En-bloc esophagectomy for esophageal cancer

Initial experience with modified en bloc robot-assisted minimally invasive oesophagectomy for thoracic oesophageal squamous cell carcinoma

BACKGROUND

The feasibility and safety of en bloc robot-assisted minimally invasive oesophagectomy (RAMIE) need to be verified.

METHODS

Forty-seven patients who received conventional RAMIE and 31 who received modified en bloc RAMIE at Henan Cancer Hospital were included in the study cohort. We compared the perioperative outcomes of conventional RAMIE and modified en bloc RAMIE.

RESULTS

Compared with the conventional RAMIE group, the en bloc RAMIE group yielded a higher total number of lymph nodes (p = 0.001), especially thoracic lymph nodes (p = 0.025) and left recurrent laryngeal nerve (RLN) lymph nodes (p = 0.005). No notable differences were found in the rate of total complications (p = 0.663) or RLN injury (p = 0.891) between the two groups. The preoperative and postoperative serological indicators were comparable between the two groups.

CONCLUSIONS

Modified en bloc RAMIE was safe and feasible for patients with oesophageal squamous cell carcinoma and improved lymph node dissection, especially thoracic and left RLN lymph node dissection.

Risk factors for early local lymph node recurrence of thoracic ESCC after McKeown esophagectomy

Objectives

Even underwent radical resection, some patients of thoracic esophageal squamous cell carcinoma (ESCC) are still exposed to local recurrence in a short time. To this end, the present study sought to differentiate patient subgroups by assessing risk factors for postoperative early (within one year) local lymph node recurrence (PELLNR).

Methods

ESCC patients were selected from a prospective database, and divided into high- and low-risk groups according to the time of their local lymphatic recurrence (within one year or later). Survival analysis was conducted by the Cox regression model to evaluate the overall survival (OS) between the two groups. The hazard ratio (HR) and 95% confidence interval (CI) of different variables were also calculated. Logistic regression analysis was used to explore the high-risk factors for PELLNR with the odds ratio (OR) and 95% CI calculated.

Results

A total of 432 cases were included. The survival of patients in the high-risk group (n = 47) was significantly inferior to the low-risk group (n = 385) (HR = 11.331, 95% CI: 6.870-16.688, P < 0.001). The 1-year, 3-year, and 5-year OS rate of the patients in high/low-risk groups were 74.5% vs. 100%, 17% vs. 88.8%, and 11.3% vs. 79.2%, respectively (P < 0.001). Risk factors for local lymph node recurrence within one year included upper thoracic location (OR = 4.071, 95% CI: 1.499-11.055, P = 0.006), advanced T staging (pT3-4, OR = 3.258, 95% CI: 1.547-6.861, P = 0.002), advanced N staging (pN2-3, OR = 5.195, 95% CI: 2.269-11.894, P < 0.001), and neoadjuvant treatment (OR = 3.609, 95% CI: 1.716-7.589, P = 0.001). In neoadjuvant therapy subgroup, high-risk group still had unfavorable survival (Log-rank P < 0.001). Multivariate analysis demonstrated that upper thoracic location (OR = 5.064, 95% CI: 1.485-17.261, P = 0.010) and advanced N staging (pN2-3) (OR = 5.999, 95% CI: 1.986-18.115, P = 0.001) were independent risk factors for early local lymphatic recurrence. However, the cT downstaging (OR = 0.862, 95% CI: 0.241-3.086, P = 0.819) and cN downstaging (OR = 0.937, 95% CI: 0.372-2.360, P = 0.890) for patients in the neoadjuvant subgroup failed to lower PELLNR. The predominant recurrence field type was single-field.

Conclusions

Thoracic ESCC patients with lymph node recurrence within one year delivered poor outcomes, with advanced stages (pT3-4/pN2-3) and upper thoracic location considered risk factors for early recurrence.

