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Sasaki M, Tamamura H, Tameshige Y, Azuma Y, Maeda Y, Matsushita K, Sato Y, Takamatsu S, Inoue K, Tabata Y, Yoshimura H, Yamamoto K. Dose Evaluation in 2-Phase Method for Advanced Esophageal Cancer by Hybrid Irradiation Techniques. Int J Part Ther 2024; 11:100010. [PMID: 38764603 PMCID: PMC11098852 DOI: 10.1016/j.ijpt.2024.100010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/10/2023] [Accepted: 12/18/2023] [Indexed: 05/21/2024] Open
Abstract
Purpose In concurrent chemoradiotherapy for advanced esophageal cancer, a 2-phase method consisting of initial irradiation of a wide elective nodal region and boost irradiation of the primary lesion is commonly employed. Although dose escalation to the primary lesion may be required to achieve higher local control rates, the radiation dose to critical organs must not exceed dose constraints. To achieve an optimum balance of dose prescription and dose reduction to surrounding organs, such as the lungs and heart, we compared hybrid dose distributions and investigated the best combination of the following recent irradiation techniques: volumetric modulation arc therapy (VMAT), proton broad-beam irradiation, and intensity-modulated proton beam therapy (IMPT). Materials and Methods Forty-five patients with advanced esophageal cancer whose primary lesions were located in the middle- or lower-thoracic region were studied. Radiotherapy plans for the initial and boost irradiation in the 2-phase method were calculated using VMAT, proton broad-beam irradiation, and IMPT calculation codes, and the dose-volume histogram indices of the lungs and heart for the accumulated plans were compared. Results In plans using boost proton irradiation with a prescribed dose of 60 Gy(RBE), all dose-volume histogram indices were significantly below the tolerance limits. Initial and boost irradiation with VMAT resulted in the median dose of V30 Gy(RBE)(heart) of 27.4% and an achievement rate below the tolerance limit of 57.8% (26 cases). In simulations of dose escalation up to 70 Gy(RBE), initial and boost IMPT resulted in the highest achievement rate, satisfying all dose constraints in 95.6% (43 cases). Conclusion Applying VMAT to both initial and boost irradiation is not recommended because of the increased risk of the cardiac dose exceeding the tolerance limit. IMPT may allow dose escalation of up to 70 Gy(RBE) without radiation risks to the lungs and heart in the treatment of advanced esophageal cancer.
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Affiliation(s)
- Makoto Sasaki
- Proton Therapy Center, Fukui Prefectural Hospital, Fukui, Japan
| | | | - Yuji Tameshige
- Proton Therapy Center, Fukui Prefectural Hospital, Fukui, Japan
| | - Yuya Azuma
- Kouseikai Proton Therapy Center, Nara, Japan
| | - Yoshikazu Maeda
- Proton Therapy Center, Fukui Prefectural Hospital, Fukui, Japan
| | | | - Yoshitaka Sato
- Proton Therapy Center, Fukui Prefectural Hospital, Fukui, Japan
| | - Shigeyuki Takamatsu
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Ishikawa, Japan
| | | | - Yoji Tabata
- Kouseikai Proton Therapy Center, Nara, Japan
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Wang XY, Fu XY, Yang H, Wen J, Lin P, Fu JH. Clinical value of station 4R node dissection in esophageal squamous cell carcinoma. World J Surg Oncol 2023; 21:387. [PMID: 38110961 PMCID: PMC10726609 DOI: 10.1186/s12957-023-03280-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 12/09/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND Many controversies still exist concerning the optimal extent of lymphadenectomy during esophagectomy in esophageal squamous cell carcinoma (ESCC). The objective of this study was to explore the characteristics of 4R metastasis and evaluate the clinical value of 4R node dissection in ESCC. METHODS A total of 736 ESCC patients who underwent radical esophagectomy between 2005 and 2013 were retrospectively collected, among which 393 ones underwent 4R dissection. Propensity score matching (PSM) method was applied to reduce the effects of confounding variables between the 4R dissection and non-dissection groups to analyze overall survival. RESULTS Patients showed a low 4R metastasis rate of 5.1% (20/393) (5.2%, 5.8%, and 1.8% for upper, middle, and lower tumors, respectively). Correlation analyses identified that 4R metastasis was significantly associated with station 2R metastasis (p < 0.001) and pathologic tumor-node-metastasis (pTNM) stage (p < 0.001). All 4R metastases were observed in stages IIIB and IVA. Moreover, patients with station 4R dissection failed to achieve significantly improved overall survival compared with those without 4R dissection, regardless of tumor stage (overall: p = 0.696; stage 0-IIIA: p = 0.317; stage IIIB-IVA: p = 0.619). CONCLUSION 4R metastasis is likely to be associated with more aggressive disease, and routine 4R node dissection might not be necessary for ESCC patients.
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Affiliation(s)
- Xin-Ye Wang
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, China
- Guangdong Esophageal Cancer Institute, Collaborative Innovation Centre of Cancer Medicine, State Key Laboratory of Oncology in South China, Guangzhou, 510060, China
| | - Xia-Yu Fu
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, China
- Guangdong Esophageal Cancer Institute, Collaborative Innovation Centre of Cancer Medicine, State Key Laboratory of Oncology in South China, Guangzhou, 510060, China
| | - Hong Yang
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, China
- Guangdong Esophageal Cancer Institute, Collaborative Innovation Centre of Cancer Medicine, State Key Laboratory of Oncology in South China, Guangzhou, 510060, China
| | - Jing Wen
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, China
- Guangdong Esophageal Cancer Institute, Collaborative Innovation Centre of Cancer Medicine, State Key Laboratory of Oncology in South China, Guangzhou, 510060, China
| | - Peng Lin
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, China
- Guangdong Esophageal Cancer Institute, Collaborative Innovation Centre of Cancer Medicine, State Key Laboratory of Oncology in South China, Guangzhou, 510060, China
| | - Jian-Hua Fu
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, China.
- Guangdong Esophageal Cancer Institute, Collaborative Innovation Centre of Cancer Medicine, State Key Laboratory of Oncology in South China, Guangzhou, 510060, China.
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Lin K, Li B, Sun Y, Hu H, Zhang Y, Xiang J, Chen H. Precise pattern of lymphatic spread of esophageal squamous cell carcinoma: results of 1074 patients with N1 disease. J Cancer Res Clin Oncol 2023; 149:15819-15825. [PMID: 37668800 DOI: 10.1007/s00432-023-05359-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/27/2023] [Indexed: 09/06/2023]
Abstract
PURPOSE The route of lymphatic spread in esophageal cancer remains unclear. The present study aimed to determine the pattern of lymphatic metastasis in its early stages. METHODS The data were reviewed of 1074 patients who underwent curative esophagectomy for thoracic esophageal squamous cell carcinoma and metastasis in 1-2 lymph nodes between January 2015 and December 2021. The frequencies of lymph node metastasis were analyzed by the anatomic sites and regions involved. RESULTS Of the 1074 patients, 668 patients (62.2%) with one positive lymph node and 406 (37.8%) with two positive lymph nodes. Paracardial lymph nodes were the most frequently involved nodes (35.1%), followed by right thoracic recurrent nerve nodes (24.0%), middle thoracic paraesophageal nodes (14.7%), left thoracic recurrent nerve nodes (10.4%), subcarinal nodes (8.0%), lower thoracic paraesophageal nodes (7.8%), and upper thoracic paraesophageal nodes (5.7%). The frequency of lymph node metastasis in other sites was less than 3%. The majority of lymph node metastases occurred in the longitudinal direction to the perigastric (36.5%) and bilateral recurrent nerve regions (33.4%) and in the transverse direction to the paraesophageal region (27.7%). As the tumor location changed from the upper to the lower thoracic esophagus, the frequencies of lymph node metastasis decreased in the bilateral recurrent nerve region but increased in the perigastric region. CONCLUSION Bilateral recurrent nerve nodes, paraesophageal lymph nodes, and perigastric nodes were the most common sites of early lymph node metastasis. Esophageal squamous cell carcinoma involves more longitudinal than transverse lymph node metastases.
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Affiliation(s)
- Kailin Lin
- Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, 270 Dong'an Rd, Shanghai, 20032, China
- Institute of Thoracic Oncology, Fudan University, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Bin Li
- Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, 270 Dong'an Rd, Shanghai, 20032, China
- Institute of Thoracic Oncology, Fudan University, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Yihua Sun
- Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, 270 Dong'an Rd, Shanghai, 20032, China
- Institute of Thoracic Oncology, Fudan University, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Hong Hu
- Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, 270 Dong'an Rd, Shanghai, 20032, China
- Institute of Thoracic Oncology, Fudan University, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Yawei Zhang
- Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, 270 Dong'an Rd, Shanghai, 20032, China
- Institute of Thoracic Oncology, Fudan University, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Jiaqing Xiang
- Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, 270 Dong'an Rd, Shanghai, 20032, China
- Institute of Thoracic Oncology, Fudan University, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Haiquan Chen
- Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, 270 Dong'an Rd, Shanghai, 20032, China.
- Institute of Thoracic Oncology, Fudan University, Shanghai, 200032, China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
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Wang Y, Yang W, Wang Q, Zhou Y. Mechanisms of esophageal cancer metastasis and treatment progress. Front Immunol 2023; 14:1206504. [PMID: 37359527 PMCID: PMC10285156 DOI: 10.3389/fimmu.2023.1206504] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
Esophageal cancer is a prevalent tumor of the digestive tract worldwide. The detection rate of early-stage esophageal cancer is very low, and most patients are diagnosed with metastasis. Metastasis of esophageal cancer mainly includes direct diffusion metastasis, hematogenous metastasis, and lymphatic metastasis. This article reviews the metabolic process of esophageal cancer metastasis and the mechanisms by which M2 macrophages, CAF, regulatory T cells, and their released cytokines, including chemokines, interleukins, and growth factors, form an immune barrier to the anti-tumor immune response mediated by CD8+ T cells, impeding their ability to kill tumor cells during tumor immune escape. The effect of Ferroptosis on the metastasis of esophageal cancer is briefly mentioned. Moreover, the paper also summarizes common drugs and research directions in chemotherapy, immunotherapy, and targeted therapy for advanced metastatic esophageal cancer. This review aims to serve as a foundation for further investigations into the mechanism and management of esophageal cancer metastasis.
