Operable squamous esophageal cancer: current results from the East

Changes in the recent three decades and survey on the current status of surgical treatment for esophageal cancer in China

BACKGROUND

To review the changes and survey on status quo of the surgical treatment for esophageal cancer in China. The differences in diagnosis and treatment for esophageal cancer among hospitals in different regions across China were also investigated.

METHODS

We sent questionnaires to 46 hospitals across China, investigating the volume of esophageal cancer surgeries, surgical procedures, and perioperative management under the guidance of esophageal surgery chiefs.

RESULTS

A total of 46 questionnaires were sent out and collected. The survey results showed that in the past 5 years, the volume of surgeries for esophageal cancer remained stable by 23.9% of those hospitals, increased by 30.4%, and decreased by 45.7%. Of those patients treated by surgery, 19.1% were in the early stages, and 80.9% were in locally advanced stages. In terms of surgical procedures, 73.4% of the patients were treated by minimally invasive surgery and 85.7% of esophageal substitutes were a gastric conduit, 93.1% of the substitutes were pulled to the neck through the esophageal bed. For the lymph node dissection, 78.5% of the patients had a complete two-field lymph node dissection including the para-recurrent laryngeal nerve lymph nodes. Of the patients with neoadjuvant therapy, 53.5% received chemotherapy or chemotherapy plus immunotherapy (47.0%), and 43.5% had chemoradiation.

CONCLUSIONS

Currently, in China, minimally invasive surgery-oriented multimodality treatment, including complete two-field lymph node dissection, has become the standard approach for esophageal cancer management. Over the past decade, this standardized approach has significantly improved prognosis compared to previous decades.

Minimally invasive versus open esophagectomy for resectable thoracic esophageal cancer (NST 1502): a multicenter prospective cohort study

Background

Whether minimally invasive esophagectomy (MIE) is superior to open esophagectomy (OE) in the treatment of esophageal squamous cell carcinoma (ESCC) is still uncertain. Therefore, this multicenter prospective study aimed to compare MIE with OE in postoperative parameters and long-term survival.

Methods

All hospitalized patients with cT1b-3N0-1M0 thoracic ESCC treated by MIE or OE were enrolled from 19 selected centers from April 1, 2015 to December 31, 2018. The propensity score matching (PSM) was performed to minimize the selection bias. The basic clinicopathological characteristics and 3-year overall survival (OS) as well as disease-free survival (DFS) of two groups were compared by R version 3.6.2.

Results

MIE were performed in 1,387 patients and OE in 335 patients. 335 cases in each group were finally matched by PSM, and no significant differences in the essential demographic characteristics were observed between the MIE and OE groups after PSM. Compared with OE, MIE had significantly less intraoperative bleeding, less total drainage volume, shorter postoperative hospital stay, and harvested significantly more lymph nodes (LNs) (all P < 0.001). There were no significant differences in the major postoperative complications and death rates between MIE and OE. The 3-year OS and DFS were 77.0% and 68.1% in the MIE group versus 69.3% and 60.9% in the OE group (OS: P = 0.03; DFS: P = 0.09), and the rates were 75.1% and 66.5% in the MIE group versus 66.9% and 58.6% in the OE group for stage cII patients (OS: P = 0.04, DFS: P = 0.09), respectively.

Conclusions

Compared with OE, MIE is a safe and effective treatment approach with similar mortality and morbidity. It has the advantages in harvesting more LNs, improving postoperative recovery and survival of stage cII ESCC patients.

Advantages of McKeown minimally invasive oesophagectomy for the treatment of oesophageal cancer: propensity score matching analysis of 169 cases

BACKGROUND

Oesophagectomy, the gold standard for oesophageal cancer treatment, causes significantly high morbidity and mortality. McKeown minimally invasive oesophagectomy (MIE) is preferred for treating oesophageal malignancies; however, limited studies with large sample sizes focusing on the surgical and oncological outcomes of this procedure have been reported. We aimed to compare the clinical safety and efficacy of McKeown MIE with those of open oesophagectomy (OE).

PATIENTS AND METHODS

Overall, 338 oesophageal cancer patients matched by gender, age, location, size, and T and N stages (McKeown MIE: 169 vs OE: 169) were analysed. The clinicopathologic features, operational factors, postoperative complications, and prognoses were compared between the groups.

RESULTS

McKeown MIE resulted in less bleeding (200 mL vs 300 mL, p<0.01), longer operation time (335.0 h vs 240.0 h, p<0.01), and higher number of harvested lymph nodes (22 vs 9, p<0.01) than OE did. Although the rate of recurrent laryngeal nerve injury in the two groups was not significantly different, incidence of anastomotic leakage (8 vs 24, p=0.003) was significantly lower in the McKeown MIE group. In addition, patients who underwent McKeown MIE had higher 5-year overall survival than those who underwent OE (69.9% vs 40.4%, p<0.001).

CONCLUSION

McKeown MIE is proved to be feasible and safe to achieve better surgical and oncological outcomes for oesophageal cancer compared with OE.

Analysis of a registry database for esophageal cancer from high-volume centers in China

Esophageal cancer has a high incidence among malignancies in China, but a comprehensive picture of the status of its surgical management in China has hitherto not been available. A nationwide database has recently been established to address this issue.

METHOD

A National Database was setup through a network platform, and data was collected from 70 high-volume centers (>100 esophagectomies/per year) across China. Data was entered between January 2009 and December 2014, and was analyzed in June 2015 after a minimal follow-up of 6 months for all patients. 8181 patients with complete data who received surgery for primary esophageal cancer on the Database were included in the analysis.

RESULT

In this series, there were 6052 males and 2129 females, with a mean age of 60.5 years (range: 22-90 years). The pathology in 95.5% of patients was squamous cell carcinoma. The pathological stage distribution was 1.2% in stage 0, 2.5% in Ia, 11.5% in Ib, 14.8% in IIa, 36.1% in IIb, 19.3% in IIIa, 8.3% in IIIb, 6.2% in IIIc. 1800 patients (22.0%) with locally advanced disease received preoperative neoadjuvant therapy and 3592 patients (43.9%) underwent postoperative adjuvant chemotherapy and/or radiotherapy. The esophagectomies were performed through left thoracotomy approach in 5870 cases (72.6%), through right chest approach in 2215 cases (27.4%) including right thoracotomy (21.3%) and VATS (6.1%). The 30-day postoperative mortality rate was 0.6% (43 patients), and the overall postoperative complication rate was 11.6% (951 patients). The 1-, 3-, and 5-year overall survival rates were 82.6%, 61.6%, and 52.9%, respectively.

