Occult cervical nodal metastasis in esophageal cancer: preliminary results of three-field lymphadenectomy

Three-Field Versus Two-Field Lymphadenectomy in Minimally Invasive Esophagectomy: 3-Year Survival Outcomes of a Randomized Trial

BACKGROUND

Minimally invasive esophagectomy (MIE) has been used widely for the treatment of esophageal cancer. However, the optimal extent of lymphadenectomy for esophagectomy in MIE remains unclear. This trial aimed to investigate the 3-year survival and recurrence outcomes in a randomized controlled trial comparing MIE with either three-field lymphadenectomy (3-FL) or two-field lymphadenectomy (2-FL).

METHODS

Between June 2016 and May 2019, 76 patients with resectable thoracic esophageal cancer were enrolled in a single-center randomized controlled trial and randomly assigned to MIE that included either 3-FL or 2-FL at a 1:1 ratio (n = 38 patients each). The survival outcomes and recurrence patterns were compared between the two groups.

RESULTS

The 3-year cumulative overall survival (OS) probability was 68.2 % (95 % confidence interval [CI], 52.72-83.68 %) for the 3-FL group and 68.6 % (95 % CI, 53.12-84.08 %) for the 2-FL group. The 3-year cumulative probability of disease-free survival (DFS) was 66.3 % (95 % CI, 50.03-82.57 %) for the 3-FL group and 67.1 % (95 % CI, 51.03-83.17 %) for the 2-FL group.. The OS and DFS differences in the two groups were comparable. The overall recurrence rate did not differ significantly between the two groups (P = 0.737). The incidence of cervical lymphatic recurrence in the 2-FL group was higher than in the 3-FL group (P = 0.051).

CONCLUSIONS

Compared with 2-FL in MIE, 3-FL tended to prevent cervical lymphatic recurrence. However, it was not found to add survival benefit for the patients with thoracic esophageal cancer.

Postoperative lymphatic recurrence distribution and delineation of the radiation field in lower thoracic squamous cell esophageal carcinomas: a real-world study

Background

To study lymphatic recurrence distribution after radical surgery in the real world and guide clinical tumor volume delineation for regional lymph nodes during postoperative radiotherapy for lower thoracic squamous cell esophageal carcinomas.

Methods

We enrolled patients who underwent radical esophagectomy, without radiation before or after surgery, at 3 cancer hospitals. Patients were classified into groups according to tumor locations. We included patients with tumors in the lower thoracic segment and analyzed the postoperative lymph node recurrence mode. A cutoff value of 10% was used to differentiate high-risk lymph node drainage areas from others.

Results

We enrolled 1905 patients in the whole study series, including 652 thoracic esophageal carcinomas that met our inclusion criteria; there were 241 cases of lower thoracic esophageal carcinomas. 1st, 2nd, 4th, 7th, 8th groups of lymph nodes, according to the 8th edition of the AJCC classification, displayed as high-risk recurrence areas, representing 17.8%, 23.9%, 11.7%, 10.9% and 12.2% of lymph node recurrence. Stage III-IV tumors located in the lower segment of the thoracic esophagus showed a tendency to recur in the left gastric nodes (7.9%) and celiac nodes (10.6%).

Conclusions

According to our results, we recommended including the 4th, 7th and 8th groups of lymph nodes in the radiation field, and for patients with stage III-IV disease, the 17th and 20th groups of nodes should be irradiated during postoperative treatment. Whether including 1st/2nd groups in preventive irradiation needed more proofs.

Interstitial 125I Brachytherapy as a Salvage Treatment for Refractory Cervical Lymph Node Metastasis of Thoracic Esophageal Squamous Cell Carcinoma After External Irradiation With a CT-Guided Coplanar Template-Assisted Technique: A Retrospective Study