Three-field versus two-field lymphadenectomy for esophageal squamous cell carcinoma: A long-term survival meta-analysis

BACKGROUND

In the setting of esophageal squamous cell carcinoma, controversy exists regarding the optimal extent of lymphadenectomy, while conclusive evidence regarding the advantages of 3-field versus 2-field lymphadenectomy remains controversial. The purpose of the present meta-analysis was to investigate the effect of 3-field lymphadenectomy versus 2-field lymphadenectomy on overall survival.

METHODS

Systematic review and meta-analyses were computed to compare 3-field lymphadenectomy versus 2-field lymphadenectomy in the setting of esophageal squamous cell carcinoma. Risk ratio, weighted mean difference, hazard ratio, and restricted mean survival time difference were used as pooled effect size measures.

RESULTS

Fourteen studies (3,431 patients) were included. Overall, 1,664 (48.8%) patients underwent 3-field lymphadenectomy, and 1,767 (51.5%) underwent 2-field lymphadenectomy. Three-field lymphadenectomy was associated with a significantly improved 5-year overall survival (hazard ratio: 0.80; 95% confidence interval 0.71-0.90; P < .001). The restricted mean survival time difference showed a statistically significant difference between 3-field lymphadenectomy versus 2-field lymphadenectomy up to 48 months (1.6 months; P = .04), however, no significant differences were found at 60-month follow-up (1.2 months; P = .14). No significant differences were found in term of postoperative mortality, anastomotic leak, pulmonary complications, chylothorax, and recurrent nerve palsy.

CONCLUSION

For resectable esophageal squamous cell carcinoma, 3-field lymphadenectomy seems associated with a slight trend toward improved 5-year overall survival; however, its clinical benefit remains limited.

Esophageal Cancer: Recent advances

Esophageal carcinoma has, over the past decade, undergone a sea of change, not only in its pathological distribution, but also in the diagnosis, staging and subsequent management. Although the advent of better imaging techniques has helped in diagnosing patients at an earlier period, the majority of them have unresectable disease at the time of presentation. Despite aggressive treatment protocols involving either one or a combination of the options of surgery, radiation, and chemotherapy, the five-year survival remains dismal in the order of 10 to 15%. The two most commonly used surgical techniques for resecting the esophagus, the Ivor Lewis and the trans-hiatal esophagectomy, have similar results in terms of morbidity, mortality and, more importantly, five-year survival following resection. There has been an increasing interest in the surgical treatment of carcinoma esophagus by a minimally invasive approach, as meta-analysis of clinical series have shown that a faster recovery time without any statistically significant difference in the in-hospital mortality or morbidity when compared to conventional surgery. Nonrandomized studies suggest that patients receiving neoadjuvant chemo-radiation have a five year survival advantage compared with those treated with surgery alone, especially if they had a complete histological response to the preoperative regimen. Lastly, palliative procedures, form the mainstay of management of patients with non-resectable disease.

Altered localization of p120 catenin in the cytoplasm rather than the membrane correlates with poor prognosis in esophageal squamous cell carcinoma

BACKGROUND

P120 catenin (p120ctn), a regulator of cell adhesion, has previously been found in many malignancies, and suggested a role in invasion, metastasis and survival. The aim of this study was to investigate correlations between altered localization of p120ctn and clinical-pathological characteristics in esophageal squamous cell carcinoma (ESCC).

METHODS

Immunohistochemical staining for p120ctn was performed on tissue samples from 118 patients with ESCC. The expression of p120ctn was scored for intensity and cellular localization by Image-pro Plus 6.0. Correlations between immunohistochemical staining of p120ctn and pathological characteristics and clinical prognosis were determined using SPSS 18.0 software.

RESULTS

Membrane expression of p120ctn in ESCCs was lower than that in adjacentnormal esophageal epithelial tissues (P = 0.041), while overall cellular expression of p120ctn was not different between the two tissue types (P = 0.787). Furthermore, neither overall cellular expression nor localized membrane expression was associated with histological and clinical variables. The high ratio of membrane expression to overall cellular expression (M/C) of p120ctn was inversely associated with lymph node invasion (P = 0.001), tumor differentiation (P = 0.012) and advanced tumor stage (P = 0.005); however, it was poorly associated with T stage (P = 0.274). The high M/C ratio of p120ctn was inversely correlated with poor survival; the 5-year OS (overall survival) and the 5-year DFS (disease free survival) for the high M/C ratio group were significantly higher than those of the low M/C ratio group (41.0% vs. 6.7%, P = 0.000; 44.1% vs. 24.9%, P = 0.007). Both the M/C ratio of p120ctn and N status were independent variables for the prediction of overall survival (P = 0.007 and P = 0.027). The M/C of p120ctn predicted a 0.49-fold risk of ESCC death (p = 0.007, 95% CI 0.29-0.83).