CONCLUSION

This National Registry Database from high-volume centers provides a comprehensive picture of surgical management for esophageal cancer in China for the first time. Squamous cell carcinoma predominates, but there is heterogeneity with respect to the surgical approach and perioperative oncologic management. Overall, surgical mortality and morbidity rates are low, and good survival rates have been achieved due to improvement of surgical treatment technology in recent years.

Hypertension predicts a poor prognosis in patients with esophageal squamous cell carcinoma

Background

We investigated the relationship between the preoperative hypertension and prognosis of esophageal squamous cell cancer (ESCC) patients who had underwent esophagectomy.

Results

We detected 52% patients with hypertension, including 317 patients with newly diagnosed hypertension and 194 patients with history of hypertension. Compared with patients of normal blood pressure, all patients with hypertension and newly diagnosed hypertension were observed to have worse overall and ESCC-specific survival outcome (p < 0.05). After adjusted in multivariate Cox regression analysis, hypertension (HR: 1.343, 95% CI: 1.064, 1.695; HR: 1.315, 95% CI: 1.039, 1.664) and newly diagnosed hypertension (HR: 1.414, 95% CI: 1.095, 1.826; HR: 1.420, 95% CI: 1.098, 1.836) were inversely associated with overall and ESCC-specific survival outcome, respectively. While no association was found between history of hypertension and overall or ESCC-specific survival outcome (HR: 1.229, 95% CI: 0.892, 1.694; HR: 1.132, 95% CI: 0.812, 1.578).

Conclusions

Hypertension was an independent risk factor and resulted in inferior prognosis for ESCC patients who had underwent esophagectomy.

Methods

A total of 982 ESCC patients who had underwent esophagectomy from August 2010 to December 2015 were enrolled in our study with a follow up of 6 years. The Kaplan-Meier method and log-rank test were respectively used to calculate and compare survival rate, and Cox proportional hazards regression model was applied to identify independent prognostic factors.

Comparison of short-term outcomes and three yearsurvival between total minimally invasive McKeown and dual-incision esophagectomy

Background

The aim of this study was to compare the short‐term outcomes and three‐year survival between dual‐incision esophagectomy (DIE) and total minimally invasive McKeown esophagectomy (MIME) for esophageal cancer patients with negative upper mediastinal lymph nodes requiring esophagectomy and neck anastomosis.

Methods

One hundred and fifty patients underwent DIE, while 361 patients received total MIME. Perioperative outcomes and three‐year survival were compared in unmatched and propensity score matched data between two groups.

Results

Both unmatched and matched analysis demonstrated that there were no significant differences in the number of lymph nodes harvested, or major or minor complication rates between the DIE and MIME groups. Compared with patients who underwent DIE, patients who underwent total MIME had longer operation duration (310 minutes vs. 345 minutes; P = 0.002). However, there was significantly less intraoperative blood loss in the total MIME compared with the DIE group (191 mL vs. 287 mL, respectively; P < 0.001). Kaplan‐Meier analysis demonstrated a trend that patients who underwent MIME had longer overall (79.5% vs. 64.1%; P = 0.063) and disease‐free three‐year survival (65.3% vs. 82.8%; P = 0.058) compared with patients who underwent DIE.

Conclusions

Both total MIME and DIE are feasible for the surgical treatment of esophageal cancer patients with negative upper mediastinal lymph nodes requiring esophagectomy and neck anastomosis. However, MIME was associated with better overall and disease‐free three‐year survival compared with DIE.

The impact of operative approaches on outcomes of middle and lower third esophageal squamous cell carcinoma

BACKGROUND

The aim of this study was to investigate the perioperative outcomes and 3-year overall survival (OS) of 2 approaches including Sweet and open Ivor Lewis esophagectomy in the surgical treatment of middle and lower third esophageal squamous cell carcinoma.

METHODS

The medical records of 1,746 consecutive patients who underwent esophagectomy for middle and lower esophageal cancer between January 2009 and September 2015 at the First Department of Thoracic Oncologic Surgery of Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College were retrospectively reviewed. The clinical variables and 3-year survival were compared between Sweet (n=1,701) and open Ivor Lewis (n=45) approaches in unmatched and propensity score matching analysis.

RESULTS

Patients who received esophagectomy by Sweet approach had shorter duration of surgery (mean 212 vs. 390 min; P<0.001), more lymph nodes removed (mean 24 vs. 19; P=0.005), lower overall complications rate (24.4% vs. 11.7%; P=0.009), lower total hospital cost (¥77,200 vs. 106,000; P=0.045) compared with patients who received open Ivor Lewis approach. After propensity score matching analysis, Sweet approach was still associated with decreased duration of surgery (mean 210 vs. 390 min; P<0.001), more lymph nodes removed (mean 24 vs. 19; P=0.050), and lower total hospital cost (¥86,800 vs. 106,000; P=0.045) compared with Ivor Lewis approach. However, there were no significant differences in overall complication rates (24.4% vs. 24.4%; P=1.000) between two approaches. There was no significant difference in 3-year OS between Sweet and open Ivor Lewis approaches (59.9% vs. 61.4%; P=0.637) in unmatched analysis and in matched analysis (77.8% vs. 61.4%; P=0.264).

CONCLUSIONS

In this cohort, for middle and lower third esophageal squamous cell carcinoma patients, both Sweet and open Ivor Lewis approaches are feasible in terms of perioperative outcomes and 3-year OS.

Potential impact of (18)FDG-PET/CT on surgical approach for operable squamous cell cancer of middle-to-lower esophagus

Background

Fluorodeoxyglucose-positron emission tomography (PET)/computed tomography (CT) is reported to have a significant advantage over CT for staging esophageal cancer (EC). However, whether PET/CT may play a useful role in guiding surgical approach remains undetermined.

Methods

Patients with potentially resectable squamous cell EC were randomized into either PET/CT group or CT group. The surgical data and survival outcomes were compared.

Results

Compared to the CT group, the right-sided approach was more frequently used (42.6% versus 25.5%, P=0.065) in the PET/CT group in order to allow surgical access to radiographically suspicious lymph nodes inaccessible from the left, thus enabling the removal of more involved lymph nodes (2.83 versus 1.76; P=0.039) as well as their stations (1.65 versus 1.08; P=0.042). Although the overall survival between the two groups was similar, the PET/CT group had a longer disease-free survival (DFS) than the CT group (27.1 months versus 18.9 months; P=0.019), especially in the subgroup of node-positive patients (22.5 months versus 13.5 months; P=0.02). Preoperative imaging arm was the only prognostic factor found to independently influence DFS.

Conclusion

For patients with middle-to-lower EC, surgical approaches directed by PET/CT may increase the likelihood of complete resection and affect DFS.