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Affiliation(s)
- Yusheng Wang
- Department of Thoracic Surgery, The First People’s Hospital of Changzhou, Changzhou, Jiangsu, China
| | - Wei Yang
- Department of Gastroenterology, Kunshan Hospital of Traditional Chinese Medicine, Kunshan, Jiangsu, China
| | - Qianyun Wang
- Department of Gastroenterology, Kunshan Hospital of Traditional Chinese Medicine, Kunshan, Jiangsu, China
| | - Yong Zhou
- Department of Gastroenterology, Kunshan Hospital of Traditional Chinese Medicine, Kunshan, Jiangsu, China
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Zhong Z, Wang D, Liu Y, Shao S, Chen S, He S, Yang N, Li C, Ren J, Zhao Y, Wang Q, Wang G, Sun C, Zhang S. Lymph drainage and cervical fascia anatomy-oriented differential nodal CTV delineation at the supraclavicular region for esophageal cancer and nasopharyngeal cancer. Radiother Oncol 2022; 177:113-120. [PMID: 36336111 DOI: 10.1016/j.radonc.2022.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/05/2022] [Accepted: 10/30/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE To determine the differences in supraclavicular lymph node metastasis between esophageal cancer (EC) and nasopharyngeal cancer (NPC) and explore the feasibility of differential supraclavicular clinical target volume (CTV) contouring between these two diseases based on the involvement of different fascial spaces. MATERIALS AND METHODS One hundred patients with supraclavicular nodes positive for EC or NPC were enrolled, and their pre-treatment images were reviewed. The distribution patterns of nodes between the two diseases were compared in the context of node levels defined by the 2017 Japanese Esophageal Society and 2013 International Consensus on Cervical Lymph Node Level Classification. Grouping supraclavicular nodes based on sub-compartments formed by the cervical fascia was discussed, and the feasibility of differential CTV contouring based on the differences in the involvement of these sub-compartments between EC and NPC was explored. RESULTS The 2013 Consensus on cervical node levels and 2017 Japanese Esophageal Society node station could not practically guide supraclavicular CTV contouring. We divided the supraclavicular space into six sub-compartments: the para-esophageal space (PES), carotid sheath space (CSS), sub-thyroid pre-trachea space (STPTS), pre-vascular space (PVS), and vascular lateral space (VLS) I and II. EC mainly spread to the PES, STPTS, CSS, and VLS I, whereas NPC tended to spread to the CSS, VLS I, and VLS II. These combinations of sub-compartments may help constitute the supraclavicular CTVs for EC and NPC. CONCLUSIONS The fascia anatomy-based sub-compartments sufficiently distinguished metastasis to the supraclavicular space between EC and NPC, thus facilitating differential CTV contouring between these two diseases.
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Affiliation(s)
- Zuxian Zhong
- Graduate School, Chengdu Medical College, Chengdu, China; Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, School of Medicine, University of Electronic Science and Technology of China, Sichuan Cancer Center, Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, China
| | - Dan Wang
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, School of Medicine, University of Electronic Science and Technology of China, Sichuan Cancer Center, Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, China; Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yi Liu
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, School of Medicine, University of Electronic Science and Technology of China, Sichuan Cancer Center, Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, China; Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shilong Shao
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Sihao Chen
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, School of Medicine, University of Electronic Science and Technology of China, Sichuan Cancer Center, Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, China; Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shanshan He
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, School of Medicine, University of Electronic Science and Technology of China, Sichuan Cancer Center, Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, China; Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ningjing Yang
- Department of Radiology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Churong Li
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, School of Medicine, University of Electronic Science and Technology of China, Sichuan Cancer Center, Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, China
| | - Jing Ren
- Department of Radiology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yue Zhao
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, School of Medicine, University of Electronic Science and Technology of China, Sichuan Cancer Center, Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, China
| | - Qifeng Wang
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, School of Medicine, University of Electronic Science and Technology of China, Sichuan Cancer Center, Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, China
| | - Guotai Wang
- School of Mechanical and Electrical Engineering, University of Electronic Science and Technology of China, Chengdu, China
| | - Chuntang Sun
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children(Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Shichuan Zhang
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, School of Medicine, University of Electronic Science and Technology of China, Sichuan Cancer Center, Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, China; Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China.
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Yang Y, Li Y, Qin J, Zhang R, Chen X, He J, Gao S. Mapping of Lymph Node Metastasis From Thoracic Esophageal Cancer: A Retrospective Study. Ann Surg Oncol 2022; 29:5681-5688. [PMID: 35543907 DOI: 10.1245/s10434-022-11867-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/20/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES This retrospective study was designed to investigate the optimal extent of dissection for thoracic esophageal cancer (EC) based on the incidence of lymph node metastasis (LNM). METHODS We retrospectively identified 1014 patients with thoracic esophageal carcinoma who underwent esophagectomy at our institution between May 2018 and November 2020. Also, the location and rate of LNM in relation to the postoperative pathological results were retrieved. We separately counted the metastasis rates of routinely excised lymph node stations according to the Japan Esophageal Society (JES) staging system. RESULTS A total of 1666 consecutive patients were screened, and 1014 were enrolled. Generally, the rates of LNM in thoracic EC may be arranged in the descending order of station 7 > station 106recR > station 2 > station 106recL. Esophageal cancer in the middle and lower thoracic segment also had a high rate of LNM along bilateral recurrent laryngeal nerve. Stations 106tbL and 111 were the lowest frequent sites of metastasis with rate less than 5%; only the patients with clinically positive LNs need to dissect. The cT3-4, cN+, or G3 were independent risk factors for LNM and neoadjuvant therapy did not change the distribution of LNM for thoracic EC cases. CONCLUSIONS This study accurately identified the distribution of LNM for thoracic EC patients. Neoadjuvant therapy could not change the overall distribution of LNM in thoracic EC patients. However, whether LNs dissection at stations 106tbL and 111 is related to the survival of thoracic EC or not, needs a long follow-up time to verify.
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Affiliation(s)
- Yafan Yang
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yin Li
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Jianjun Qin
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Ruixiang Zhang
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiankai Chen
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie He
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shugeng Gao
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Chen X, Chen Y, Wang F, Liu S, Chen P, He H. Clinical value of lymph node dissection for stage T1b mid-thoracic esophageal squamous cell carcinoma. J Gastrointest Oncol 2021; 12:1223-1227. [PMID: 34532082 DOI: 10.21037/jgo-21-339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/18/2021] [Indexed: 11/06/2022] Open
Abstract
Background Surgery remains the mainstay of treatment for esophageal squamous cell carcinoma (ESCC), during which lymph node (LN) dissection, especially recurrent laryngeal nerve (RLN) LN dissection, is particularly important and challenging. This study aimed to investigate the LN metastasis of stage T1b mid-thoracic ESCC and explore the clinical value of RLN LN dissection. Methods The clinicopathological data of 254 patients with stage T1b mid-thoracic ESCC who underwent the McKeown procedure ("tri-incisional esophagectomy") and three-field LN dissection (3FD) at Fujian Cancer Hospital from January 2010 to December 2015 were retrospectively analyzed. The value of LN dissection (especially RLN LNs) was evaluated by calculating the metastasis rate of each LN station. The efficacy index (EI) of the dissection was calculated by multiplying the frequency (%) of metastases to a station and the 5-year survival rate (%) of patients with metastases to that station, and then dividing by 100. Results The stage T1b mid-thoracic ESCC had the highest rate of metastasis in the paracardiac LNs (4.3%), followed by RLN LNs (2.8%) and the left gastric artery LNs (2.8%). The 5-year survival rate was highest in patients who received lesser gastric curvature LN dissection (100%), followed by patients who underwent right RLN LN dissection (80%), and was 50% in patients who had undergone dissection of the left RLN LNs, upper paraesophageal LNs, subcarinal LNs, and left gastric artery LNs, respectively. In addition, dissection of the right RLN LNs had the highest EI value (2.2), followed by the dissection of LNs along the lesser curvature of the stomach (1.6) and left gastric artery LNs (1.4). Conclusions Right RLN LNs have a metastasis rate only lower than that of the paracardiac LNs, but could be the most valuable location for performing dissection.
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Affiliation(s)
- Xiaofeng Chen
- Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fujian Provincial Key Laboratory of Tumor Biotherapy, Department of Thoracic Tumor Surgery, Fujian Cancer Hospital, Fuzhou, China
| | - Yujie Chen
- Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fujian Provincial Key Laboratory of Tumor Biotherapy, Department of Thoracic Tumor Surgery, Fujian Cancer Hospital, Fuzhou, China
| | - Feng Wang
- Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fujian Provincial Key Laboratory of Tumor Biotherapy, Department of Thoracic Tumor Surgery, Fujian Cancer Hospital, Fuzhou, China
| | - Shuoyan Liu
- Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fujian Provincial Key Laboratory of Tumor Biotherapy, Department of Thoracic Tumor Surgery, Fujian Cancer Hospital, Fuzhou, China
| | - Peng Chen
- Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fujian Provincial Key Laboratory of Tumor Biotherapy, Department of Thoracic Tumor Surgery, Fujian Cancer Hospital, Fuzhou, China
| | - Hao He
- Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fujian Provincial Key Laboratory of Tumor Biotherapy, Department of Thoracic Tumor Surgery, Fujian Cancer Hospital, Fuzhou, China
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Chen S, Shi Y, Lu Z, Wang M, Cong L, Yang B, Chen X, Cai J, Yang X. Esophageal Carcinosarcoma: Analysis of Clinical Features and Prognosis of 24 Cases and a Literature Review. Cancer Control 2021; 28:10732748211004886. [PMID: 33998308 PMCID: PMC8204522 DOI: 10.1177/10732748211004886] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective: Esophageal carcinosarcoma (ECS) is a rare malignant tumor that accounts for only 0.5%-2.8% of all esophageal malignancies. As most current studies are case reports, the relationship between clinical features and prognosis remains controversial. Methods: We investigated the clinical features and prognosis of 24 patients with ECS in a single center from 2006 to 2018. There were 18 male and 6 female patients aged 52-82 years with a median age of 62.5 years. In addition, we included 9 studies on ECS from PubMed and a literature review. Results: The median follow-up time of the 24 patients was 70.5 (range, 10-156)months. The 3-year and 5-year survival rates were 83.3% and 70.8%, respectively. Among the 24 patients, none of the 10 (41.7%) stage T1 cancer patients had lymph node metastasis; however, lymph node metastasis was noted in 8 (57.1%) stage T2-4 cancer patients. The literature review revealed that 211 patients had a 5-year survival rate of 11.8%-68.2%, and 54.5%-95.8% study participants had early stage ECS. Although the information provided in the literature review is limited, it appears to be a characteristic of the early stage of the disease and predicts better prognosis when ECS is diagnosed, which is similar to the result of the current study. Conclusion: Our results indicate that ECS has a favorable prognosis, even among patients with early stage ECS who undergo radical esophagectomy with lymph node dissection. Because of the low incidence of ECS, further studies with more cases need to investigate this rare malignancy.