Purpose: To analyze the outcome and prognosis of patients with refractory cervical lymph node metastasis of thoracic esophageal squamous cell carcinoma after external irradiation, who underwent interstitial ¹²⁵I brachytherapy as a salvage treatment with a CT-guided coplanar template-assisted technique. We also want to compare the dosimetry of 3D printed coplanar template-assisted interstitial ¹²⁵I brachytherapy preoperative and postoperative, and to explore the accuracy of this technology. Material and methods: We retrospectively collected and analyzed the results of 32 patients with refractory cervical lymph node metastasis of thoracic esophageal squamous cell carcinoma after external irradiation, who underwent interstitial ¹²⁵I brachytherapy as a salvage treatment with a CT-guided coplanar template-assisted technique from January 2012 to December 2017. Results: The actual D90 were 114 to 240 Gy, and the median postoperative dosimetry assessment was 177.5 Gy. The local control rates at 3, 6, 9, and 12 months were 87.5%, 59.38%, 40.63%, and 31.25%, respectively. The median local control time was 7.5 months. The median overall survival time was 10.5 months (95% CI, 8.9-13.4), and the survival rates of 1- and 2-year, respectively, were 43.75% and 9.38%. There were 36 lesions in 32 patients. By performing a paired t-test analysis, there was no significant difference in D90, D100, V100, V150, V200, GTV volume, CI, EI, and HI between preoperative and postoperative (P > .05). Conclusions: Interstitial ¹²⁵I brachytherapy can be used as a salvage treatment for patients with refractory cervical lymph node metastasis of thoracic esophageal squamous cell carcinoma after external irradiation. With the auxiliary function of 3D printed coplanar template, the main dosimetry parameters verified after the operation can meet the requirements of the preoperative plan with good treatment accuracy.

Three-Field Lymphadenectomy in Minimally Invasive Esophagectomy for Squamous Cell Carcinoma

BACKGROUND

Minimally invasive esophagectomy (MIE) has been used widely for the treatment of esophageal cancer. However, there is still a lack of consensus on the extent of lymphadenectomy in MIE. The objective of this study was to investigate the safety and efficacy of three-field lymphadenectomy (3-FL) in MIE, compared with the standard two-field lymphadenectomy (2-FL).

METHODS

A single-center randomized controlled trial was conducted, enrolling patients with resectable thoracic esophageal cancer (cT1-3,N0-3,M0) between June 2016 and May 2019. Eligible patients were randomized into two groups to receive either 3-FL or 2-FL during MIE procedures. Perioperative outcomes of the two groups were compared. The trial was registered in the Chinese Clinical Trial Registry (ChiCTR-INR-16007957).

RESULTS

Seventy-six eligible patients were randomly assigned to the 3-FL group (n = 38) and the 2-FL group (n = 38). Compared with patients in the 2-FL group, patients in the 3-FL group had more lymph nodes harvested (54.7 ± 16.5vs 30.9 ± 9.6, P < .001) and more metastatic lymph nodes identified (3.5 ± 4.5 vs 1.7 ± 2.0, P = .027). Patients in the 3-FL group were diagnosed with a more advanced final pathologic TNM stage than patients in the 2-FL group. There was no significant difference between the two groups in blood loss, major postoperative complications, or duration of hospital stay, except that the operation time was longer in the 3-FL group than in the 2-FL group (270.5 ± 45.4 minutes vs 236.7 ± 47.0 minutes, P = .002).

CONCLUSIONS

Three-field lymphadenectomy allowed harvesting of more lymph nodes and more accurate staging without increased surgical risks compared with 2-FL MIE for esophageal cancer.

Hypofractionated Radiotherapy in Combination With Chemotherapy Improves Outcome of Patients With Esophageal Carcinoma Tracheoesophageal Groove Lymph Node Metastasis

This study investigated the efficiency and safety of hypofractionated radiotherapy (HFR) combined with paclitaxel chemotherapy for the treatment of postsurgery tracheoesophageal groove lymph node (TGLN) metastasis in patients with esophageal cancer (EC). Fifty-three EC patients with TGLN metastasis after surgery admitted to the Yancheng Third People's Hospital from January 2013 to June 2015 were included in this study. They were randomly divided into the HFR group (n = 25) and conventional fractioned radiotherapy (CFR) group (n = 28) based on the random grouping method. Patients in the HFR group received treatment with radiation of 60 Gy (5 fractions per week, total 20 fractions) combined with paclitaxel chemotherapy at a dose of 50 mg once per week for 4 weeks. Patients in the CFR group received radiation of 60 Gy (5 fractions per week, total 30 fractions) combined with paclitaxel chemotherapy at a dose of 50 mg once per week for 6 weeks. The adverse events and treatment outcomes in these two groups were analyzed. It was found that there was no significant difference in the incidence of radiation esophagitis in the HFR group compared with that of the CFR group (grades 3-4, 44.0 vs. 25.0%; P = 0.149). There was no statistical difference in the incidence of radiation pneumonitis between these two groups (grades 3-4, 16.0 vs. 7.1%; P = 0.314). No statistical difference was noticed in complete response (CR), partial response (PR), and no response (NR) between these two groups. The median overall survival (OS) in the HRF group was significantly longer compared with that of the CRF group (24.2 months (95% CI, 16.2-32.1 months) vs. 11.8 months (95% CI, 9.2-14.4 months); P = 0.024). Our results indicated that the combination of HFR and chemotherapy improved the prognosis of EC patients with TGLN metastasis with no increased adverse events.