Open three-stage transthoracic oesophagectomy versus minimally invasive thoraco-laparoscopic oesophagectomy for oesophageal cancer: protocol for a multicentre prospective, open and parallel, randomised controlled trial

INTRODUCTION

Oesophageal cancer is the eighth most common cause of cancer worldwide. In 2009 in China, the incidence and death rate of oesophageal cancer was 22.14 per 100 000 person-years and 16.77 per 100 000 person-years, respectively, the highest in the world. Minimally invasive oesophagectomy (MIO) was introduced into clinical practice with the aim of reducing the morbidity rate. The mechanisms of MIO may lie in minimising the reaction to surgical injury and inflammation. There are some randomised trials regarding minimally invasive versus open oesophagectomy, with 100-850 subjects enrolled. To date, no large randomised controlled trial comparing minimally invasive versus open oesophagectomy has been reported in China, where squamous cell carcinoma predominated over adenocarcinoma of the oesophagus.

METHODS AND ANALYSIS

This is a 3 year multicentre, prospective, randomised, open and parallel controlled trial, which aims to compare the effectiveness of minimally invasive thoraco-laparoscopic oesophagectomy to open three-stage transthoracic oesophagectomy for resectable oesophageal cancer. Group A patients receive MIO which involves thoracoscopic oesophagectomy and laparoscopic gastric mobilisation with cervical anastomosis. Group B patients receive the open three-stage transthoracic oesophagectomy which involves a right thoracotomy and laparotomy with cervical anastomosis. Primary endpoints include respiratory complications within 30 days after operation. The secondary endpoints include other postoperative complications, influences on pulmonary function, intraoperative data including blood loss, operative time, the number and location of lymph nodes dissected, and mortality in hospital, the length of hospital stay, total expenses in hospital, mortality within 30 days, survival rate after 2 years, postoperative pain, and health-related quality of life (HRQoL). Three hundred and twenty-four patients in each group will be needed and a total of 648 patients will finally be enrolled into the study.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Institutional Ethics Committees of all participating institutions. The findings of this trial will be disseminated to patients and through peer-reviewed publications and international presentations.

TRIAL REGISTRATION NUMBER

NCT02355249.

High-resolution microendoscopy for esophageal cancer screening in China: A cost-effectiveness analysis

AIM

To study the cost-effectiveness of high-resolution microendoscopy (HRME) in an esophageal squamous cell carcinoma (ESCC) screening program in China.

METHODS

A decision analytic Markov model of ESCC was developed. Separate model analyses were conducted for cohorts consisting of an average-risk population or a high-risk population in China. Hypothetical 50-year-old individuals were followed until age 80 or death. We compared three different strategies for both cohorts: (1) no screening; (2) standard endoscopic screening with Lugol's iodine staining; and (3) endoscopic screening with Lugol's iodine staining and an HRME. Model parameters were estimated from the literature as well as from GLOBOCAN, the Cancer Incidence and Mortality Worldwide cancer database. Health states in the model included non-neoplasia, mild dysplasia, moderate dysplasia, high-grade dysplasia, intramucosal carcinoma, operable cancer, inoperable cancer, and death. Separate ESCC incidence transition rates were generated for the average-risk and high-risk populations. Costs in Chinese currency were converted to international dollars (I$) and were adjusted to 2012 dollars using the Consumer Price Index.

RESULTS

The main outcome measurements for this study were quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER). For the average-risk population, the HRME screening strategy produced 0.043 more QALYs than the no screening strategy at an additional cost of I$646, resulting in an ICER of I$11808 per QALY gained. Standard endoscopic screening was weakly dominated. Among the high-risk population, when the HRME screening strategy was compared with the standard screening strategy, the ICER was I$8173 per QALY. For both the high-risk and average-risk screening populations, the HRME screening strategy appeared to be the most cost-effective strategy, producing ICERs below the willingness-to-pay threshold, I$23500 per QALY. One-way sensitivity analysis showed that, for the average-risk population, higher specificity of Lugol's iodine (> 40%) and lower specificity of HRME (< 70%) could make Lugol's iodine screening cost-effective. For the high-risk population, the results of the model were not substantially affected by varying the follow-up rate after Lugol's iodine screening, Lugol's iodine test characteristics (sensitivity and specificity), or HRME specificity.

CONCLUSION

The incorporation of HRME into an ESCC screening program could be cost-effective in China. Larger studies of HRME performance are needed to confirm these findings.

Esophageal leiomyosarcoma: clinical analysis and surgical treatment of 12 cases

Leiomyosarcoma of the esophagus is a rare malignant tumor with slow growth and late metastasis. The aim of this study was to reassess the clinical characteristics and treatment modality in one of the largest series of esophageal leiomyosarcomas from a single institution. From February 1973 to December 2011, 12 cases of esophageal leiomyosarcoma were identified. The principal symptoms included progressive dysphagia in 11 cases (91.7%), retrosternal/back pain in four (33.3%), weight loss in four (33.3%), upper gastrointestinal hemorrhage in two (16.7%), and emesis in two (16.7%). The average duration of symptoms was 10.6 months. The location of the primary tumor was in the middle thoracic esophagus in five cases, and lower thoracic esophagus in seven cases. Six cases were classified as the polypoid type, five cases as the infiltrative type, and only one case as the intramural type. All 12 of the patients underwent esophagectomies, and radical resections were achieved in these patients. Based on the Kaplan-Meier Method, the 3-, 5-, and 10-year survival rates were 80.0%, 58.3%, and 31.1%, respectively, with a median survival of 63 months. Five-year survival rates for patients with polypoid or intramural tumors (n = 7) was 83.3%, and for patients with infiltrative tumor (n = 5) it was 25.0%. One of the patients had tumor resected four times and survived for 161 months. In conclusion, patients presenting with esophageal leiomyosarcomas have an excellent prognosis, and radical resection may achieve acceptable results.

Adjuvant chemotherapy after esophagectomy: is there a role in the treatment of the lymph node positive thoracic esophageal squamous cell carcinoma?

BACKGROUND

Esophageal squamous cell carcinoma (ESCC) patients with regional lymph node metastases have poor prognosis after surgery. The purpose of this study was to investigate the impact of various treatment modalities on survival in these patients.

METHODS

We retrospectively reviewed data from 349 patients who had undergone left transthoracic esophagectomy for thoracic ESCC from January 2008 to December 2010 at our institute. All patients had lesions in the mid or lower third of the thoracic segment and had pathological positive lymph node metastasis. Of these patients, 143 patients received surgery alone, 154 patients underwent postoperative radiotherapy alone, and 52 patients underwent taxane-based chemotherapy. Univariate and multivariate Cox regression analyses were used to analyze prognostic factors and survival.