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Affiliation(s)
- Shusen Chen
- Department of Radiation Oncology, Nantong Tumor Hospital, Affiliated Tumor Hospital of Nantong University, Nantong, China
| | - Yu Shi
- Department of Radiation Oncology, Affiliated Hospital of Nantong University, Nantong, China
| | - Zhengjing Lu
- Department of Pediatrics, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Mingwei Wang
- Department of Radiation Oncology, Nantong Third People's Hospital, Nantong, China
| | - Longfei Cong
- Department of Oncology, Jiangsu Rudong County People's Hospital, Nantong, Jiangsu, China
| | - Baixia Yang
- Department of Radiation Oncology, Nantong Tumor Hospital, Affiliated Tumor Hospital of Nantong University, Nantong, China
| | - Xudong Chen
- Department of Pathology, Nantong Tumor Hospital, Affiliated Tumor Hospital of Nantong University, Nantong, China
| | - Jing Cai
- Department of Radiation Oncology, Nantong Tumor Hospital, Affiliated Tumor Hospital of Nantong University, Nantong, China
| | - Xi Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Wang Y, Ye D, Kang M, Zhu L, Yang M, Jiang J, Xia W, Kang N, Chen X, Wang J, Wang F. Mapping of Cervical and Upper Mediastinal Lymph Node Recurrence for Guiding Clinical Target Delineation of Postoperative Radiotherapy in Thoracic Esophageal Squamous Cell Carcinoma. Front Oncol 2021; 11:663679. [PMID: 33981612 PMCID: PMC8107680 DOI: 10.3389/fonc.2021.663679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/06/2021] [Indexed: 11/24/2022] Open
Abstract
Background The lower neck and upper mediastinum are the major regions for postoperative radiotherapy (PORT) in thoracic esophageal squamous cell carcinoma (TESCC). However, there is no uniform standard regarding the delineation of nodal clinical target volume (CTVnd). This study aimed to map the recurrent lymph nodes in the cervical and upper mediastinal regions and explore a reasonable CTVnd for PORT in TESCC. Methods We retrospectively reviewed patients in our hospital with first cervical and/or upper mediastinal lymph node recurrence (LNR) after upfront esophagectomy. All of these recurrent lymph nodes were plotted on template computed tomography (CT) images with reference to surrounding structures. The recurrence frequency at different stations was investigated and the anatomic distribution of recurrent lymph nodes was analyzed. Results A total of 119 patients with 215 recurrent lymph nodes were identified. There were 47 (39.5%) patients with cervical LNR and 102 (85.7%) patients with upper mediastinal LNR. The high-risk regions were station 101L/R, station 104L/R, station 106recL/R, station 105 and station 106pre for upper TESCC and station 104L/R, station 106recL/R, station 105, station 106pre and station 106tbL for middle and lower TESCCs. LNR in the external group of station 104L/R was not common, and LNR was not found in the narrow spaces where the trachea was in close contact with the innominate artery, aortic arch and mediastinal pleura. LNR below the level of the cephalic margin of the superior vena cava was also not common for upper TESCC. Conclusions The CTVnd of PORT in the cervical and upper mediastinal regions should cover station 101L/R, station 104L/R, station 106recL/R, station 105 and station 106pre for upper TESCC and station 104L/R, station 106recL/R, station 105, station 106pre and station 106tbL for middle and lower TESCCs. Based on our results, we proposed a useful atlas for guiding the delineation of CTVnd in TESCC.
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Affiliation(s)
- Yichun Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Dongmei Ye
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Mei Kang
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Liyang Zhu
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Mingwei Yang
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jun Jiang
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wanli Xia
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ningning Kang
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiangcun Chen
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jie Wang
- Department of Medical Imaging, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Fan Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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10
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Qie P, Yin Q, Xun X, Song Y, Zhou S, Liu H, Feng J, Tian Z. Long non-coding RNA SPRY4-IT1 as a promising indicator for three field lymph-node dissection of thoracic esophageal carcinoma. J Cardiothorac Surg 2021; 16:48. [PMID: 33757566 PMCID: PMC7988958 DOI: 10.1186/s13019-021-01433-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 03/16/2021] [Indexed: 01/04/2023] Open
Abstract
Background Esophageal squamous cell carcinoma(ESCC) is one of the most common tumors worldwide. Esophagectomy with three-field lymph node dissection(3FLND) is the radical surgical procedure for esophageal cancer. However, 3FLND is not widely used due to it’s higher mortality rate and higher incidence of postoperative complications. There is an urgent need to identify novel biomarkers that can guide the most proper lymph-node dissection in esophageal cancer patients. Method Ninety-two patients with thoracic ESCC undergoing 3FLND were enrolled into our study from the Department of Thoracic Surgery of the Fourth Hospital affiliated to the Hebei Medical University and Hebei General Hospital between Jun 2011 and Dec 2015. Retrospectively collected data from these 92 patients was used to explore the relationship between the lymph-node metastasis、recurrence and the SPRY4-IT1 expression level and to determine whether 3FLND should be performed in patients with thoracic ESCC. Results The findings revealed that the SPRY4-IT1 expression was significantly higher in esophageal cancer tissues than in adjacent noncancerous tissues. (P < 0.01). Furthermore, the high expression of SPRY4-IT1 was significantly correlated with tumor differentiation (P = 0.029), T classification (P = 0.013), lymph node metastasis(P = 0.022) and pathological stage (P = 0.001). The increased expression of SPRY4-IT1 was associated with a higher risk of cervical and superior mediastinal lymph-node metastasis(P = 0.039).However, no significant association was observed between the risk of cervical and superior mediastinal lymph-node recurrence and the SPRY4-IT1 expression level in the thoracic ESCC patients performed 3FLND(P = 0.509). Conclusions Our data support the assumption that the high expression of SPRY4-IT1 is associated with a high risk of lymph node metastasis and it has potential application as a indicator for guiding on three-field lymph node dissection in patients with thoracic ESCC. Randomized controlled trials with a large cohort of patients will be needed to confirm this conclusion in the future.
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Affiliation(s)
- Peng Qie
- Hebei Medical University, Shijiazhuang, 050017, Hebei Province, People's Republic of China
| | - Qifan Yin
- Hebei General Hospital, 348,West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Xuejiao Xun
- Hebei General Hospital, 348,West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Yongbin Song
- Hebei General Hospital, 348,West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Shaohui Zhou
- Hebei General Hospital, 348,West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Huining Liu
- Hebei General Hospital, 348,West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Junpeng Feng
- Hebei Chest Hospital, Shijiazhuang, 050041, Hebei Province, People's Republic of China
| | - Ziqiang Tian
- Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Shijiazhuang, 050035, Hebei Province, People's Republic of China. .,Thoracic Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050035, Hebei Province, People's Republic of China.
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11
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Li ZX, Li XD, Liu XB, Xing WQ, Sun HB, Wang ZF, Zhang RX, Li Y. Clinical evaluation of right recurrent laryngeal nerve nodes in thoracic esophageal squamous cell carcinoma. J Thorac Dis 2020; 12:3622-3630. [PMID: 32802441 PMCID: PMC7399419 DOI: 10.21037/jtd-20-774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background The accuracy of clinical N staging of esophageal squamous cell carcinoma is suboptimal. As an important station of lymph node metastasis, station C201 (right recurrent laryngeal nerve nodes) has rarely been evaluated alone. We aimed to explore an effective way to evaluate the right recurrent laryngeal nerve nodes in thoracic esophageal squamous cell carcinoma. Methods We retrospectively analyzed 628 thoracic esophageal squamous cell carcinoma patients who underwent radical resection without neoadjuvant therapy from two Chinese cancer centers. The diameter of the short axis of the largest right recurrent laryngeal nerve node (DC201) was measured on contrast-enhanced multi-slice computed tomography (MSCT). Right recurrent laryngeal nerve nodes were examined by postoperative pathologic results. The receiver operating characteristic (ROC) curve was generated to assess the diagnostic capabilities of DC201 to determine the right recurrent laryngeal nerve nodes status. Results ROC curve analysis revealed that the optimal cut-off point of DC201 was 6 mm, with an area under curve (AUC), sensitivity, specificity, and Youden index of 0.896, 71.9%, 88.8%, and 0.607 respectively. When the cut-off point of DC201 was set to 10 mm, sensitivity, specificity and the Youden index were 14.1%, 99.6% and 0.137 respectively. Among 128 patients with right recurrent laryngeal nerve node metastasis, 71 and 108 patients had the largest right recurrent laryngeal nerve node located above the suprasternal notch level and in the tracheoesophageal groove respectively. Conclusions When DC201 ≥6.0 mm instead of DC201 ≥10 mm was used to dictate the right recurrent laryngeal nerve nodes metastasis, contrast-enhanced MSCT could evaluate the status of right recurrent laryngeal nerve nodes with high sensitivity and specificity. The largest right recurrent laryngeal nerve nodes were mainly located in the tracheoesophageal groove and/or above the suprasternal notch.
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Affiliation(s)
- Zhen-Xuan Li
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiao-Dong Li
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangzhou, China
| | - Xian-Ben Liu
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Wen-Qun Xing
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Hai-Bo Sun
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Zong-Fei Wang
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Rui-Xiang Zhang
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Yin Li
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China.,Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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12
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Anomalies of the right vertebral vein increasing the difficulty of lymph-node dissection along the right recurrent laryngeal nerve: a single-institution, retrospective study. Esophagus 2020; 17:257-263. [PMID: 32088787 DOI: 10.1007/s10388-020-00723-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/09/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Radical lymph-node dissection along the recurrent laryngeal nerves (RLN) improves the prognosis of patients with esophageal cancer. The RLN is a landmark for achieving adequate lymph-node dissection. However, the right RLN is sometimes covered by the right vertebral veins (VVs), making it undetectable. We investigated the relationship between this anomaly of the right VVs and the challenges of performing lymphadenectomy along the right RLN. METHODS Patients with esophageal cancer, who underwent thoracoscopic esophagectomy with radical lymph-node dissection, were registered. The patterns of the right VVs were evaluated by preoperative computed tomography. The time required for identifying the right RLN or completing the lymphadenectomy was determined by reviewing surgical videos. RESULTS In total, 178 patients were enrolled. Eighty patients (45%) had right VVs passing dorsal to the right subclavian artery (Dorsal group). More time was required to detect the right RLN in these cases (11 vs 9.5 min for the other cases, p = 0.034). In the Dorsal group, there were 15 patients who had specific VV patterns: The right VV converged on the lower portion of the right brachiocephalic vein (BCV), or passed through to the more medial side of the mediastinum. These patients required more time for detecting the right RLN (25 vs 9 min, p < 0.0001) and for completing the lymphadenectomy (41 vs 32 min, p = 0.048) than the other cases. CONCLUSION The right VVs behind the subclavian artery, joining the lower part of the BCV or passing through the medial side, made it difficult to identify the right RLN and complete the lymphadenectomy.
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13
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Hagens ERC, van Berge Henegouwen MI, Gisbertz SS. Distribution of Lymph Node Metastases in Esophageal Carcinoma Patients Undergoing Upfront Surgery: A Systematic Review. Cancers (Basel) 2020; 12:cancers12061592. [PMID: 32560226 PMCID: PMC7352338 DOI: 10.3390/cancers12061592] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/09/2020] [Accepted: 06/12/2020] [Indexed: 12/16/2022] Open
Abstract
Metastatic lymphatic mapping in esophageal cancer is important to determine the optimal extent of the radiation field in case of neoadjuvant chemoradiotherapy and lymphadenectomy when esophagectomy is indicated. The objective of this review is to identify the distribution pattern of metastatic lymphatic spread in relation to histology, tumor location, and T-stage in patients with esophageal cancer. Embase and Medline databases were searched by two independent researchers. Studies were included if published before July 2019 and if a transthoracic esophagectomy with a complete 2- or 3-field lymphadenectomy was performed without neoadjuvant therapy. The prevalence of lymph node metastases was described per histologic subtype and primary tumor location. Fourteen studies were included in this review with a total of 8952 patients. We found that both squamous cell carcinoma and adenocarcinoma metastasize to cervical, thoracic, and abdominal lymph node stations, regardless of the primary tumor location. In patients with an upper, middle, and lower thoracic squamous cell carcinoma, the lymph nodes along the right recurrent nerve are often affected (34%, 24% and 10%, respectively). Few studies describe the metastatic pattern of adenocarcinoma. The current literature is heterogeneous in the classification and reporting of lymph node metastases. This complicates evidence-based strategies in neoadjuvant and surgical treatment.