Comparison of short- and long-term outcomes between 3-field and modern 2-field lymph node dissections for thoracic oesophageal squamous cell carcinoma: a propensity score matching analysis

OBJECTIVES

Our goal was to compare short- and long-term outcomes between 3-field lymphadenectomy (3-FL) and modern 2-field lymphadenectomy (2-FL) in patients with thoracic oesophageal squamous cell carcinoma.

METHODS

We reviewed clinical outcomes for 298 patients with thoracic oesophageal squamous cell carcinoma who underwent 3-FL or modern 2-FL from March 2008 to December 2013 at a major cancer hospital in Guangzhou, southern China. Propensity score matching was used to balance baseline differences, and 83 pairs of cases were selected. Postoperative complications, recurrence patterns and survival outcomes were compared between the 2 groups.

RESULTS

Compared with modern 2-FL, 3-FL led to higher overall operative morbidity rates [78.3% vs 61.4%, odds ratio (OR) 2.266, 95% confidence interval (CI) 1.143-4.490; P = 0.019], with higher recurrent nerve palsy rates (47.0% vs 19.3%, OR 3.712, 95% CI 1.852-7.438; P < 0.0001), more respiratory failures (18.1% vs 6.0%, OR 3.441, 95% CI 1.189-9.963; P = 0.023) and longer postoperative hospital stays (23 vs 17 days, P = 0.002). The 5-year overall survival rate (58.5% vs 59.4%; P = 0.960) and the 5-year disease-free survival rate 50.1% vs 54.5%; P = 0.482) were comparable between the 2 groups. Multivariable analysis showed that additional cervical lymph node dissection was not associated with overall survival [hazard ratio (HR) 1.039, 95% CI 0.637-1.696; P = 0.878] and disease-free survival (HR 0.868, 95% CI 0.548-1.376; P = 0.547). The overall recurrence rate and cervical nodal recurrence rate were not significantly different between the 2 groups.

CONCLUSIONS

Additional cervical lymphadenectomy did not lead to added survival benefit when compared with modern 2-FL in patients with thoracic oesophageal squamous cell carcinoma. Recurrence was similar in patients undergoing 3-FL and modern 2-FL. 3-FL resulted in more postoperative complications.

Should the clinical significance of supraclavicular and celiac lymph node metastasis in thoracic esophageal cancer be reevaluated?

Background

Lower thoracic esophageal cancer (LTEC) with celiac node metastasis and upper thoracic esophageal cancer (UTEC) with supraclavicular node metastasis were previously categorized as M1a diseases. Our study aimed to investigate whether the clinical significance of supraclavicular and celiac lymph node metastasis should be reevaluated in thoracic esophageal cancer.

Methods

A total of 6178 patients with thoracic esophageal cancer were identified from the Surveillance, Epidemiology, and End Results (SEER) database during 2004–2015. Treatment strategies and outcomes (OS, overall survival; CSS, cancer‐specific survival) of patients with different nodal status were reviewed. The Cox proportional hazards regression model was applied to evaluate the prognostic factors. Statistical analyses were performed in all subgroups.

Results

Multivariate analysis identified supraclavicular node metastasis but not celiac node metastasis as an independent predictor of both OS and CSS in LTEC. However, metastasis to supraclavicular or celiac nodes was not an independent predictor of OS and CSS in UTEC. Surgery was not associated with increased OS and CSS for UTEC with celiac or supraclavicular node metastasis but was favored as a predictor of better OS and CSS for LTEC with celiac or supraclavicular node metastasis. Radiotherapy benefited OS and CSS in LTEC involving celiac or supraclavicular nodes and in UTEC involving celiac nodes, while only OS benefited from radiotherapy in UTEC involving supraclavicular nodes.

Conclusions

These results provide preliminary evidence that the clinical significance of supraclavicular and celiac lymph node metastasis should be reevaluated in thoracic esophageal cancer with different prognostic information according to the primary sites.