RESULTS

At a median follow-up of 53.1 months, the 3-year OS were 47.7% for the patients with surgery alone, 44.0% for the patients with adjuvant radiotherapy, and 58.9% for the patients with adjuvant chemotherapy. Multivariate analysis showed that postoperative therapy with adjuvant chemotherapy was significant positive predictor of survival.

CONCLUSIONS

Postoperative taxane-based adjuvant chemotherapy improved survival of patients with lymph node positive thoracic ESCC compared with surgery alone. Further randomized prospective studies to confirm these findings are warranted.

Genome-wide association study identifies common variants in SLC39A6 associated with length of survival in esophageal squamous-cell carcinoma

We conducted a genome-wide scan of SNPs to identify variants associated with length of survival in 1,331 individuals with esophageal squamous-cell carcinoma (ESCC), with associations validated in 2 independent sets including 1,962 individuals with this cancer. We identified rs1050631 in SLC39A6 as associated with the survival times of affected individuals, with the hazard ratio for death from ESCC in the combined sample being 1.30 (95% confidence interval (CI) = 1.19-1.43; P = 3.77 × 10(-8)). rs7242481, located in the 5' UTR of SLC39A6, disturbs a transcriptional repressor binding site and results in upregulation of SLC39A6 expression. Immunohistochemical staining of ESCC tissues showed that higher expression of SLC39A6 protein was correlated with shorter length of survival in individuals with advanced ESCC (P = 0.013). Knockdown of SLC39A6 expression suppressed proliferation and invasion in ESCC cells. These results suggest that SLC39A6 has an important role in the prognosis of ESCC and may be a potential therapeutic target.

Mucin 1 and vascular endothelial growth factor C expression correlates with lymph node metastatic recurrence in patients with N0 esophageal cancer after Ivor-Lewis esophagectomy

BACKGROUND

The purpose of the present study was to investigate the risk factors associated with lymph node metastatic recurrence in patients with N0 esophageal cancer after Ivor-Lewis esophagectomy based on the detection of Mucin 1 mRNA and vascular endothelial growth factor (VEGF) C mRNA.

METHODS

The subjects were 82 patients with pN0 esophageal cancer who underwent Ivor-Lewis esophagectomy with two-field lymph node dissection from January 2001 to January 2005. A total of 501 lymph nodes obtained from these patients were re-evaluated by reverse transcriptase-polymerase chain reaction (RT-PCR) to detect mucin l (MUC1) mRNA; VEGF-C mRNA was also detected in esophageal cancer issues by RT-PCR. The diagnosis of lymph node micrometastasis (LNMM) was based on the detection of MUC1 mRNA. The Kaplan-Meier method was used to calculate the survival rate and lymph nodal metastatic rate, the log-rank test was performed to compare the recurrence rate, and Cox regression multivariate analysis was performed to determine independent prognostic factors.

RESULTS

MUC1 mRNA was detected in 29 lymph nodes from 23 patients, which accounted for 5.79% of all the 501 lymph nodes and 28.05% of all 82 patients, respectively. Vascular endothelial growth factor C mRNA was identified in esophageal cancer issues from 42 (51.22%) patients. The overall 3- and 5-year survival rates of 82 patients were 78.0 and 51.2%, respectively. First recurrence exhibiting lymph nodal metastasis was recognized in 37 patients (45.1%) in the first 3 years after operation. The lymph node metastatic rate in patients in the first 3 years after operation was significantly associated with T status (p < 0.05) and the lymph node metastatic rate of the patients with LNMM was significantly higher than that of the patients without LNMM (p < 0.01). The lymph node metastatic rate of the patients with VEGF-C mRNA expression in esophageal cancer tissues was significantly higher than that of the patients without VEGF-C mRNA expression (p < 0.01).The results of multivariate analysis confirmed that VEGF-C mRNA expression in esophageal cancer tissues, LNMM, and T status in patients with N0 esophageal cancer were independent relevant factors for 3-year lymph node metastatic recurrence after Ivor-Lewis esophagectomy.

CONCLUSIONS

Vascular endothelial growth factor C mRNA expression in esophageal cancer tissues, LNMM, and T status in patients with N0 esophageal cancer were independent risk factors for 3-year lymph node metastatic recurrence after Ivor-Lewis esophagectomy. Adjunctive therapy might be beneficial in controlling the locoregional recurrence and elevated healing rates for certain patients.

Clinical study on lymph node metastatic recurrence in patients with N0 esophageal squamous cell cancer

Esophageal squamous cell cancer (ESCC) is one of the most common malignancies treated by thoracic surgeons. It is aggressive and generally associated with a poor prognosis. One of the most important prognostic factors is the presence of the lymph node metastasis (LNM). The purpose of the present study was to investigate the risk factor with lymph node metastatic recurrence in patients with N0 esophageal squamous cancer after Ivor Lewis esophagectomy based on the detection of mucin1 (MUC1) mRNA. The subjects were 82 patients with pN0 ESCC who underwent Ivor Lewis esophagectomy with two-field lymph node dissection from January 2001 to January 2005. All lymph nodes (501 stations) obtained from these patients were reevaluated by reverse transcriptase-polymerase chain reaction (RT-PCR) to detect MUC1mRNA. The diagnosis of lymph node micrometastasis (LNMM) was based on the detection of MUC1 mRNA. The Kaplan-Meier method was used to calculate the survival rate and lymph nodal metastatic rate. Log-rank test was performed to compare the recurrence rate, and Cox regression multivariate analysis was performed to determine independent prognostic factors. The overall 3-year survival rates of 82 patients were 78.0%, and the first recurrence exhibiting lymph nodal metastasis was recognized in 37 patients (45.1%) in the first 3 years after operation. Lymph node metastatic rate in patients in the first 3 years after operation was significantly associated with the T status (P < 0.05). MUC1 mRNA was identified in at least one lymph node station from 23 (28.1%) patients. Also, lymph node metastatic rate of the patients with LNMM was significantly higher than that of the patients without LNMM (P < 0.01).The results of multivariate analysis confirmed that LNMM and T status in patients with N0 ESCC were independent risk factors for 3-year lymph node metastatic recurrence after Ivor Lewis esophagectomy. Adjunctive therapy might be beneficial in controlling the locoregional recurrence and elevated healing rates for certain patients.

Defining cure for esophageal cancer: analysis of actual 5-year survivors following esophagectomy

BACKGROUND

Esophagectomy is the mainstay of curative treatment for localized esophageal cancer. However, what constitutes cure is not well defined. This study was undertaken to characterize actual 5-year survivors following esophagectomy and to determine prognostic factors for disease-specific survival (DSS) from 60 months.

MATERIALS AND METHODS

Between 1987 and 2004, 398 consecutive patients underwent esophagectomy and had potential for 5 years follow-up. Clinicopathological factors associated with DSS from 5 years onward were analyzed.