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14
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Chao YK, Wen YW, Chuang WY, Cerfolio RJ. Transition from video-assisted thoracoscopic to robotic esophagectomy: a single surgeon's experience. Dis Esophagus 2020; 33:5480067. [PMID: 31022725 DOI: 10.1093/dote/doz033] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 03/23/2019] [Indexed: 12/11/2022]
Abstract
Lymph node dissection (LND) along the left recurrent laryngeal nerve (RLN) is a technically challenging part of esophageal cancer surgery, especially after chemoradiotherapy (CRT). Robotic surgery holds promise to increase its safety and feasibility. The aim of this study was to describe a single thoracoscopic surgeon's experience related to the transition from video-assisted esophagectomy (VATE) to robotic esophagectomy (RE)-with a special focus on the safety of left RLN LND. Patients who underwent minimally invasive esophagectomy and RLN dissection following CRT were dichotomized according to the use of robotic surgery (robotic esophagectomy [RE] versus video-assisted thoracoscopic esophagectomy [VATE]). The following parameters were determined: (1) number of dissected nodes, (2) rates of RLN palsy, (3) rates of perioperative complications, and (4) learning curve. Learning curve analysis was performed using the 10-patient moving average (MA) for operation times and with the cumulative sum (CUSUM) method for left RLN LND (target failure rate: 15%). The RE and VATE groups consisted of 39 and 67 patients, respectively. The intraoperative identification of the left RLN was more common in the RE group (97.4%) than in the VATE group (68.7%; P < 0.001). Postoperative left RLN palsy was significantly more frequent in the VATE group (26.9%) than in the RE group (10.3%; P = 0.042), with a higher rate of pneumonia in the former (16.4% versus 2.6%; P = 0.03). The MA chart revealed a downward trend followed by a flattening of the RE operation time at operation number 17 and 29, respectively. CUSUM analysis showed that the left RLN palsy rate decreased to the target rate after 12 operations. We conclude that at least 12 cases are required for a surgeon with prior experience in VATE to safely accomplish left RLN LND through a robotic approach.
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Affiliation(s)
- Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou
| | - Yu-Wen Wen
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou.,Clinical Informatics and Medical Statistics Research Center
| | - Wen-Yu Chuang
- Department of Pathology, Chang Gung Memorial Hospital-Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Robert J Cerfolio
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, USA
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15
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Gan X, Wang X, Zhang B, Cheng H, Zhong B, Zhong H, Li X, Cao Q. Lymphadenectomy Along Bilateral Recurrent Laryngeal Nerves Under Single-Incision Mediastinoscopy. Ann Thorac Surg 2020; 109:e449-e452. [PMID: 32035045 DOI: 10.1016/j.athoracsur.2019.12.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/02/2019] [Accepted: 12/15/2019] [Indexed: 12/11/2022]
Abstract
This report proposes an approach for lymphadenectomy along bilateral recurrent laryngeal nerves (RLNs) under mediastinoscopy through a single left-neck incision. After pneumomediastinum is established, esophagectomy is begun over the aortic arch to the level of the lower edge of the left main bronchus, and lymphadenectomy along the left RLN is also accomplished. At the level of the lower edge of the right subclavian artery, between the trachea and the esophagus, the instruments can gain access to the right RLN. The lymphadenectomy may be performed up to 2 cm above the upper edge of the right subclavian artery.
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Affiliation(s)
- Xiangfeng Gan
- Department of Cardiothoracic Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Sun Yat-Sen University, Zhuhai, China
| | - Xiaojin Wang
- Department of Cardiothoracic Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Sun Yat-Sen University, Zhuhai, China
| | - Bin Zhang
- Department of Cardiothoracic Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Sun Yat-Sen University, Zhuhai, China
| | - Hua Cheng
- Department of Cardiothoracic Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Sun Yat-Sen University, Zhuhai, China
| | - Beilong Zhong
- Department of Cardiothoracic Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Sun Yat-Sen University, Zhuhai, China
| | - Hongcheng Zhong
- Department of Cardiothoracic Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Sun Yat-Sen University, Zhuhai, China
| | - Xiaojian Li
- Department of Cardiothoracic Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Sun Yat-Sen University, Zhuhai, China
| | - Qingdong Cao
- Department of Cardiothoracic Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Sun Yat-Sen University, Zhuhai, China.
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16
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Chao YK, Chiu CH, Liu YH. Safety and oncological efficacy of bilateral recurrent laryngeal nerve lymph-node dissection after neoadjuvant chemoradiotherapy in esophageal squamous cell carcinoma: a propensity-matched analysis. Esophagus 2020; 17:33-40. [PMID: 31428901 PMCID: PMC7223830 DOI: 10.1007/s10388-019-00688-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 08/13/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND We sought to evaluate the safety and oncological efficacy of bilateral recurrent laryngeal nerve (RLN) lymph-node dissection (LND) in patients with esophageal squamous cell carcinoma (ESCC) who had undergone neoadjuvant chemoradiotherapy (nCRT). METHODS We retrospectively examined the records of ESCC patients who were judged to be ycN-RLN(-) following nCRT. Patients were divided into two groups according to the extent of LND [standard two-field LND (STL group) versus total two-field LND (TTL group)]. Only lower mediastinal and upper abdominal lymph nodes were removed in the STL group. In addition to the standard procedure, patients in the TTL group underwent resection of upper mediastinal lymph nodes located along the bilateral RLN. Using propensity score matching, 29 pairs were identified and compared with regard to perioperative complications, lymph-node metastases rates, overall survival (OS), and disease-specific survival (DSS). RESULTS No significant intergroup differences were identified in terms of in-hospital mortality and morbidity. Metastases to the RLN lymph nodes were identified in 20.7% (6/29) of TTL patients, being the only site of lymph-node metastases in three of them. TTL was associated with lower upper mediastinal lymph-node recurrence rate (6.5%) compared with STL (21.5%, p = 0.134), although the overall recurrence rate was similar (STL, 44.8% versus TTL, 46.4%). No significant intergroup differences were also evident with regard to 3-year DSS and OS rates. CONCLUSIONS RLN LND can be safely performed in ESCC patients who had undergone nCRT, ultimately resulting in an improved local control, and should be practiced as part of the surgical routine.
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Affiliation(s)
- Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyüan, Taiwan.
| | - Chien-Hung Chiu
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyüan, Taiwan
| | - Yun-Hen Liu
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyüan, Taiwan
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17
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Xu J, Zheng B, Zhang S, Zeng T, Chen H, Zheng W, Chen C. The clinical significance of the intraoperative pathological examination of bilateral recurrent laryngeal nerve lymph nodes using frozen sections in cervical field lymph node dissection of thoracic esophageal squamous cell carcinoma. J Thorac Dis 2019; 11:3525-3533. [PMID: 31559059 DOI: 10.21037/jtd.2019.07.59] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background The aim of this study was to evaluate intraoperative pathological examination of the left and right recurrent laryngeal nerve lymph nodes (LNs) using frozen section as a predictor of cervical LN metastasis. Methods Retrospectively collected data from 69 patients with esophageal squamous cell carcinoma who had undergone intraoperative pathological examination of the left and right recurrent laryngeal nerve LNs using frozen sections and three-field LN dissection in the Fujian Medical University Union Hospital from December 2015 to April 2018, was used to explore the relationship between recurrent laryngeal nerve LN metastasis and cervical LN metastasis and to determine whether cervical-field LN dissection should be performed in patients with thoracic esophageal cancer. Results In the entire cohort, 15.9% (11/69) of patients had metastasis in the cervical LNs. We detected 1,195 cervical LN, with an average of 17.3 LN dissections per patient; 28 (2.3%) cases had LN metastasis. Patients with recurrent laryngeal nerve LN metastasis tended to have a high incidence of cervical LN metastasis (P=0.017). Multivariate analysis showed that left recurrent laryngeal nerve LN metastasis was the only independent risk factor for cervical LN metastasis (P=0.02). The incidence of postoperative pulmonary infection was 18.8% (13/69), chylothorax was 2.9% (2/69), anastomotic leakage was 2.9% (2/69), and hoarseness was 8.7% (6/69) for the entire cohort. There was no significant increase in complications compared with patients with 2-field LN dissection in our hospital during the same period. Additional studies are necessary to establish postoperative locoregional recurrence rates and long-term survival. Conclusions Intraoperative pathological examination of left recurrent laryngeal nerve LN using frozen sections has some prognostic value in predicting cervical LN metastasis and it can be an indicator for the selection of cervical-field dissection in thoracic esophageal carcinoma.
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Affiliation(s)
- Jinxin Xu
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Bin Zheng
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Shuliang Zhang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Taidui Zeng
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Hao Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Wei Zheng
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Chun Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
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Ikawa T, Ishihara R, Konishi K, Morimoto M, Hirata T, Kanayama N, Yamamoto S, Matsuura N, Wada K, Hayashi K, Ogawa K, Teshima T. Failure patterns after adjuvant chemoradiotherapy following endoscopic resection for superficial esophageal squamous cell carcinoma. Cancer Med 2019; 8:4547-4554. [PMID: 31222974 PMCID: PMC6712456 DOI: 10.1002/cam4.2365] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/04/2019] [Accepted: 06/05/2019] [Indexed: 12/30/2022] Open
Abstract
Background This study evaluated the locations of lymph node recurrence and their association with irradiation fields used for radiotherapy after adjuvant chemoradiotherapy following endoscopic resection for superficial esophageal squamous cell carcinoma. Methods Medical records of 96 consecutive patients with superficial esophageal squamous cell carcinoma who underwent adjuvant chemoradiotherapy following endoscopic resection were reviewed. Computed tomography was used to identify whether nodal recurrences were within the elective nodal irradiation field. The cumulative incidence of recurrence was calculated, accounting for death as a competing risk. Univariate and multivariate analyses identified factors predicting nodal recurrence. Results The median follow‐up period was 61 months (range: 6‐137 months). Seven patients (7.3%) developed lymph node recurrence only; two patients (2.1%) developed nodal plus local recurrence. Six of the seven cases without local recurrence involved the elective nodal irradiation field, with five cases involving the recurrent nerve lymph nodes. The 5‐year cumulative incidence of lymph node recurrence was higher for T1b tumors with lymphovascular invasion than for T1a tumors with lymphovascular invasion (17.6% vs 6.2%, P = 0.086; HR: 3.74, 95% CI: 0.80‐17.52, P = 0.094) and T1b tumors without lymphovascular invasion (17.6% vs 3.3%, P = 0.031; HR: 6.78, 95% CI: 0.80‐57.63, P = 0.080). Conclusions Lymph node recurrence frequently involved the elective nodal irradiation field, with recurrent nerve lymph nodes being common metastasis sites. The high incidence of nodal recurrence for T1b tumors with lymphovascular invasion highlights a need for new strategies for treating this subset of superficial esophageal squamous cell carcinomas.