Comparison of two major staging systems of esophageal cancer-toward more practical common scale for tumor staging

The latest 8th edition of TNM Classification of Malignant Tumours by Union for International Cancer Control (UICC) and 11th edition of Japanese Classification of Esophageal Cancer by Japan Esophageal Society (JES) are the two major classifications widely accepted as tools for clinical staging of esophageal cancer. Both systems consist of three main categories, i.e., T, N, and M, but large difference exists between the two. JES system has more detailed sub-classification of T1 tumors reflecting meticulous work by Japanese investigators on superficial esophageal cancer. N-category shows the largest difference. UICC defines the N-category according to only the number of the metastatic regional lymph nodes. The definition of regional nodes in UICC system is static and uniform, and supraclavicular nodes are definitely excluded. In JES system, regional nodes are subgrouped into five different patterns according to the main tumor location, and the supraclavicular nodes are always regional nodes for thoracic esophageal cancer. Japanese surgeons have described the evidence that regional nodes should be dynamically defined according to tumor location and supraclavicular nodes should be included in regional nodes. Compared to the simplified N-category, the staging matrix of UICC system is somewhat complicated. The clinical stage and pathological stage of UICC system are not identical and difference exists also between squamous cell carcinoma (SCC) and adenocarcinoma. It has another system of pathological prognostic grouping. We can imagine several reasons for the difference occurred between the two systems. One is the difference of major pathology. Another reason is the difference of basic concept of cancer treatment. The relative "dependence" on radical surgery in Japan has required the detailed definition of each lymph node station and the evaluation of "efficacy index" of each station. The strict and detailed definition of lymph node stations has been regarded as an obstacle to those who are not familiar with it. Some simplification can be done but maintaining dynamic definition of regional lymph nodes linked to tumor location. If UICC system can accept this concept, I think the two systems can be unified to realize more practical and useful staging system as an international common language.

Clinicopathologic analysis of lymph node status in superficial esophageal squamous carcinoma

BACKGROUND

Endoscopic approaches are gradually considered as a reliable treatment of intramucosal esophageal squamous carcinoma. However, endoscopic resection (ER) is limited by the potential lymph node metastasis (LNM) at various depths of mucosal and submucosal invasion.

METHODS

We conducted a retrospective review of 498 patients with pT1 superficial esophageal squamous carcinoma (SESC) who underwent surgical resection from January 2008 to August 2015. Pathological characteristics of tumors including location, size, appearance, differentiation, invasion depth, and nodal status were reviewed, and risk factors were analyzed.

RESULTS

LNM was found in 0.0, 2.7, 6.3, 18.2, 15.9, and 34.3 % of the m1, m2, m3, sm1, sm2, and sm3 lesions, respectively. Univariate logistic regression identified the presence of the tumor size > 2 cm (p < 0.05), the presence of the poor tumor differentiation (p < 0.05), and the depth of tumor invasion (p < 0.05) and angiolymphatic invasion (p < 0.05) to be the important risk factors associated with the prevalence of tumor-positive lymph nodes. These findings were confirmed in multivariate logistic regression as independent predictors for LNM.

CONCLUSIONS

ER is considered as a reliable treatment of m1 to m2 lesions. Radical surgical resection (SR) is the standard and irreplaceable therapy of sm1 to sm3 lesions. Patients with m3 lesions should undergo ER as the initial procedure for diagnosis. And this treatment is supported only by a successful description of the tumor's characteristics, including (1) only muscularis mucosa invasion and without invasion of the resection margins and (2) without any risk predictors for LNM. Otherwise, SR is recommended.

Macrophage-Targeted Indocyanine Green-Neomannosyl Human Serum Albumin for Intraoperative Sentinel Lymph Node Mapping in Porcine Esophagus

BACKGROUND

The sentinel lymph node (SLN) concept has been proposed to avoid unnecessary invasive LN dissection in surgery for esophageal cancer. This study evaluated a new macrophage-targeting fluorescent agent, indocyanine green-neomannosyl human serum albumin (ICG:MSA), for SLN mapping using a custom-made intraoperative color and fluorescence-merged imaging system (ICFIS) in porcine esophagus.

METHODS

The LN targeting ability of ICG:MSA, indocyanine green-human serum albumin (ICG:HSA), and ICG was examined in vitro using the U937 differentiated monocyte cell line and in vivo in a mouse footpad model using fluorescence imaging. SLN identification in rabbit esophagus was then performed using ICG:MSA, ICG:HSA, and ICG. Finally, intraoperative SLN detection was conducted in porcine esophagus after esophagoscopic injection of ICG:MSA.