RESULTS

Median DSS was 25 months. Neoadjuvant therapy was administered to 159 of 398 (40%). There were 114 of 398 (29%) actual 5-year survivors. On multivariate analysis, 5-year survivors were significantly more likely to have lower T classification, N classification, and R0 resections compared with patients who died less than 5 years after surgery. There were 66 of 398 patients (17%) with positive margins, and 6 of these were 5-year survivors. Of the 114 5-year survivors, 17 (15%) subsequently died of esophageal cancer. Prognostic factors for DSS after surviving 5 years were age and T classification for patients treated with neoadjuvant therapy and surgery alone, respectively. Powerful prognostic factors from time of treatment, including nodal status, were no longer prognostic factors after surviving to 5 years.

CONCLUSIONS

No single clinicopathological variable negated survival to 5 years. Prognostication once surviving 5 years is difficult. The majority of 5-year survivors can be considered cured of esophageal cancer.

Esophagoplasty using previously resected stomach proposed by A.A. Rusanov: history and the current state

To perform esophageal reconstruction in patients after distal gastrectomy colonic or jejunal transplant is usually used. But the use of remnant stomach in esophagoplasty appears to be an interesting idea. This method preserves some advantages of esophagogastroplasty as such. It is possible to pull-up the remnant stomach to the needed level, using mobilization with the spleen and pancreatic tail and its transposition into the left pleural cavity. This type of esophageal replacement, currently widely adopted in China, was proposed and first performed in 1958 by Professor A.A. Rusanov from Russia (former USSR). Different aspects of this method including historical are discussed in the literature review.

Current trends in extended lymph node dissection for esophageal carcinoma

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Risk analysis in resection of thoracic esophageal cancer in the era of endoscopic surgery

BACKGROUND

Surgical outcomes after thoracoscopic esophagectomy were compared with those after open esophagectomy, and the prognostic values of factors potentially related to mortality and morbidity were evaluated.

METHODS

We performed a retrospective chart review of 153 patients who underwent esophagectomy for thoracic esophageal cancer. The thoracic surgical procedures were categorized into the following three groups: esophagectomy under standard thoracotomy (n = 37), assisted thoracoscopic esophagectomy with utility minithoracotomy (n = 38), and complete thoracoscopic esophagectomy (n = 78). Mortality and morbidity were compared among the three groups. Then, in a separate multivariate analysis, data on 14 potentially prognostic variables were extracted, and the relation to postoperative outcomes was examined.

RESULTS

Respiratory complications were the most frequent complications in all three groups, and their rate of occurrence was not significantly among the three groups. The 30-day and in-hospital mortality rates were significantly higher in the open group than in the other groups. Multivariate analysis demonstrated that patient age, sex, induction chemoradiation, and forced expiratory volume were independently significant contributing factors for respiratory complications, while the serum total protein concentration and open esophagectomy were significant factors for in-hospital mortality.

CONCLUSIONS

Our results demonstrated that respiratory complications are still the main cause of operative morbidity when using the thoracoscopic esophagectomy protocol and that use of the thoracoscopic procedure does not decrease the risk of respiratory complications. The use of the thoracoscopic procedure improved postoperative in-hospital mortality. The advantages of thoracoscopic esophagectomy should be investigated further. At this point in time, however, thoracoscopic esophagectomy can be considered a feasible, safe, and advantageous surgical option.

A comparison of transhiatal and transthoracic resections on the prognosis in patients with squamous cell carcinoma of the esophagus

AIM

The aim of this study was to investigate the long-term prognosis for squamous cell carcinoma of the esophagus treated either by the transhiatal (TH) or by the transthoracic (TT) operative approach.

PATIENTS AND METHODS

Two hundred and twenty-nine patients (median age: 56 (29-84) years) with squamous cell carcinoma of the esophagus underwent esophageal resection between September 1985 and April 2004. In 70 patients, the transhiatal approach and in 159, the transthoracic approach was applied. An extended mediastinal lymph-node dissection was only carried out in the course of the transthoracic technique.

RESULTS

Demographic data and tumor stages were comparable in both groups. A significantly better long-term survival was observed in patients with transthoracic approach for those who had undergone curative procedures (R0) (24 versus 13 months), as well as for those either without (pN0) (38 versus 14 months) or with lymph-node involvement (pN1), and for those with > or =16 (=median) dissected thoracic lymph nodes (25 versus 12 months) (p<0.05*). Patients with regional lymph-node involvement (pN1) were seen to have a significant prognostic advantage in cases with more than 16 (=median), rather than less than 16 mediastinal lymph nodes resected (p=0.045*).

CONCLUSION

The prognosis in patients with squamous cell carcinoma of the esophagus is influenced by the number of dissected mediastinal lymph nodes. Patients with regional lymph-node involvement appear to benefit from an extended lymphadenectomy, in spite of the higher rate of complications and mortality associated with this procedure.

Immediate preoperative laparoscopic staging for squamous cell carcinoma of the esophagus

BACKGROUND

Conventional preoperative staging for esophageal carcinoma could be inaccurate. Laparoscopy has been applied for the staging of various upper gastrointestinal malignancies. It can identify peritoneal and liver deposits not shown by imaging, and could reduce the number of nontherapeutic laparotomies. This study aimed to evaluate the efficacy of laparoscopic staging for the management of squamous cell carcinoma involving the mid and distal esophagus.

METHODS

A retrospective review was performed for all patients with esophageal cancer evaluated for surgical resection from January 1998 to January 2004. Laparoscopy was performed for all the patients with mid and distal esophageal cancer immediately before open gastric mobilization. The efficacy of laparoscopy for the management of squamous cell carcinoma of the esophagus was evaluated.

RESULTS

Among the 63 patients with potentially resectable disease shown on conventional imaging, 54 (84%) underwent esophagectomy with curative intent after laparoscopic staging. Seven patients (11%) underwent laparoscopy alone because of abdominal metastases (n = 5) or other medical conditions (n = 2) that precluded esophagectomy. Two patients (3%) had exploratory right thoracotomy without esophagectomy despite normal laparoscopic findings. The sensitivity and specificity of laparoscopic staging were 100% in this series of patients (100% sensitivity and specificity means no false-positives or -negatives).

CONCLUSION

Laparoscopic staging is valuable for the management of patients with mid and distal squamous cell carcinoma of the esophagus. Patients with metastatic disease and those with prohibitive surgical risk can thus avoid unnecessary laparotomy and be offered other treatment methods.