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Affiliation(s)
- Toshiki Ikawa
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Koji Konishi
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Masahiro Morimoto
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Takero Hirata
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Naoyuki Kanayama
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Sachiko Yamamoto
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Noriko Matsuura
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kentaro Wada
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kenji Hayashi
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Teruki Teshima
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
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Chao YK, Li ZG, Wen YW, Kim DJ, Park SY, Chang YL, van der Sluis PC, Ruurda JP, van Hillegersberg R. Robotic-assisted Esophagectomy vs Video-Assisted Thoracoscopic Esophagectomy (REVATE): study protocol for a randomized controlled trial. Trials 2019; 20:346. [PMID: 31182150 PMCID: PMC6558787 DOI: 10.1186/s13063-019-3441-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 05/13/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Radical lymph node dissection (LND) along the left recurrent laryngeal nerve (RLN) is surgically demanding and can be associated with substantial postoperative morbidity. The question of whether robot-assisted esophagectomy (RE) might be superior to video-assisted thoracoscopic esophagectomy (VATE) for performing LND along the RLN in patients with esophageal squamous cell carcinoma (ESCC) remains open. METHODS/DESIGN We will conduct a multicenter, open-label, randomized controlled trial (Robotic-assisted Esophagectomy vs Video-Assisted Thoracoscopic Esophagectomy (REVATE)) enrolling patients with ESCC scheduled to undergo LND along the RLN. Patients will be randomly assigned to either RE or VATE. The primary outcome measure will be the rate of unsuccessful LND along the left RLN, which will be defined as: failure to remove lymph nodes along the left RLN (i.e., no identifiable nodes on pathology reports); or occurrence of permanent (duration > 6 months) left RLN palsy following LND. Secondary outcomes will include the number of successfully removed RLN nodes, postoperative recovery, length of hospital stay, 30-day and 90-day mortality, quality of life, and oncological outcomes. DISCUSSION The REVATE study provides an opportunity to explore whether RE could facilitate LND along the left RLN-a complex surgical procedure that, as of now and with the use of VATE, remains difficult to perform and associated with a significant burden of morbidity. TRIAL REGISTRATION ClinicalTrials.gov, NCT03713749 . Registered on 22 October 2018.
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Affiliation(s)
- Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
| | - Zhi-Gang Li
- Division of Thoracic Surgery Shanghai Chest Hospital, Shanghai, China
| | - Yu-Wen Wen
- Clinical Informatics and Medical Statistics Research Center Chang Gung University, Taoyuan, Taiwan
| | - Dae-Joon Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seong-Yong Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yu-Ling Chang
- School of Nursing, Chang Gung University, Taoyuan, Taiwan
| | | | - Jelle P. Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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20
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Xue LY, Qin XM, Liu Y, Liang J, Lin H, Xue XM, Zou SM, Zhang MY, Zhang BH, Hui ZG, Zhao ZT, Ren LQ, Zhang YM, Liu XY, Yuan YL, Ying JM, Gao SG, Song YM, Wang GQ, Dawsey SM, Lu N. Clinicopathological parameters predicting recurrence of pT1N0 esophageal squamous cell carcinoma. World J Gastroenterol 2018; 24:5154-5166. [PMID: 30568392 PMCID: PMC6288646 DOI: 10.3748/wjg.v24.i45.5154] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/22/2018] [Accepted: 11/13/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To identify the clinicopathological characteristics of pT1N0 esophageal squamous cell carcinoma (ESCC) that are associated with tumor recurrence.
METHODS We reviewed 216 pT1N0 thoracic ESCC cases who underwent esophagectomy and thoracoabdominal two-field lymphadenectomy without preoperative chemoradiotherapy. After excluding those cases with clinical follow-up recorded fewer than 3 mo and those who died within 3 mo of surgery, we included 199 cases in the current analysis. Overall survival and recurrence-free survival were assessed by the Kaplan-Meier method, and clinicopathological characteristics associated with any recurrence or distant recurrence were evaluated using univariate and multivariate Cox proportional hazards models. Early recurrence (≤ 24 mo) and correlated parameters were assessed using univariate and multivariate logistic regression models.
RESULTS Forty-seven (24%) patients had a recurrence at 3 to 178 (median, 33) mo. The 5-year recurrence-free survival rate was 80.7%. None of 13 asymptomatic cases had a recurrence. Preoperative clinical symptoms, upper thoracic location, ulcerative or intraluminal mass macroscopic tumor type, tumor invasion depth level, basaloid histology, angiolymphatic invasion, tumor thickness, submucosal invasion thickness, diameter of the largest single tongue of invasion, and complete negative aberrant p53 expression were significantly related to tumor recurrence and/or recurrence-free survival. Upper thoracic tumor location, angiolymphatic invasion, and submucosal invasion thickness were independent predictors of tumor recurrence (Hazard ratios = 3.26, 3.42, and 2.06, P < 0.001, P < 0.001, and P = 0.002, respectively), and a nomogram for predicting recurrence-free survival with these three predictors was constructed. Upper thoracic tumor location and angiolymphatic invasion were independent predictors of distant recurrence. Upper thoracic tumor location, angiolymphatic invasion, submucosal invasion thickness, and diameter of the largest single tongue of invasion were independent predictors of early recurrence.
CONCLUSION These results should be useful for designing optimal individual follow-up and therapy for patients with T1N0 ESCC.
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Affiliation(s)
- Li-Yan Xue
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
- Center for Cancer Precision Medicine, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xiu-Min Qin
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yong Liu
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jun Liang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Hua Lin
- Department of Medical Record, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xue-Min Xue
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Shuang-Mei Zou
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Mo-Yan Zhang
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Bai-Hua Zhang
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
- The 2nd Department of Thoracic Surgery, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, CSU, Changsha 410006, Hunan Province, China
| | - Zhou-Guang Hui
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Zi-Tong Zhao
- State Key Laboratory of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Li-Qun Ren
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
- Department of Pathology, Chengde Medical College, Chengde 067000, Hebei Province, China
| | - Yue-Ming Zhang
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xiu-Yun Liu
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yan-Ling Yuan
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jian-Ming Ying
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Shu-Geng Gao
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yong-Mei Song
- State Key Laboratory of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Gui-Qi Wang
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Sanford M Dawsey
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD 20892, United States
| | - Ning Lu
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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21
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Wang Y, Zhu L, Xia W, Wang F. Anatomy of lymphatic drainage of the esophagus and lymph node metastasis of thoracic esophageal cancer. Cancer Manag Res 2018; 10:6295-6303. [PMID: 30568491 PMCID: PMC6267772 DOI: 10.2147/cmar.s182436] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The lymphatic drainage of the inner layers (mucosa and submucosa) and the outer layers (muscularispropria and adventitia) of the thoracic esophagus is different. Longitudinal lymphatic vessels and long drainage territory in the submucosa and lamina propria should be the bases for bidirectional drainage and direct drainage to thoracic duct and extramural lymph nodes (LN). The submucosal vessels for direct extramural drainage are usually thick while lymphatic communication between the submucosa and intermuscular area is usually not clearly found, which does not facilitate transversal drainage to paraesophageal LN from submucosa. The right paratracheal lymphatic chain (PLC) is well developed while the left PLC is poorly developed. Direct drainage to the right recurrent laryngeal nerve LN and subcarinal LN from submucosa has been verified. Clinical data show that lymph node metastasis (LNM) is frequently present in the lower neck, upper mediastinum, and perigastric area, even for early-stage thoracic esophageal cancer (EC). The lymph node metastasis rate (LNMR) varies mainly according to the tumor location and depth of tumor invasion. However, there are some crucial LN for extramural relay which have a high LNMR, such as cervical paraesophageal LN, recurrent laryngeal nerve LN, subcarinal LN, LN along the left gastric artery, lesser curvature LN, and paracardial LN. Metastasis of thoracic paraesophageal LN seems to be a sign of more advanced EC. This review gives us a better understanding about the LNM and provides more information for treatments of thoracic EC.
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Affiliation(s)
- Yichun Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui, P.R. China, ;
| | - Liyang Zhu
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui, P.R. China, ;
| | - Wanli Xia
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui, P.R. China
| | - Fan Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui, P.R. China, ;
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22
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Wang Y, Zhu L, Xia W, Wu L, Wang F. The impact of adjuvant therapies on patient survival and the recurrence patterns for resected stage IIa-IVa lower thoracic oesophageal squamous cell carcinoma. World J Surg Oncol 2018; 16:216. [PMID: 30404621 PMCID: PMC6223077 DOI: 10.1186/s12957-018-1516-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 10/23/2018] [Indexed: 12/19/2022] Open
Abstract
Background This study evaluated the impact of adjuvant therapies on patient survival and disease recurrence patterns to identify an effective adjuvant therapy for resected lower thoracic oesophageal squamous cell carcinoma (LTESCC). Methods Clinical data of 127 patients with stage IIa-IVa LTESCC with a minimum 2-year follow-up after oesophagectomy were analysed. The survival and recurrence patterns were compared among patients who received adjuvant radiotherapy, adjuvant chemotherapy, adjuvant chemoradiotherapy, or surgery alone. Results Eighty-eight patients (69.3%) were identified as having disease recurrence. The regional lymph node recurrence rate was 57.5%, and the recurrence rates were high in the lower neck, upper mediastinum, and upper abdomen. Compared to surgery alone, adjuvant radiotherapy or chemoradiotherapy significantly decreased the recurrence rate (p < 0.05). Adjuvant chemoradiotherapy significantly improved overall survival, disease-free survival, and locoregional recurrence-free survival compared to surgery alone (p = 0.01, 0.01, and 0.00, respectively). Pathologically positive lymph nodes (PPLNs) in the lower mediastinum represented a potential risk factor for cervical recurrence (HR 2.97, 95%CI 1.19–7.39). Multivariable analysis showed that postoperative radiotherapy (HR 0.30, 95%CI 0.13–0.68) and PPLNs in the upper mediastinum (HR 3.72, 95%CI 1.30–10.67) were independent risk factors for upper mediastinal recurrence, while postoperative radiotherapy (HR 0.37, 95%CI 0.16–0.85) and PPLNs in the abdomen (HR 2.57, 95%CI 1.12–5.92) were independent risk factors for abdominal recurrence. Conclusion Adjuvant chemoradiotherapy was the most effective adjuvant therapy for resected stage IIa-IVa LTESCC. The lower neck, upper mediastinum, and upper abdomen were high-risk regions for postoperative radiotherapy. The regions of PPLNs may be important factors for individual targets.