RESULTS

The fluorescence signal of U937 cells treated by ICG:MSA was significantly higher than that of ICG or ICG:HSA (ICG: 1.0 ± 0.37; ICG:HSA: 3.4 ± 0.28, ICG:MSA: 6.8 ± 1.61; ICG to ICG:HSA, p = 0.03; ICG:HSA to ICG:MSA, p = 0.04; ICG to ICG:MSA, p = 0.0009). ICG:MSA was retained in popliteal LNs as long as 3 h, while ICG rapidly diffused through the entire mouse lymphatic system within 5 min. Esophageal SLN was detected within 15 min after injection of either ICG or ICG:MSA, but ICG:MSA provided more distinguishable images of LNss than ICG in rabbit esophagus. The SLN was also successfully detected in all porcine esophagus; the mean number of SLNs identified per esophagus was 1.6 ± 0.55.

CONCLUSIONS

ICG:MSA has more specific macrophage-targeting properties, which could overcome the limitation of the low SLN retention of ICG, and could provide more precise real-time SLN detection during esophageal cancer surgery.

Intraoperative recurrent laryngeal nerve monitoring: a useful method for patients with esophageal cancer

It is well accepted that recurrent laryngeal nerve paralysis is a severe complication of esophagectomy or lymphadenectomy performed adjacent to the recurrent laryngeal nerves. Herein, determination of the effectiveness of implementing continuous recurrent laryngeal nerve monitoring to reduce the incidence of recurrent laryngeal nerve paralysis after esophagectomy was sought. A total of 115 patients diagnosed with esophageal cancer were enrolled in the thoracic section of the Tangdu Hospital of the Fourth Military Medical University from April 2008 to April 2009. Clinical parameters of patients, the morbidity, and the mortality following esophageal resection were recorded and compared. After the surgery, a 2-year follow up was completed. It was found that recurrent laryngeal nerve paralysis and postoperative pneumonia were more frequently diagnosed in the patients that did not receive continuous recurrent laryngeal nerve monitoring (6/61 vs. 0/54). Furthermore, positive mediastinal lymph nodes (P = 0.015), total mediastinal lymph nodes (P < 0.001), positive total lymph nodes (P = 0.027), and total lymph nodes (P < 0.001) were more often surgically removed in the patients with continuous recurrent laryngeal nerve monitoring. These patients also had a higher 2-year survival rate (P = 0.038) after surgery. It was concluded that continuous intraoperative recurrent laryngeal nerve monitoring is technically safe and effectively identifies the recurrent laryngeal nerves. This may be a helpful method for decreasing the incidence of recurrent laryngeal nerve paralysis and postoperative pneumonia, and for improving the efficiency of lymphadenectomy.

Clinicopathologic factors predicting lymph node metastasis in superficial esophageal squamous cell carcinoma

OBJECTIVE

Surgical resection is the treatment of choice for superficial esophageal squamous cell carcinoma (SESCC), but it is associated with high mortality and morbidity rates. Recently, endoscopic resection for SESCC has been indicated for patients with a low risk of lymph node metastasis (LNM). Therefore, to successfully treat SESCC with endoscopic resection, it is very important to identify patients with a low risk for LNM. The objective of this study was to investigate clinicopathologic factors that predict LNM in patients who underwent esophagectomy for SESCC.

METHODS

The study included 104 patients with SESCC from three university hospitals in Pusan, Korea. Clinicopathologic factors were evaluated to identify independent factors predicting LNM by univariate and multivariate analyses.

RESULTS

In univariate analysis, the depth of tumor invasion and lymphovascular invasion had significant influences on LNM (p=0.001 and p<0.001, respectively). Gross type, tumor size, and tumor differentiation were not predictive for LNM. In multivariate analysis, the depth of tumor invasion and lymphovascular invasion were significantly associated with LNM in patients with SESCC (OR 9.04, p=0.049; OR 11.61, p=0.002, respectively).

CONCLUSIONS

The depth of tumor invasion and lymphovascular invasion were independent predictors of LNM in patients with SESCC. Therefore, endoscopic resection could be performed in patients with SESCC that is limited to the mucosa, without lymphovascular invasion.

Clinical outcomes of basaloid squamous cell carcinoma of the esophagus: a retrospective analysis of 142 cases

BACKGROUND

Basaloid squamous cell carcinoma of the esophagus (BSCCE) is a rare and distinctive tumor with no standard treatment. This study aimed to explore treatment in relation to prognosis of the disease.