[Preoperative evaluation of prognostic factors in esophageal squamous cell cancer]

Despite substantial improvements in the surgical therapy of esophageal squamous cell cancer, the prognosis still remains poor. This is mainly due to locally advanced tumors (T3-4, N+) or systemic metastases (M1) in the majority of patients at initial presentation. It is of the utmost importance to reliably detect relevant pretherapeutic prognostic indicators for optimal individual therapeutic strategies. Pretherapeutic prognostic indicators should therefore discriminate precisely between incurable and potentially curative disease. Preoperative or definitive multimodal treatment is increasingly being offered to patients with locally advanced tumors and opens a broad field for innovative techniques such as pretherapeutic molecular response prediction or early response detection by PET scan to further individualize and optimize treatment strategies.

Chirurgie réparatrice en cancérologie ORL : principales méthodes et indications

Oncologic cervicofacial surgery and plastic surgery have had a common evolution over the last 50 years where progress erasing from one was beneficial to the other one. We review here the historical evolution of these specialties and present the state of the art of plastic surgery in the field of cervicofacial oncology.

Long-term effect on carcinoma of esophagus of distal subtotal gastrectomy

AIM: To investigate the surgical treatment and long-term survival for patients with carcinoma of esophagus after distal subtotal gastrectomy.

METHODS: Resections of the tumor through left thoracotomy were performed in 85 patients with esophageal carcinoma following distal subtotal gastrectomy. The procedure involved preserving the left short gastric artery and transporting the residual stomach, the spleen and tail of the pancreas into the left thoracic cavity, and using the residual stomach to reconstruct the alimentary tract.

RESULTS: The resectable rate was 91.8%, complication rate 10.3%, and no death occurred in the postoperative period. The 1-, 3-, 5-, and 10-year survival rates were 85.7%, 50.7%, 30.6% and 18.8%, respectively.

CONCLUSION: Surgical resection is the optimal management method for the patients with esophageal carcinoma after distal subtotal gastrectomy. The reconstruction of digestive tract using anastomosis of the esophagus and the residual stomach is not only simple but also can achieve a better curative effect, promoting the digestive function and improving the quality of life.

Therapeutic options for esophageal cancer

Options for the treatment of esophageal cancer used to be very limited, with surgical resection and radiotherapy methods aimed at both cure or palliation, and, in those unfortunate patients with severe dysphagia, intubation with a plastic prosthesis to restore esophageal luminal patency. Progress in the management of this cancer in the past two decades includes refinement in surgical techniques and perioperative care, better radiological staging methods, enhanced means of planning and delivering radiotherapy, multimodality treatments, and better designs in esophageal prosthesis. For individual patients, a stage-directed therapeutic plan can be used. Long-term survival, however, remains suboptimal for this deadly disease. The current review presents an overview of the commonly employed therapeutic options for esophageal cancer at the beginning of the 21st century.

Analysis of pulmonary complications after three-field lymph node dissection for esophageal cancer

BACKGROUND

Pulmonary complications are a major component of morbidity and mortality after esophagectomy, and have not been well studied after extended lymphadenectomy.

METHODS

Four hundred forty-one patients underwent three-field lymph node dissection and were retrospectively reviewed. Pulmonary complications developed in 32 patients (7.3%) and resulted in 11 deaths (34.4% of pulmonary complications were fatal, and 62.4% of all mortality was caused by pulmonary complications). Pulmonary complications were divided into primary (group A) and secondary pulmonary morbidities (group B), and analyzed separately. Perioperative arterial blood gases on room air were compared with a matched control group (group C).

RESULTS

All primary complications occurred in the first postoperative week, whereas secondary complications were distributed evenly after operation. The incidence of serious infection (60% versus 23.5%, p = 0.041) and respiratory failure (70.6% versus 31.6%, p = 0.045) was significantly higher in group B as compared with group A and was associated with a higher death rate (47.1% versus 15.8%, p = 0.047). Changes in arterial blood gases were similar in groups A and C, both PaO(2) and pH were reduced in group B, and PaCO(2) was increased. Independent risk factors for primary pulmonary complications were history of major operation, abnormal spirometry, and chronic renal dysfunction. Predictive factors for secondary pulmonary complications were old age, concomitant total gastrectomy, major anastomotic leakage, and bilateral vocal cord palsy.

CONCLUSIONS

Pulmonary complications can be kept at a low level, but they still account for most of the mortality after three-field lymph node dissection. Primary and secondary pulmonary complications are two distinct entities that should be managed differently. Arterial blood gases on room air are helpful in the management of pulmonary complications.

Derivação retroesternal com tubo gástrico isoperistáltico no carcinoma irressecável de esôfago

OBJETIVO: Avaliar o benefício do tratamento paliativo pela derivação esofágica com o tubo gástrico isoperistáltico em pacientes com carcinoma de esôfago irressecável. MÉTODO: Foram estudados 53 pacientes com carcinoma espino celular do esôfago sem condições de ressecabilidade avaliados por critérios endoscópicos e radiológicos. A maioria dos pacientes era do sexo masculino com idade média de 56,8 anos. A operação realizada foi a derivação esofágica com o tubo gástrico isoperistáltico, de grande curvatura e transposto através do espaço retro esternal. RESULTADOS: Vinte e oito pacientes (52,0%) desenvolveram uma ou mais complicações, sendo a mais freqüente a deiscência e/ou estenose da anastomose cervical (15 pacientes - 28,3%). Em 48 pacientes que sobreviveram, 37 (77,0%) referiram alívio da disfagia no seguimento pós-operatório. A média de sobrevida em 23 pacientes foi de sete meses e meio (seis a 13 meses) e 14 pacientes estão em seguimento com o tempo variável entre dois e 16 meses, com boa evolução, com perda de seguimento nos 11 pacientes restantes. CONCLUSÕES: Tubo gástrico isoperistáltico tem aceitável morbidade e mortalidade para a população em estudo, permitindo paliação da disfagia na maioria dos casos.

Changing disease burden and management issues for esophageal cancer in the Asia-Pacific region

The changing epidemiology of esophageal cancer in developed countries is from squamous cell type to adenocarcinomas arising from Barrett's epithelium and the gastric cardia. This has implications for management of this disease. Earlier diagnosis of cancer from screening high-risk patients with Barrett's esophagus is potentially possible, and mucosal ablation together with acid-suppressive therapies have been investigated to revert Barrett's epithelium in its premalignant stage. When a cancer has developed, the strategies of staging methodology and surgical approaches also differ from those applicable for squamous cell cancers located in more proximal locations of the esophagus. By contrast, in the Asia-Pacific region (with the exceptions of Australia and New Zealand), squamous cell cancers in the middle portion of the esophagus remain the main cell type seen. An overall increase in life expectancy has led to more elderly patients presenting with carcinoma of the esophagus. This is of particular importance when surgical resection is contemplated. Advances in surgical management, multimodality programs, and endoscopic therapies are most marked in recent years. Treatment for patients with esophageal cancer should be individualized. The choice depends on expertise and facilities available, tumor and patient factors, and local economics.