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Affiliation(s)
- Yichun Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, No.218, Jixi Road, Hefei, 230022, Anhui, People's Republic of China.
| | - Liyang Zhu
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, No.218, Jixi Road, Hefei, 230022, Anhui, People's Republic of China
| | - Wanli Xia
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, People's Republic of China
| | - Liming Wu
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, No.218, Jixi Road, Hefei, 230022, Anhui, People's Republic of China
| | - Fan Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, No.218, Jixi Road, Hefei, 230022, Anhui, People's Republic of China
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23
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Abstract
BACKGROUND It is still unclear that dissection of recurrent laryngeal nerve nodes is mandatory in patients with cT1 middle or lower thoracic esophageal squamous cell carcinoma when the nodes are negative in preoperative staging workup. We aimed to evaluate the feasibility of near-infrared image-guided lymphatic mapping of bilateral recurrent laryngeal nerve nodes. METHODS The day before operation, we injected indocyanine green (ICG) into the submucosal layer by endoscopy. At the time of upper mediastinal dissection, ICG-stained basins were identified along the bilateral recurrent laryngeal nerves and retrieved under guidance of the Firefly system. After the operation, remnant ICG-unstained basins were dissected from the specimen to assess the presence of metastasis. RESULTS Of 29 patients enrolled, ICG-stained basins could be identified in 25 patients (86.2%), and 6 of them (24.0%) had nodal metastasis; 4 in the right recurrent laryngeal nerve chain, 1 in the left recurrent laryngeal nerve chain, and 1 in both recurrent laryngeal nerve chains. On pathologic examination of 345 recurrent laryngeal nerve nodes, two metastatic nodes were identified in ICG-unstained basins along the left recurrent laryngeal nerve in a patient who had lymph node metastases in ICG-stained basins along both recurrent laryngeal nerves. Negative predictive value in detection of nodal metastasis was 100% for the right recurrent laryngeal nerve chain and 98.2% for the left recurrent laryngeal nerve chain. CONCLUSIONS Real-time assessment of recurrent laryngeal nerve nodes with near-infrared image was technically feasible, and we could detect lymphatic basins that most likely have nodal metastasis. Our technique might be useful in determining the optimal extent of lymphadenectomy.
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24
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Kumakura Y, Yokobori T, Yoshida T, Hara K, Sakai M, Sohda M, Miyazaki T, Yokoo H, Handa T, Oyama T, Yorifuji H, Kuwano H. Elucidation of the Anatomical Mechanism of Nodal Skip Metastasis in Superficial Thoracic Esophageal Squamous Cell Carcinoma. Ann Surg Oncol 2018; 25:1221-1228. [PMID: 29476296 PMCID: PMC5891562 DOI: 10.1245/s10434-018-6390-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Indexed: 01/04/2023]
Abstract
Background Lymph node metastasis (LNM) is a standard mechanism of cancer progression in esophageal squamous cell carcinoma (ESCC). We aimed to clarify the anatomical mechanism of skip nodal metastasis to mediastinal zones by analyzing the relationship between LNM to sentinel zones and lymphatic vessel counts in the muscle layer adjacent to the outer esophagus. Methods We examined the surgical records of 287 patients with ESCC who underwent potentially curative surgery (three-field lymphadenectomy) and whole esophagi, including pharynges and stomachs from 10 cadavers, to determine the number of lymphatic vessels in the intra-outer longitudinal muscle layer adjacent to the outer esophagus of the cervical (Ce), upper thoracic, middle thoracic (Mt), lower thoracic (Lt), and abdominal esophagi (Ae). Results The frequency of LNM to the middle mediastinal and supraclavicular zones, including the Mt and Ce, respectively, was lower than to the upper and lower mediastinal and abdominal zone in patients with superficial and advanced thoracic ESCC. In cadavers, the lymphatic vessel counts of the intra-outer longitudinal muscle layer in the Mt and Ce were significantly lower than those of the Lt and Ae, suggesting that lymphatic flow toward the outside of the Mt and Ce was not more abundant than to other sites. Conclusion Our anatomical data suggested that the absence of intra-muscle lymphatic vessels in the middle mediastinal and supraclavicular zones causes skip LNM in patients with thoracic ESCC. Thus, standard esophagectomy with lymph node dissection, including distant zones, may be appropriate for treating patients with superficial thoracic ESCC. Electronic supplementary material The online version of this article (10.1245/s10434-018-6390-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yuji Kumakura
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Takehiko Yokobori
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
| | - Tomonori Yoshida
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Keigo Hara
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Makoto Sakai
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Makoto Sohda
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tatsuya Miyazaki
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Hideaki Yokoo
- Department of Human Pathology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tadashi Handa
- Department of Diagnostic Pathology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tetsunari Oyama
- Department of Diagnostic Pathology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Hiroshi Yorifuji
- Department of Anatomy, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Hiroyuki Kuwano
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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25
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Lin D, Jiang S, Ma L, Hu H, Ye T, Shao L, Song Z, Xiang J. Clinical analyses on salvage lymphadenectomy through cervical incision for patients with cervical and cervicothoracic recurrences after esophagectomy. J Thorac Dis 2017; 9:3832-3839. [PMID: 29268392 DOI: 10.21037/jtd.2017.09.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Locoregional recurrences are often observed after esophagectomy with lymphadenectomy. The treatment strategy for these patients has not been established completely. The purpose of this study was to evaluate the prognosis of salvage lymphadenectomy through the cervical incision for cervical and cervicothoracic recurrences. Methods We retrospectively reviewed patients underwent initial esophagectomy and then salvage lymphadenectomy in Fudan University Shanghai Cancer Center during July 2006 and September 2016. Survival curve was calculated by Kaplan-Meier method. Prognostic factors for post-salvage lymphadenectomy overall survival (PSL-OS) were identified by univariate and multivariate analyses. Results The median disease-free survival (DFS) was 8 months. The median PSL-OS was 40 months (95% CI: 8.850-71.150). The 1-, 2-, 3- and 5-year PSL-OS rate were 87%, 58%, 52% and 41%, respectively. Univariate and multivariate analyses confirmed the initial TNM stage was the only independent prognostic factor for PSL-OS (P=0.000 by log-rank test, P=0.009 by Cox hazards model, HR 3.999, 95% CI: 1.413-11.316) among these patients. Conclusions PSL survival could be considerable for patients with early initial tumor stage. Prospective studies are warranted to clarify the value of salvage lymphadenectomy.
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Affiliation(s)
- Dong Lin
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Shujun Jiang
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Longfei Ma
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Hong Hu
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Ting Ye
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Longlong Shao
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Zuodong Song
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Jiaqing Xiang
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
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26
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Lymph Node Evaluation in Robot-Assisted Versus Video-Assisted Thoracoscopic Esophagectomy for Esophageal Squamous Cell Carcinoma: A Propensity-Matched Analysis. World J Surg 2017; 42:590-598. [DOI: 10.1007/s00268-017-4179-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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27
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Tachimori Y. Pattern of lymph node metastases of squamous cell esophageal cancer based on the anatomical lymphatic drainage system: efficacy of lymph node dissection according to tumor location. J Thorac Dis 2017; 9:S724-S730. [PMID: 28815068 DOI: 10.21037/jtd.2017.06.19] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Knowing the anatomical lymphatic drainage of the esophagus is crucial to understanding the dissemination pattern of esophageal tumor. During the embryonal growth, the middle and lower part of the esophagus stretches as the lymphatic networks develop in the submucosal layer. The abundant submucosal lymphatics drain in a longitudinal fashion directly to their proximal and distal ends. The lymphatic route from the proximal esophagus through recurrent nerve nodes to supraclavicular nodes are a component of the mesentery of the proximal esophagus. The lower esophagus mostly drains its lymph into paracardial nodes related to celiac nodes through the mesentery of the distal esophagus. Lymphatic routes to mid and lower paraesophageal nodes usually originate from the intermuscular area of the muscularis propria. The lymphatic communication between the submucosa and intermuscular area is limited. The anatomical concept was confirmed clinically by a large series of single institution and the nationwide registry in Japan. The clinical data for the incidence of involved nodes verified the anatomical observations that long longitudinal extension of lymphatic drainage in the submucosa connected to the upper mediastinum lymphatics and paracardial lymphatics. The extent of dissection should be not tailored according to the anatomical distance from the tumor but according to the incidences of metastasis of each area, those were differed by tumor location. The areas for node dissection should be modified according to the tumor location. Although in patients with tumor limited to within the submucosal layer, even with tumors located in the mid- and lower esophagus, lymphatic metastasis was frequent in the upper mediastinum and perigastric area via the abundant submucosal lymphatics in a longitudinal fashion. When tumor invades or penetrates the muscle layer, the incidence of paraesophageal lymph node metastasis in the middle and lower mediastinum increases.
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Affiliation(s)
- Yuji Tachimori
- Cancer Care Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
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28
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Li M, Zhang X, Zhao F, Luo Y, Kong L, Yu J. Involved-field radiotherapy for esophageal squamous cell carcinoma: theory and practice. Radiat Oncol 2016; 11:18. [PMID: 26846932 PMCID: PMC4743321 DOI: 10.1186/s13014-016-0589-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 01/14/2016] [Indexed: 12/14/2022] Open
Abstract
Esophageal carcinoma (EC) is characterized by a high rate of lymph node metastasis and its spread pattern is not always predictable. Chemoradiotherapy has an important role in the treatment of EC in both the inoperable and the pre-operative settings. However, regarding the target volume for radiation, different clinical practices exist. Theoretically, in addition to the clinical target volume administered to the gross lesion, it might seem logical to deliver a certain dose to the uninvolved regional lymph node area at risk for microscopic disease. However, in practice, it is difficult because of the intolerance of normal tissue to radiotherapy (RT), particularly if all regions containing the cervical, mediastinal, and upper abdominal nodes are covered. To date, the use of elective nodal irradiation (ENI) is still controversial in the field of radiotherapy. Some investigators use involved-field radiotherapy (IFRT) in order to reduce treatment-related toxicities. It is thought that micrometastases can be controlled, to some extent, by chemotherapy and the abscopal effects of radiation. It is the presence of overtly involved lymph nodes rather than the micrometastatic nodes negatively affects survival in patients with EC. In another hand, lymph nodes stationed near primary tumors also receive considerable incidental irradiation doses that may contribute to the elimination of subclinical lesions. These data indicate that an irradiation volume covering only the gross tumor is appropriate. When using ENI or IFRT, very few patients experience solitary regional node failure and out-of-field lymph node failure is not common. Primary tumor recurrence and distant metastases, rather than regional lymph node failure, affect the overall survival in patients with EC. The available evidence indicates that the use of ENI seems to prevent or delay regional nodal relapse rather than improve survival. In a word, these data suggest that IFRT is feasible in EC patients.
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Affiliation(s)
- Minghuan Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, Shandong Province, 250117, China.
| | - Xiaoli Zhang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, Shandong Province, 250117, China. .,Department of Oncology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China.
| | - Fen Zhao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, Shandong Province, 250117, China.
| | - Yijun Luo
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, Shandong Province, 250117, China.
| | - Li Kong
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, Shandong Province, 250117, China.
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, Shandong Province, 250117, China.
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Ji X, Cai J, Chen Y, Chen LQ. Lymphatic spreading and lymphadenectomy for esophageal carcinoma. World J Gastrointest Surg 2016; 8:90-94. [PMID: 26843917 PMCID: PMC4724592 DOI: 10.4240/wjgs.v8.i1.90] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/06/2015] [Accepted: 12/02/2015] [Indexed: 02/06/2023] Open
Abstract
Esophageal carcinoma (EC) is a highly lethal malignancy with a poor prognosis. One of the most important prognostic factors in EC is lymph node status. Therefore, lymphadenectomy has been recognized as a key that influences the outcome of surgical treatment for EC. However, the lymphatic drainage system of the esophagus, including an abundant lymph-capillary network in the lamina propria and muscularis mucosa, is very complex with cervical, mediastinal and celiac node spreading. The extent of lymphadenectomy for EC has always been controversial because of the very complex pattern of lymph node spreading. In this article, published literature regarding lymphatic spreading was reviewed and the current lymphadenectomy trends for EC are discussed.