CONCLUSIONS

The reduced M/C ratio of p120ctn acted as an independent prognostic factor for ESCC patient survival and for the migration and invasive behavior of the disease.

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C. Mariette, G. Piessen, C. Vons Lymph node invasion is the principal prognostic factor in cancers of the stomach and esophagus which have a tendency to early lymphatic spread.The anatomy of regional lymph node groupings is described and standard and extended types of lymphadenectomy are defined. We discuss he role of lymph node dissection - particularly extended lymphadenectomy - and assess whether there is demonstrable benefit in terms of morbidity and mortality, loco-regional recurrence, and survival. Articles from the surgical literature with the highest levels of evidence are analyzed. Practical guidelines for treatment choice are proposed.

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C. Mariette, G. Piessen, C. Vons Lymph node invasion is the principal prognostic factor in cancers of the stomach and esophagus which have a tendency to early lymphatic spread.The anatomy of regional lymph node groupings is described and standard and extended types of lymphadenectomy are defined. We discuss he role of lymph node dissection - particularly extended lymphadenectomy - and assess whether there is demonstrable benefit in terms of morbidity and mortality, loco-regional recurrence, and survival. Articles from the surgical literature with the highest levels of evidence are analyzed. Practical guidelines for treatment choice are proposed.

Avaliação da reconstrução do trato alimentar com tubo gástrico ou colônico na esofagectomia por câncer de esôfago

OBJETIVO: Relatar a experiência com as principais técnicas de reconstrução do trato alimentar após esofagectomia por câncer de esôfago. METODOS: Foram analisados retrospectivamente 68 pacientes submetidos à esofagectomia entre fevereiro de 1997 e novembro de 2005. Todos os pacientes incluídos no estudo foram submetidos à esofagectomia com reconstrução com tubo gástrico ou colônico e anastomose cervical. RESULTADOS: A idade média foi de 55,4 anos (25-74 anos), 50 pacientes eram do sexo masculino e 18 pacientes do sexo feminino, 27 pacientes apresentavam o tumor localizado no esôfago médio e 41 pacientes no esôfago distal, sendo carcinoma epidermóide em 35 pacientes e adenocarcinoma em 33 pacientes. A ressecção foi por via transtorácica em 35 indivíduos e por via transhiatal em 33. A reconstrução com tubo gástrico se deu em 58 pacientes e com tubo colônico em 10 pacientes. A morbidade total da série foi de 52,9%. A mortalidade operatória foi de 5,8%. A sobrevida média foi de 35 meses. CONCLUSÃO: A esofagectomia com reconstrução com tubo gástrico e anastomose cervical é factível tecnicamente, sendo um procedimento realizado de rotina nos pacientes portadores de câncer de esôfago com indicação cirúrgica. Utilizamos, e recomendamos, a reconstrução com tubo colônico principalmente nos pacientes com cirurgia prévia no estômago ou quando da necessidade de ressecção ampliada deste, impossibilitando a confecção da reconstrução do trânsito alimentar com a gastroplastia.

Clinicopathologic Features of Superficial Esophageal Cancer: Results of Consecutive 100 Patients

BACKGROUND

The depth of tumor penetration is a crucial factor in determining the prognosis of patients with esophageal carcinoma. Patients with superficial esophageal carcinoma (SEC) have a far more favorable clinical course compared with those with advanced cancers. The outcome for patients with mucosal cancer is excellent with a 5-year survival rate exceeding 80%. On the other hand, submucosal cancer often metastasizes to regional and/or distant lymph nodes or other organs, and the prognosis of these patients are far from satisfactory.