Pulmonary complications after esophagectomy

BACKGROUND

Pulmonary complications are common in patients who have undergone esophagectomy. There are no good predictive variables for these complications. In addition, the role that preoperative treatment with chemotherapy and radiation may play in postoperative complications remains unclear.

METHODS

We performed a retrospective review of all patients who underwent esophagectomy by a single surgeon at our institution over a 6-year period. Data were analyzed for a correlation between patient risk factors and pulmonary complications, including mortality, prolonged mechanical ventilation, and hospital length of stay.

RESULTS

Complete data were available on 61 patients. Nearly all patients had some pulmonary abnormality (eg, pleural effusion), although most of these were clinically insignificant. Pneumonia was the most common clinically important complication, and 19.7% of patients required prolonged ventilatory support. Significant risk factors identified included impaired pulmonary function, especially for patients with forced expiratory volume in 1 second (FEV1) less than 65% of predicted, preoperative chemoradiotherapy, and age.

CONCLUSIONS

Impaired lung function is a significant risk factor for pulmonary complications after esophagectomy. Patients with FEV1 less than 65% of predicted appear to be at greatest risk. There also seems to be an associated risk of preoperative chemoradiotherapy for pulmonary complications after esophagectomy.

Impact of splenectomy on the early outcome after oesophagectomy for squamous cell carcinoma of the oesophagus

AIM

Operative procedures for oesophageal malignancies are becoming more extensive and may result in fatal complications. Splenectomy compromises the immune system and can lead to increased susceptibility to infections. The aim of the present study was to report the early outcome of patients who underwent oesophagectomy and simultaneous splenectomy due to oesophageal squamous cell carcinoma (SCC).

METHODS

Pre-operative risks and post-operative morbidity and mortality in 135 patients who had undergone extensive oesophagectomy without simultaneous splenectomy for SCC of the thoracic oesophagus were compared with those of 14 patients who had undergone oesophagectomy associated with splenectomy.

RESULTS

Post-operative pneumonia, intra-abdominal abscess, post-operative sepsis and anastonotic leakage were significantly increased when splenectomy was added to the original operation. The incidence of in-hospital death was significantly higher among splenectomized than non-splenectomized patients (35.7% vs 8.1%, P<0.01). Pulmonary complications and leakage were the main causes of death. Multivariate analysis recognized splenectomy as an independent prognostic factor for in-hospital death following transthoracic oesophagectomy for SCC.

CONCLUSION

The addition of splenectomy to transthoracic oesophagectomy for oesophageal carcinoma can be a fatal combination. Preservation of the spleen should be the primary intention. In circumstances that necessitate splenectomy precautions should be taken to prevent post-operative infectious complications.

Cancer of the esophagus and gastro-esophageal junction: potentially curative therapies

The definition of potential curative tumors of the esophagus and gastro-esophageal junction remains problematic. This is due to a lack of accuracy in clinical staging despite recent advances in CT, endoscopic ultrasonography (EUS), positron emission tomography scan and minimally invasive staging modalities. As a result much controversy persists regarding indications for surgery and extent of resection and lymphadenectomy. Today surgery with curative option results in five-year survival of over 30%. Multimodality regimens, especially neoadjuvant chemoradiotherapy, seem to be beneficial in patients with a complete response on pathologic staging. Other indications are investigational and should be studied within carefully monitored study protocols. In early carcinoma T(is)-T(1a) endoluminal ablation technique seem to open promising perspectives provided of discrimination between T(is)-T(1a) and T(1b) can be made by the use of 20mhz EUS probes.

Pretreatment surgical lymph node staging predicts results of trimodality therapy in esophageal cancer

OBJECTIVE

Prediction of responders to induction therapy in esophageal cancer (EC) patients is important. In this study, we evaluated the role of thoracoscopic/laparoscopic (Ts/Ls) staging in prediction of treatment response and survival in EC patients with trimodality treatment.

METHODS

Retrospective study of EC patients who had undergone Ts/Ls staging and received trimodality treatment at the University of Maryland Medical Center and the Baltimore Veterans Administration Hospitals from July, 1991 to December, 1999. Preoperative therapy consisted of concurrent chemotherapy (5-FU + cisplatinum) and radiotherapy.

RESULTS

Forty-four EC patients who underwent pretreatment Ts/Ls staging during the study period were able to complete concurrent chemoradiotherapy followed by surgical resection. There were 36 men and 8 women aged 40 to 77 (median age 62). Twenty-seven (61.4%) patients were found to have lymph node metastasis by surgical staging. Fourteen patients (31.8%) had a pathologic complete response. Patients with positive lymph nodes had a lower response rate than those with negative lymph nodes (14.8% vs. 58.8%, P=0.006). Other clinicopathologic features including gender, weight loss, clinical TNM stage, surgical T stage, and histology did not correlate with treatment response. Univariate analysis showed that weight loss and treatment response were important prognostic factors for disease-free survival (P=0.01 and P=0.02, respectively). Histology, surgical N stage and surgical TNM stage appeared to be associated with prognosis (P=0.067-0.097). Multivariate analysis revealed that only surgical N status and weight loss were significant prognostic factors (P=0.05, and P=0.006, respectively).

CONCLUSIONS

Surgical Ts/Ls staging provides accurate evaluation of tumor spread in EC patients. Pretreatment N status was the single most important predictor of response to induction treatment as well as a reliable prognosticator of survival.

P53 gene protein overexpression predicts results of trimodality therapy in esophageal cancer patients

BACKGROUND

P53 protein overexpression in esophageal cancer and its correlation with response and survival after chemoradiation was retrospectively investigated.

METHODS

Pretreatment and resection specimens were stained by automatic p53 immunohistochemical staining technique.

RESULTS

P53 was expressed in 84.0% of esophagoscopy (EGD) biopsies; 71.4% of patients with metastasis of thoracoscopy/laparoscopy lymph nodes (TS/LS LN) identified by hematoxylin/eosin (H/E) were p53 (+); 14.2% of patients with negative TS/LS LN by H/E were p53 (+). Eleven out of 18 patients with p53 (+) in pretreatment EGD remained p53 (+) after chemoradiation; 38.8% of these patients had a pathological complete response (pCR). The median survival of this group was 15 months. Of 4 patients with p53 (-) pretreatment EGD, all of those were still p53 (-) after chemoradiation; 75% of these patients had pCR. The median survival was 30 months. In patients with p53 (+) TS/LS LN, 23% had a pCR after chemoradiation with a median survival of 16 months. In patients with p53 (-) TS/LS LN, 50.0% had a pCR with a median survival of 31.5 months.