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Shan HB, Zhang R, Li Y, Gao XY, Lin SY, Luo GY, Li JJ, Xu GL. Application of Endobronchial Ultrasonography for the Preoperative Detecting Recurrent Laryngeal Nerve Lymph Node Metastasis of Esophageal Cancer. PLoS One 2015; 10:e0137400. [PMID: 26372339 PMCID: PMC4570776 DOI: 10.1371/journal.pone.0137400] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 08/17/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The preoperative detection of recurrent laryngeal nerve lymph node (RLN LN) metastasis provides important information for the treatment of esophageal cancer. We investigated the possibility of applying endobronchial ultrasonography (EBUS) with conventional preoperative endoscopic ultrasonography (EUS) and computerized tomography (CT) examination to evaluate RLN LN metastasis in patients with esophageal cancer. METHODS A total of 115 patients with advanced thoracic esophageal cancer underwent EBUS examinations. Patients also underwent EUS and CT imaging as reference diagnostic methods. Positron emission tomography /computed tomography (PET/CT) was also introduced in partial patients as reference method. The preoperative evaluation of RLN LN metastasis was compared with the surgical and pathological staging in 94 patients who underwent radical surgery. RESULTS The sensitivities of the preoperative evaluations of RLN LN metastasis by EBUS, EUS and CT were 67.6%, 32.4% and 29.4%, respectively. The sensitivity of EBUS was significantly different from that of EUS or CT, especially in the detection of right RLN LNs. In addition, according to the extra data from reference method, PET/CT was not superior to EBUS or EUS in detecting RLN LN metastasis. Among all 115 patients, 21 patients who were diagnosed with tracheal invasions by EUS or EBUS avoided radical surgery. Another 94 patients who were diagnosed as negative for tracheobronchial tree invasion by EUS and EBUS had no positive findings in radical surgery. CONCLUSIONS EBUS can enhance the preoperative sensitivity of the detection of RLN LN metastasis in cases of thoracic esophageal cancer and is a useful complementary examination to conventional preoperative EUS and CT, which can alert thoracic surgeons to the possibility of a greater range of preoperative lymph node dissection. EBUS may also indicate tracheal invasion in cases of esophageal stricture.
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Affiliation(s)
- Hong-Bo Shan
- Department of Endoscopy, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Rong Zhang
- Department of Endoscopy, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yin Li
- Department of Endoscopy, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiao-Yan Gao
- Department of Endoscopy, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Shi-Yong Lin
- Department of Endoscopy, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Guang-Yu Luo
- Department of Endoscopy, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jian-Jun Li
- Department of Endoscopy, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Guo-Liang Xu
- Department of Endoscopy, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
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Ren Y, Su C, Zhou Y, Zhao X, Yang CL, Liu YY. Effect of bilateral supraclavicular postoperative radiotherapy in middle and lower thoracic esophageal carcinoma. World J Gastroenterol 2014; 20:17970-17975. [PMID: 25548496 PMCID: PMC4273148 DOI: 10.3748/wjg.v20.i47.17970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 10/21/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate whether postoperative radiotherapy is an alternative to neck lymph node surgery and if it provides a survival benefit for those receiving two-field, chest and abdomen, lymphadenectomy.
METHODS: A total of 530 cases with middle and lower thoracic esophageal carcinoma in our hospital from January 2008 to April 2009 were selected and analyzed, of which 219 cases received right chest, upper abdominal incision Ivor-Lewis surgery and simultaneously underwent mediastinal and abdominal two-field lymphadenectomy. If regional lymph node metastasis occurred within the recurrent laryngeal nerve, the patients would receive bilateral supraclavicular radiotherapy (DT = 5000cGy) to be adopted at postoperative 4-5 wk (Group A) or cervical lymphadenectomy at postoperative 3-4 wk (Group B). If there were no regional lymph node metastases within the recurrent laryngeal nerve, the patients only underwent two-field, chest and abdomen, lymphadenectomy (Group C).
RESULTS: In 219 cases who underwent two-field lymphadenectomy, 91 cases were diagnosed with regional lymph node metastasis within the recurrent laryngeal nerve. Of them, 48 cases received cervical radiotherapy, and 43 cases underwent staging lymphadenectomy; 128 patients were not given the follow-up treatment of cervical radiotherapy because there was no regional lymph node metastasis within the recurrent laryngeal nerve. Five-year survival rates in group A and B were 47% and 50%, respectively, with no statistical difference between them, and the rate in group C was 58%.
CONCLUSION: For patients with middle and lower thoracic esophageal carcinoma combined with lymph node metastasis within the recurrent laryngeal nerve, cervical radiotherapy can be a substitute for surgery and provide benefit.
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Wu J, Chen QX, Zhou XM, Mao WM, Krasna MJ. Does recurrent laryngeal nerve lymph node metastasis really affect the prognosis in node-positive patients with squamous cell carcinoma of the middle thoracic esophagus? BMC Surg 2014; 14:43. [PMID: 25016483 PMCID: PMC4105105 DOI: 10.1186/1471-2482-14-43] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 07/09/2014] [Indexed: 11/17/2022] Open
Abstract
Background Recurrent laryngeal nerve (RLN) lymph node metastasis used to be shown a predictor for poor prognosis in esophageal squamous cell carcinoma. The purpose of this study was to evaluate the prognostic impact of RLN node metastasis and the number of metastatic lymph nodes in node-positive patients with squamous cell carcinoma of middle thoracic esophagus. Methods A cohort of 235 patients who underwent curative surgery for squamous cell carcinoma of middle thoracic esophagus was investigated. The prognostic impact was evaluated by univariate and multivariate analyses. Results Lymph node metastasis was found in 133 patients. Among them, 81 had metastatic RLN nodes, and 52 had at least one positive node but no RLN nodal involvement. The most significant difference in survival was detected between patients with metastatic lymph nodes below and above a cutoff value of six (P < 0.001). Multivariate analysis revealed that the number of metastatic lymph nodes was a significant factor associated with overall survival (P < 0.001), but RLN lymph node metastasis was not (P = 0.865). Conclusions RLN Lymph node metastasis is not, but the number of metastatic nodes is a prognostic predictor in node-positive patients with squamous cell carcinoma of the middle thoracic esophagus.
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Affiliation(s)
- Jie Wu
- Department of Thoarcic Surgery, Zhejinang Cancer Hospital, 38 Guangji Road, Hangzhou 310022, China.
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Kosugi SI, Kawaguchi Y, Kanda T, Ishikawa T, Sakamoto K, Akaike H, Fujii H, Wakai T. Cervical lymph node dissection for clinically submucosal carcinoma of the thoracic esophagus. Ann Surg Oncol 2013; 20:4016-21. [PMID: 23892526 DOI: 10.1245/s10434-013-3141-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND The purposes of this study were to clarify the risk factors for supraclavicular lymph node (SCLN) metastasis and the survival benefit from cervical lymph node (LN) dissections in patients with clinically submucosal (cT1b) carcinoma of the thoracic esophagus. METHODS A total of 86 patients with this disease who underwent esophagectomy with 3-field lymph node dissection were retrospectively reviewed. Multivariate logistic regression and Cox proportional hazard model were used to identify the independent risk factors for SCLN metastasis and prognostic factors, respectively. An index calculated by multiplying the frequency of metastasis at nodal basin and the 5-year overall survival rate of patients with metastasis at that basin were used to assess the therapeutic outcomes. RESULTS A total of 40 patients (47%) were found to have pathological LN metastasis. Also, 13 patients (15%) had cervical LN metastasis: 6 and 7 with carcinoma of the upper and mid-thoracic esophagus, respectively. SCLN metastasis was found in 6 patients (7%); however, there was no independent risk factor for SCLN metastasis. The 5-year overall survival rate was 72.5%. Cervical LN metastasis was an independent prognostic factor (p = .04; odds ratio 2.55; 95% confidence interval 1.03-6.31); however, there was no significant difference in survival between patients with SCLN metastasis and those without (p = .06). The calculated index of estimated benefit from cervical LN dissections was 6.9, following upper mediastinal LN of 15.6 and perigastric LN of 8.3. CONCLUSIONS We could not identify risk factors to predict SCLN metastasis. Cervical LN dissection should not be omitted in patients with cT1b carcinoma, especially of the upper and mid-thoracic esophagus.
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Affiliation(s)
- Shin-ichi Kosugi
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan,
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Kishi K, Iida T, Ojima T, Sonomura T, Shirai S, Nakai M, Sato M, Yamaue H. Esophageal gel-shifting technique facilitating eradicative boost or reirradiation to upper mediastinal targets of recurrent nerve lymph node without damaging esophagus. JOURNAL OF RADIATION RESEARCH 2013; 54:748-754. [PMID: 23436229 PMCID: PMC3709665 DOI: 10.1093/jrr/rrs137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Revised: 12/20/2012] [Accepted: 12/21/2012] [Indexed: 06/01/2023]
Abstract
We developed a new technique using hyaluronic gel injection as a spacer to safely move the esophagus away from the high-dose area during interstitial brachytherapy of a mediastinal target close to the esophagus. We percutaneously injected a high-molecular-weight hyaluronic gel mixed with contrast medium to create a space between the esophagus and the target during interstitial brachytherapy. We applied this technique to two cases of relapsed recurrent nerve lymph node metastasis from esophageal cancer: one refractory tumor after 50 Gy of radiotherapy, and one recurrence after mediastinal radiotherapy of total 64 Gy. We prescribed 20 Gy and 18 Gy in one fraction to each target, with calculated esophageal D2cc (the minimum dose to the most irradiated volume of 2 cc) of 4.0 Gy and 6.8 Gy, respectively. Calculated enhancement factor by gel shifting in equivalent dose was 2.69 and 2.34, respectively. In each patient, accumulated esophageal D1cc (minimum dose to the most irradiated volume of p cc. minimum dose to the most irradiated volume of 1 cc) was 74.4 Gy and 85.6 Gy without shifting, and 59.1 Gy and 37.6 Gy with shifting, respectively. There were no procedure-related complications. Four months after the brachytherapy, each tumor was remarkably diminished. No evidence of recurrences or late complications were observed 8 months and 9 months after the procedure, respectively. The esophageal gel-shifting technique may facilitate eradicative brachytherapy to upper mediastinal targets without damaging the esophagus, and can be used in conjunction with boost irradiation or reirradiation to overcome the problem of salvage failure.