METHODS

Among 334 patients with esophageal cancer who underwent surgery between December 1980 and December 2006, 100 patients (30%) had SEC confined to the epithelium, lamina propria mucosa, or submucosa. Patient and tumor characteristics of those 100 patients were studied.

RESULTS

The prevalence of SEC has increased from 13% (8 of 61) in the initial 5-year period (1985-1989) to 44% (41 of 93) in the recent 7-year period (2000-2006). Subjective symptoms were present in 7 (14%) of 51 mucosal cancers and in 13 (27%) of 49 submucosal cancers. The remaining 80 patients (80%) had no subjective symptoms. Ninety-one patients (91%) were diagnosed to have the lesions by endoscopy at the time of screening for gastric problems, and only nine were detected by gastrointestinal series. Four of 51 patients with mucosal cancer had venous or lymph vessel invasion, and among those, only one (2%) had a solitary perigastric lymph node metastasis. In 49 patients with submucosal cancer, 35 (71%) had lymph vessel invasion, 28 (57%) had venous invasion, and 16 (33%) had lymph node metastases. In particular, 15 of 35 patients with positive lymph vessel invasion had lymph node metastasis, whereas only 1 of 14 with negative lymph vessel invasion had lymph node metastasis (P < .05). Among 17 patients with nodal involvement, 4 patients with upper thoracic SEC had upper mediastinum and/or cervical nodal metastases, 11 patients with middle thoracic SEC had widespread upper and lower mediastinal and abdominal metastases, and 2 patients with lower thoracic SEC had lower and abdominal lymph node metastases. Seventy-nine patients were alive without recurrence at last follow-up. Five of 49 patients with submucosal cancer died of recurrent disease, and 4 of these developed regional nodal recurrence around the bilateral laryngeal recurrent nerves. Forty-two patients (42%) developed double cancers during the follow-up period, and 5 died of a second cancer. The 3- and 5-year survival rates of all 100 patients were 85% and 73%, and those disease-specific survival rates were 96% and 93%, respectively. The 3- and 5-year survival rates for patients with mucosal cancer were 89% and 83%, and those for submucosal cancer were 80%, and 64%, respectively.

CONCLUSIONS

Esophagectomy with extensive lymphadenectomy should be carried out particularly for upper thoracic submucosal cancer, whereas esophagectomy with moderate lymphadenectomy may be preferred for mucosal cancer. Patients with SEC should be examined for another primary cancer preoperatively and periodically during follow-up.

EUS-guided implantation of radiopaque marker into mediastinal and celiac lymph nodes is safe and effective

BACKGROUND

EUS is the preferred modality for local staging of esophageal cancer. The presence of a long-lasting fluoroscopically visible marker of malignant lymph nodes would facilitate subsequent radiation and surgical therapy.

OBJECTIVE

To assess the feasibility of EUS-guided implantation of a radiopaque marker (tantalum) into mediastinal and celiac lymph nodes in a porcine model.

SETTING

Survival experiments on six 50-kg pigs.

DESIGN AND INTERVENTIONS

A linear-array echoendoscope was advanced into the esophagus and the stomach. Mediastinal and celiac lymph nodes were identified and injected with 1 mL tantalum suspension by using 19- and 22-gauge FNA needles under fluoroscopy. The pigs were recovered. Fluoroscopy was repeated after 1, 2, and 4 weeks, then a postmortem examination was performed.

MAIN OUTCOME MEASUREMENTS

Long-term opacification of lymph nodes.

RESULTS

It was not possible to inject tantalum through the 22-gauge FNA needle because of its rapid precipitation inside the needle, which caused needle occlusion. Intranodal injection with the 19-gauge FNA needle was easily accomplished and resulted in excellent fluoroscopic opacification of injected lymph nodes. Repeat fluoroscopy at 1, 2, and 4 weeks demonstrated stable tantalum deposition at the injection site. There were no complications. Histologic examination of harvested lymph nodes revealed intranodal tantalum depositions without signs of infection, inflammation, tissue damage, or necrosis.