CONCLUSIONS

P53 protein overexpression in pretreatment EGD and TS/LS LN may predict response to chemoradiation and survival in esophageal cancer patients.

Prognosis of esophageal squamous cell carcinoma: analysis of clinicopathological and biological factors

OBJECTIVE

Esophageal squamous cell carcinoma (ESCC) is rather common among the Chinese, but the therapeutic outcome is dismal. Knowledge of the prognostic factors in cancerous patients may influence therapeutic strategy. However, systemic analyses of clinicopathological and biological factors for patients with ESCC are few, and the results are controversial.

METHODS

Between 1985 and 1996, 117 patients undergoing en bloc esophagectomy and gastric substitution were enrolled. None had neoadjuvant treatment. Postoperative adjuvant therapy was provided for patients at and beyond stages IIa. Clinical responses were followed routinely. Flow cytometry was used to measure DNA ploidy and synthesis-phase fraction (SPF) of the resected esophageal tissues from all patients. Immunohistochemistry was also used to examine the expression of proliferating cell nuclear antigen (PCNA), epidermoid growth factor receptor (EGFR), HER-2/neu, and p53 in the pathological sections. Clinical correlation was evaluated by chi2 with Fisher's exact test, and survival by log-rank test.

RESULTS

The overall survival rates were 74% for 1 yr, 48% for 3 yr, and 38% for 5 yr. TNM tumor staging, the number of diseased lymph nodes (N < or = 3 or N > 3), degree of cell differentiation, DNA ploidy, SPF, and lymphovascular invasion were more useful than biological markers, such as PCNA, EGFR, HER-2/neu, and p53, for the prognosis of ESCC. Multivariate analysis revealed significant correlation of tumor staging and number of diseased lymph nodes with patient survival after surgery.

CONCLUSIONS

En bloc esophagectomy may provide a rather satisfactory survival rate for patients with early stage ESCC. However, for patients with distant lymph node metastasis and those with more than three lymph nodes involved, radical surgical resection, even combined with postoperative chemoradiotherapy, cannot improve survival. The prognostic value of biological markers, including PCNA, EGFR, HER-2/neu, and p53, however, is limited.

Surgical Approaches to Esophageal Cancer

BACKGROUND: Esophageal cancer is a highly lethal malignancy. Esophageal resection remains the primary treatment in most centers. A number of approaches to esophageal resection have been described. METHODS: The authors review the current approaches to esophageal resection and adjuvant therapy for esophageal cancer. RESULTS: Transthoracic, transhiatal, and minimally invasive techniques are currently employed in esophageal surgery for malignancy. A number of authors favor extended mediastinal and cervical lymphadenectomy in hopes of improving survival. Combined chemotherapy and radiotherapy in the neoadjuvant setting appears to offer some promise. CONCLUSIONS: No consensus of opinion exists regarding the optimal approach or extent of esophageal resection for cancer. Prospective, randomized trials of neoadjuvant therapy may determine its efficacy. Newer approaches may enhance quality of life.

[Late morbidity after esophagectomy for cancer: is partial esophagectomy preferred?]

PURPOSE

The aim of this study is to report late postoperative complications occurring after oesophagectomy for cancer over a 12-month period and to compare the incidence of these complications according to the level of the anastomosis.

PATIENTS AND METHOD

This study included 106 consecutive patients 51% with subtotal oesophagectomy (thoracic anastomosis), and 49% with total oesophagectomy (cervical anastomosis). The two groups were comparable for age, mean weight loss before surgery, life expectancy, number of positive margins, TNM grading, size and tumour differentiation.

RESULTS

Late morbidity concerned 67.9% of the 106 patients. Predominant complications were dysphagia (32.1% of the 106), gastro-esophageal reflux (25.5% of the 106), and diarrhoea (18.8% of the 106). Among all the factors causing dysphagia, evaluated by logistic regression, the level of anastomosis was only found significant with a 20.4% occurrence for thoracic anastomosis and 44.2% for cervical anastomosis (P = 0.012). All the other complications were similar in the two groups.

CONCLUSION

Functional results of oesophagectomy for cancer are poor. As partial oesophagectomy morbidity is lower, total oesophagectomy should not be proposed in all cases of oesophageal cancer.

Management of dysplasia in the columnar-lined esophagus

The management of patients with high-grade dysplasia in Barrett's esophagus is complex and controversial with regard to electing continued endoscopic biopsy surveillance until an early adenocarcinoma is detected or proceeding with partial esophagogastrectomy. Clinical recommendations to patients for either option should be individualized and based on several parameters reflecting patient and clinician factors. Available data on interpretational variation in the diagnosis of dysplasia; limitation of diagnostic errors with the use of a rigorous, systematic endoscopic biopsy protocol; new information on the apparent benign natural history of high-grade dysplasia in some patients; and the morbidity and mortality of esophageal resection all suggest that recommendation for continued endoscopic biopsy surveillance is an appropriate clinical practice in selected patients. Ongoing research investigations on high-grade dysplasia in Barrett's esophagus aim to reduce the potential for diagnostic errors, simplify cancer surveillance, and develop therapeutic interventions that are safer than but as effective as surgery.

Immunohistochemical detection of p53 and c-erbB-2 in oesophageal carcinoma; no correlation with prognosis

TNM staging of oesophageal cancer provides significant prognostic information but its clinical impact is limited as many patients present with advanced disease (i.e. T3N1). Additional prognostic markers may help separate those with 'good' and 'bad' prognosis tumours and so help with decisions such as selection for adjuvant therapy. p53 and c-erbB-2 overexpression may correlate with poor prognosis in oesophageal cancer, but this is uncertain. This study aimed to investigate the value of these biomarkers as prognostic indicators in resected oesophageal cancer. Two hundred and five oesophageal tumours (127 adenocarcinoma, 78 squamous) resected by a single surgeon between June 1979 and January 1991 were investigated for p53 and c-erbB-2 overexpression using DO-7 and CB-11 immunohistochemistry. Patient survival was analysed by Kaplan-Meir life tables. Median survival was 61 weeks (range: 5-747) and survival diminished significantly with increasing UICC stage (P < 0.0001). Sixty-eight per cent of squamous tumours and 66% of adenocarcinomas overexpressed p53 but there was no statistically significant correlation with prognosis. Twenty-six per cent of squamous tumours and 23% of adenocarcinomas overexpressed c-erbB-2, but again this did not correlate with survival. p53 and c-erbB-2 are commonly overexpressed in oesophageal cancer but do not appear to be related to prognosis in this large series of resected oesophageal cancers and other candidate biomarkers must be sought.