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Affiliation(s)
- Kazushi Kishi
- Department of Radiation Oncology, Wakayama Medical University, Wakayama City, 64-8510 Japan
| | - Takeshi Iida
- Second Department of Surgery, Wakayama Medical University, Wakayama City, 641-8510 Japan
| | - Toshiyasu Ojima
- Second Department of Surgery, Wakayama Medical University, Wakayama City, 641-8510 Japan
| | - Tetsuo Sonomura
- Department of Radiology, Wakayama Medical University, Wakayama City, 641-8510 Japan
| | - Shintaro Shirai
- Department of Radiology, Wakayama Medical University, Wakayama City, 641-8510 Japan
| | - Motoki Nakai
- Department of Radiology, Wakayama Medical University, Wakayama City, 641-8510 Japan
| | - Morio Sato
- Department of Radiology, Wakayama Medical University, Wakayama City, 641-8510 Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, Wakayama City, 641-8510 Japan
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Pattern of lymphatic spread in thoracic esophageal squamous cell carcinoma: A single-institution experience. J Thorac Cardiovasc Surg 2012; 144:778-85; discussion 785-6. [DOI: 10.1016/j.jtcvs.2012.07.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 06/06/2012] [Accepted: 07/09/2012] [Indexed: 12/19/2022]
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Anatomical basis of the risk of injury to the right laryngeal recurrent nerve during thoracic surgery. Surg Radiol Anat 2012; 34:509-12. [DOI: 10.1007/s00276-012-0946-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 02/14/2012] [Indexed: 11/25/2022]
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Tanaka K, Yano M, Motoori M, Doki Y, Kishi K, Miyashiro I, Shingai T, Gotoh K, Noura S, Takahashi H, Ohue M, Yamada T, Ohigashi H, Ishikawa O. The significance of abdominal para-aortic lymph node metastasis in patients with lower thoracic esophageal cancer. Dis Esophagus 2012; 25:146-52. [PMID: 21762280 DOI: 10.1111/j.1442-2050.2011.01222.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Para-aortic lymph node (PALN) recurrence is often seen in patients with lower thoracic esophageal cancer treated by esophagectomy with extended lymph node dissection. However, the clinicopathological characteristics of patients with PALN metastasis and the significance of PALN dissection are unknown. A total of 283 patients with lower thoracic esophageal cancer underwent esophagectomy with lymphadenectomy at our hospital between April 1984 and March 2007. Among these 283 patients, 60 patients were enrolled in this retrospective study according to following criteria: (i) clinical T2 to T4 tumor, (ii) no clinical PALN metastasis, and (iii) received PALN dissection. PALN dissection was indicated by a tumor depth of at least T2 and no severe complications. The clinicopathological data, recurrence pattern, and overall survival were compared between patients with PALN and without PALN metastasis. The mean length of surgery was 587 min and the mean blood loss was 1383 mL. The morbidity was 33.3% and mortality was 5% in this series. Sixteen patients (26.7%) had PALN metastasis; these showed significantly more lymph node metastases (15.8 ± 13.2 vs. 3.0 ± 3.2, P < 0.0001) and significantly worse survival rates (53.3% vs. 79.9% at 1 year, 6.7% vs. 62.0% at 3 years, P < 0.0001) than patients without PALN metastasis. The incidence of lymph node recurrence (P < 0.0001) and hematogenous recurrence (P= 0.0487) was also higher in patients with PALN metastasis than in patients without PALN metastasis. Among the 16 patients with PALN metastasis, a univariate analysis revealed total number of metastatic nodes < 8 (P= 0.0325) to be a significant prognostic factor. A multivariate logistic regression analysis of the regional lymph nodes identified the invasion of the lower mediastinal nodes (hazard ratio = 6.120) and retroperitoneal nodes (hazard ratio = 15.167) to be significantly correlated with PALN metastasis. PALN metastasis is suggested to be related to the systemic spread of lymphatic metastasis even in lower thoracic esophageal cancer. PALN dissection for pathological PALN(+) patients should not be performed. It remains to be determined in future prospective studies whether patients without pathological PALN metastasis, but showing PALN micrometastasis, could achieve improved survival with PALN dissection.
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Affiliation(s)
- K Tanaka
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
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Nishimori H, Hayashi S, Naito M, Murakami G, Fujita M, Hosokawa M. Mucosal lymphatic vessels of the esophagus distant from the cancer margin: morphometrical analysis using 27 surgically removed specimens of squamous cell carcinoma located in the upper or middle thoracic esophagus. Okajimas Folia Anat Jpn 2012; 88:43-7. [PMID: 22184865 DOI: 10.2535/ofaj.88.43] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
PURPOSE To clarify the configuration of the esophageal mucosal lymphatics distant from cancer using D2-40 immunohistochemistry. METHODS D2-40 immunohistochemistry for human lymphatic epithelium was performed at sites about 10 cm anal from the pathologically examined margin of upper or mid- thoracic squamous cell carcinoma (27 patients). We measured the entire length of mucosal lymphatic vessels within a x10 objective field (1.2 mm along the muscularis mucosae). RESULTS The present morphometrical study demonstrated significant individual differences in the amount of mucosal lymphatic vessels, within a range of more than 10-fold (8.4 mm-0.8 mm within an objective field). However, the difference in length of the mucosal lymphatic epithelium did not correlate with either N-factor, T-factor including cancer depth or prognosis. CONCLUSION A higher density of pre-existing mucosal lymphatic vessels may not always be correlated with larger numbers of nodal metastases. Lymphatic proliferation or dilation induced by cancer seems to occur irrespective of whether pre-existing vessels are rich or sparse.
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Affiliation(s)
- Hidefumi Nishimori
- Division of Surgery, Keiyu-kai Sapporo Hospital, Sapporo, Hokkaido, Japan
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Watanabe M, Nishida K, Kimura Y, Miyazaki M, Baba H. Salvage lymphadenectomy for cervical lymph node recurrence after esophagectomy for squamous cell carcinoma of the thoracic esophagus. Dis Esophagus 2012; 25:62-6. [PMID: 21676066 DOI: 10.1111/j.1442-2050.2011.01215.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Prognosis of patients with recurrent esophageal cancer is usually unsatisfactory. We have successfully treated five patients with cervical node recurrence after esophagectomy with multimodal treatment including salvage lymphadenectomy. In order to clarify the efficacy of salvage surgery for cervical node recurrence, we have reviewed the clinical course and prognosis of these patients. From August 2004 to December 2007, 30 patients with 33 recurrent sites were treated in the Department of Surgery, Iizuka Hospital. Among these patients, there were five patients with recurrence limited within the cervical nodes. Salvage cervical lymphadenectomy was performed for all five patients. Curative resection was achieved in four patients and reduction surgery followed by planned chemoradiotherapy was performed in another patient. All stations including the suspicious node were dissected and a partial sternotomy was added for one patient whose recurrent tumor was located in the right recurrent nerve node. There was no mortality and one minor complication (subcutaneous hemorrhage) was observed. Median duration of hospital stay was 7 days. Adjuvant chemotherapy was performed for all patients. Median follow-up period was 54 months and all patients are alive without relapse of the disease. Salvage cervical lymphadenectomy is a safe and effective treatment for patients with cervical node recurrence after esophagectomy.
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Affiliation(s)
- M Watanabe
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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40
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Li H, Yang S, Zhang Y, Xiang J, Chen H. Thoracic recurrent laryngeal lymph node metastases predict cervical node metastases and benefit from three-field dissection in selected patients with thoracic esophageal squamous cell carcinoma. J Surg Oncol 2011; 105:548-52. [PMID: 22105736 DOI: 10.1002/jso.22148] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 10/24/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Recurrent laryngeal nerve lymph nodes (RLN LNs) are considered sentinel nodes for cervical LN metastases of esophageal cancer. Surgery is the treatment of choice, but whether three-field lymph node dissection (3FL), which includes cervical LN dissection, or 2FL, which does not, should be performed is controversial. METHODS We retrospectively analyzed medical records of 200 patients with esophageal cancer who underwent 3FL from January 2000 to August 2010, focusing on LN status. We also compared survival rates between these patients and those who underwent 2FL. RESULTS The rate of cervical LN metastases did not differ significantly between RLN LN+ (for metastasis) and RLN LN- 3FL groups. However, in a subgroup of patients with middle/lower thoracic esophageal tumors, cervical LN metastases were significantly more common in patients with positive rather than negative RLN LNs. Survival did not differ after 3FL versus 2FL in general. However, 3FL was associated with longer survival than 2FL in patients with RLN LN positivity and either lower thoracic esophageal tumors or more than four abdominal/thoracic LN metastases. CONCLUSIONS Metastasis to RLN LNs is a reliable indicator of cervical LN metastasis in middle/lower thoracic esophageal cancer, while 3FL offers survival benefit over 2FL in certain patient subgroups.
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Affiliation(s)
- Hecheng Li
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center (FUSCC), Shanghai, 200032, China.
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Tachimori Y, Nagai Y, Kanamori N, Hokamura N, Igaki H. Pattern of lymph node metastases of esophageal squamous cell carcinoma based on the anatomical lymphatic drainage system. Dis Esophagus 2011; 24:33-8. [PMID: 20626450 DOI: 10.1111/j.1442-2050.2010.01086.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The recent anatomical studies of the esophagus showed that submucosal longitudinal lymphatic vessels connect to the superior mediastinal and the paracardial lymphatics and lymphatic routes to periesophageal nodes originate from the muscle layer. Using clinical data for lymph node metastasis, we verify these anatomical bases to clarify the rational areas of lymph node dissection in esophageal cancer surgery. Analysis was performed on 356 consecutive patients who underwent esophagectomy with three-field dissection. Patients were divided into those with tumor limited within the submucosal layer and those with tumor invading or penetrating the muscle layer. Frequency of node metastasis was compared according to supraclavicular, upper mediastinum, mid-mediastinum, lower mediastinum, perigastric and celiac areas. In patients with tumor limited to the submucosal layer, node metastasis was more frequent in the upper mediastinum and perigastric area than the mid- or lower mediastinum. Even in patients with tumor located in the lower esophagus, node metastasis was more frequent in the upper mediastinum than the mid-mediastinum or lower mediastinum. In patients with tumor located in the mid-esophagus, node metastasis was more frequent in the supraclavicular area than the mid-mediastinum or lower mediastinum. In patients with tumor invading or penetrating the muscle layer, node metastasis in the mid- and lower mediastinum increased dramatically, but was still less frequent than those in the upper mediastinum or the perigastric area. Postoperative survival curves did not differ among the involved areas. The most predictive factor associated with lymph node metastasis for postoperative survival was not the area of involved nodes, but the number of involved nodes by multivariate analyses. These clinical results verify recent anatomical observations. The lack of difference in survival rates among the involved areas suggests that these areas should be staged equivalently. For adequate nodal staging, the upper mediastinum should be dissected for the lower esophageal tumor and supraclavicular areas should be dissected for the mid-esophageal tumor even in patients with tumor limited to within the submucosal layer.
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Affiliation(s)
- Y Tachimori
- Esophageal Surgery Division, National Cancer Center Hospital, Tokyo, Japan.
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42
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Imamura Y, Hayashi N, Sato N, Kinoshita K, Kurashige J, Saito S, Hirashima K, Karashima R, Hiyoshi Y, Nagai Y, Watanabe M, Baba H. Extensive lymphatic spread of cancer cells in patients with thoracic esophageal squamous cell carcinoma: Detection of CEA-mRNA in the three-field lymph nodes. J Surg Oncol 2010; 102:509-15. [DOI: 10.1002/jso.21621] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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43
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The normal configuration and interindividual differences in intramural lymphatic vessels of the esophagus. J Thorac Cardiovasc Surg 2009; 137:1406-14. [DOI: 10.1016/j.jtcvs.2008.08.069] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Revised: 06/11/2008] [Accepted: 08/05/2008] [Indexed: 11/23/2022]
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