CONCLUSIONS

EUS-guided implantation of tantalum as a radiopaque marker into mediastinal and celiac lymph nodes in a porcine model is technically feasible, safe, and results in long-lasting intranodal depositions to facilitate subsequent surgical and radiotherapeutic interventions.

Lymph node dissection in surgical treatment of esophageal neoplasms

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

Effect of pyloric drainage procedures on gastric passage and bile reflux after esophagectomy with gastric conduit reconstruction

BACKGROUND AND AIMS

Controversy still exists about the need for pyloric drainage procedures (pyloroplasty or pyloromyotomy) after esophagectomy with esophagogastrostomy and vagotomy. Although pyloric drainage may prevent postoperative delayed gastric emptying, it may also promote bile reflux into the oesophagus. We analysed pyloric drainage methods for their potential effect on gastric outlet obstruction and bile reflux in patients undergoing esophagectomy.

MATERIALS AND METHODS

One hundred and ninety-eight patients with esophageal carcinoma were treated by transthoracal esophagectomy with gastric conduit reconstruction either with pyloromyotomy (group II, n = 118), pyloroplasty (group III, n = 34) or without pyloric drainage (group I, n = 46) between January 2000 and December 2004. The postoperative gastrointestinal passage by radiological investigation, anastomotic leakage rate, mortality and incidence of gastroesophageal reflux by endoscopy within the first postoperative year were retrospectively analysed.

RESULTS

Patient demographics and the types of surgical procedures did not differ between the three groups. There was no difference in hospital mortality, anastomotic leakage rate, gastrointestinal passage and postoperative hospital stay between the three groups. However, more patients with pyloric drainage showed bile reflux (I = 0% vs II+III=14.9%, p = 0.069) and reflux esophagitis (I = 10.3% vs II+III = 34.5%, p < 0.05) compared to patients without pyloric drainage. On the multivariate analysis, pyloric drainage and the anastomotic height were independent and were significant risk factors associated with postoperative reflux esophagitis.

CONCLUSION

Pyloric drainage after esophagectomy with gastric conduit reconstruction should be omitted because it does not improve gastric emptying and may favour biliary reflux esophagitis.

Prognostic significance of vascular endothelial growth factor expression and microvessel density in esophageal squamous cell carcinoma: comparison with positron emission tomography

BACKGROUND

This study investigated whether the expression of vascular endothelial growth factor (VEGF) in a primary tumor and the intratumoral microvessel density (MVD) were independent prognostic factors in patients with an esophageal squamous cell carcinoma (SCC) in comparison with positron emission tomography (PET) by using (18)F-fluorodeoxyglucose (FDG) and stage.

METHODS

Fifty-one patients with a newly diagnosed esophageal SCC who underwent preoperative FDG-PET and esophagectomy with intent to cure were enrolled in this study. The VEGF expression level, the intratumoral MVD, and the Ki-67 labeling index were evaluated by using immunohistochemical staining. Only significant variables in the univariate survival analysis were examined by multivariate survival analysis with the Cox proportional hazards model.

RESULT

Cancer-related deaths occurred in 17 of 51 patients during the follow-up. Univariate survival analysis showed that the pathologic stage, pNM, maximum standardized uptake value of the primary tumor, tumor length on PET, number of PET-positive lymph nodes, PET stage, Ki-67 labeling index, intratumoral MVD, and the presence of VEGF expression were significant prognostic predictors for the overall survival. Multivariate analysis revealed that the pathologic stage, number of PET-positive nodes (0, 1, 2, or > or = 3), intratumoral MVD (cutoff, 60/mm(2)), and presence of VEGF expression were independent significant prognostic predictors for overall survival.

CONCLUSION

In addition to the pathologic stage, the intratumoral MVD, the presence of VEGF expression, and the number of FDG-PET-positive nodes were independent prognostic predictors in patients with an esophageal SCC undergoing curative surgery.

Surgical treatment of superficial esophageal cancer

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA SYNTHESIS

The collected information was organized.

CONCLUSIONS

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