoplasms

The optimal lymphadenectomy for esophageal cancer remains controversial. The choice of surgical access determines to a great extent the type of lymphadenectomy possible. En bloc resections and three-field lymphadenectomy are concepts pioneered in the West and East, respectively; both should be performed in specialized centers because such extended lymph node dissection has substantial morbidity rates. Recent focus in research is on refining the indications for these procedures. Patient management strategies should be individualized.

Postoperative gastrointestinal dysfunction after 2-field versus 3-field lymph node dissection in patients with esophageal cancer

PURPOSE

Using an instrument we developed to assess postoperative dysfunction objectively (Surg Today 2005;35:535-42), we compared postoperative dysfunction after 2 - field versus 3 - field lymph node dissection retrospectively, in patents undergoing esophageal cancer surgery.

METHODS

Subjects were selected randomly from among patients who had undergone radical surgery for squamous cell carcinoma of the thoracic esophagus followed by reconstruction with a gastric tube and a cervical anastomosis. Patients rated 32 items related to postoperative dysfunction according to a 5-grade scale. Postoperative gastrointestinal dysfunction was evaluated on the basis of the total score and the scores for seven symptom categories: decreased physical activity, symptoms of reflux, dumping-like syndrome, nausea and vomiting, passage dysfunction, pain, and diarrhea or soft feces.

RESULTS

We studied 42 patients, 22 of whom underwent 2-field lymph node dissection and 20 of whom underwent 3-field dissection. The total gastrointestinal dysfunction score was significantly higher in the 3-field group than in the 2-field group (78.4 +/- 14.1 points vs 67.9 +/- 16.9 points, P = 0.038). When we analyzed the data according to the symptom categories, the 3-field group had higher scores for decreased physical activity, symptoms of reflux, dumping-like syndrome, nausea and vomiting, and passage dysfunction.

CONCLUSION

Three-field lymph node dissection was associated with greater postoperative gastrointestinal dysfunction than 2-field lymph node dissection. Thus, the preoperative identification of those patients with esophageal cancer who are most likely to benefit from concurrent cervical lymph node dissection is essential.

Surgical treatment of superficial esophageal cancer

OBJECTIVE

The worldwide incidence of superficial esophageal cancer (SEC) is increasing. The aim of this study is to review the systematic surgical outcomes of esophagectomy for SEC.

DATA SOURCES

Only manuscripts written in English and written between 1980 and 2003 were selected from MEDLINE. The keywords consisting of superficial esophageal cancer, early esophageal cancer, and early stage or superficial stage or stage I in esophageal cancer were searched.

STUDY SELECTION

There were no exclusion criteria for published information relevant to the topics. The most representative articles were selected when there were several articles from the same institution. Case reports were excluded. DATA EXTRACTIONS: Thirty-two manuscripts were finally collected from MEDLINE and eight articles were also added from reference lists of the pertinent literatures. In evaluating the statistical analysis of the complications of the reported literature, collective method was used.

DATA SYNTHESIS

The collected information was organized.

CONCLUSIONS

The conclusions drawn from those articles showed that the overall prevalence of SEC accounted around 10% and increased to 25% in the 2000s. The overall incidence of lymph node metastasis of SEC was about 25% and its incidences in mucosal and submucosal cancer were 5 and 35%, respectively. The percentage of the cases of squamous cell carcinoma (SCC) vs adenocarcinoma (AC) widely varied depending on the geographic locations reported; most SCC cases were from the Asian countries and most AC cases were from the European countries. Clinical significance of multimodal treatment for SEC has dramatically developed in the recent era and could provide various potential therapeutic options for SEC. These concepts make it possible to individualize surgical management of SEC as part of various multimodal treatments. The operative approaches for SEC varied from minimally invasive thoracoscopic esophagectomy, limited transabdominal distal esophagectomy, conventional transthoracic esophagectomy, transhiatal esophagectomy without thoracotomy, en bloc esophagectomy, and to extended esophagectomy with a complete three-field lymph node dissection. A 5-year overall survival rate of SEC after esophagectomy was good (46 to 83%) to excellent (71 and 100%) for mucosal SEC, but far from satisfactory (33 and 78%) for submucosal SEC. Early diagnosis, development of multimodal treatment, standardization of the surgical procedure including routine lymph node dissection, and improved perioperative management of patients have led to a better survival for patients with SEC.