METHODS

A total of 142 patients with BSCCE that underwent treatment in our hospital from March 1999 to July 2010 were retrospectively analyzed. All patients received surgery, 42 postoperative radiotherapy and 28 patients chemotherapy.

RESULTS

There were 26 patients included in stage I, 60 in stage II, 53 in stage III and 3 in stage IV. The clinical symptoms and macroscopic performances of BSCCE did not differ from those of typical esophageal squamous cell carcinoma. Among 118 patients receiving endoscopic biopsy, only 12 were diagnosed with BSCCE. The median survival time (MST) of the entire group was 32 months, with 1-, 3- and 5-year overall survival (OS) of 81.4%, 46.8% and 31.0%, respectively. The 5-year OS of stage I and II patients was significantly longer than that of stages III/IV, at 60.3%, 36.1% and 10.9%, respectively (p<0.001, p=0.001). The MST and 5-year OS were 59.0 months and 47.4% in patients with tumors located in the lower thoracic esophagus, and 27.0 months and 18.1% in those with lesions in the upper/middle esophagus (p=0.002). However, the survival was not significantly improved in patients undegoing adjunctive therapy. Multivariate analysis showed TNM stage and tumor location to be independent prognostic factors. Furthermore, distant metastasis was the most frequent failure pattern, with a median recurrence time of 10 months.

CONCLUSION

BSCCE is an aggressive disease with rapid progression and a propensity for distant metastasis. It is difficult to make a definitive diagnosis via preoperative biopsy. Multidisciplinary therapy including radical esophagectomy with extended lymphadenectomy should be recommended, while the effectiveness of radiochemotherapy requires further validation for BSCCE.

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

BACKGROUND

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Postchemoradiation resected locally advanced esophageal and gastroesophageal junction carcinoma: long-term outcome with or without intraoperative radiotherapy

BACKGROUND

To report feasibility, tolerance, anatomical topography of locoregional recurrence (LRR), and long-term outcome for esophageal and esophagogastric (EG) cancer patients treated with preoperative chemoradiation (CRT) and surgery with or without a radiation boost of intraoperative electron beam radiotherapy (IOERT).

METHODS

From January 1995 to December 2010, 53 patients with primary esophageal (n = 26; 44 %) or EG carcinoma (n = 30; 56 %), and disease confined to locoregional area [clinical stage: IIb (n = 30; 57 %), IIIa (n = 14; 26 %), IIIb (n = 6; 11 %), IIIc (n = 3; 6 %)], were treated with preoperative CRT, curative (R0) resection with an extended (two-field) lymph node dissection in all cases. Thirty-seven patients also received a preanastomotic reconstruction IOERT boost (applicator diameter size 6-9 cm, dose 10-15 Gy, beam energy 6-15 MeV) over the tumor bed in the mediastinum and upper abdominal lymph node area.

RESULTS

With a median follow-up time of 27.9 months (range, 0.2-148), LRR rate was 15 % (n = 8). Five-year overall survival (OS) and disease-free survival was 48 and 36 %, respectively. Univariate log-rank analyses showed that receiving IOERT was associated with lower risk of LRR (p = 0.004). On multivariate analysis, only the IOERT group retained significance in relation to LRR (odds ratio, 0.08; 95 % confidence interval, 0.01-0.48; p = 0.01). Postoperative mortality and perioperative complications were 11 % (n = 6) and 30 % (n = 16).

CONCLUSIONS

Local control is high in the radiation-boosted area, but OS remains modest, given the high risk of distant metastases. Intensified locoregional treatment needs to be tested in the context of more efficient concurrent, neo-, and adjuvant systemic therapy.

Factors influencing the risk of recurrence in patients with esophageal carcinoma treated with surgery: A single institution analysis consisting of 1002 cases

The aim of this study was to identify the risk of recurrence in patients with thoracic esophageal squamous cell carcinoma (TESCC) treated with curative surgery. The retrospective analysis included 1002 consecutive patients with TESCC who had been treated with curative surgery in Zhejiang Cancer Hospital, China, between 2003 and 2008. Univariate and multivariate analyses using the Kaplan-Meier method and Cox proportional hazards model, respectively, were performed to identify the independent risk factors for locoregional recurrence and all the recurrence events. The 2-and 5-year recurrence rates were 39.0 and 59.2%, respectively. More than 85% of recurrences occurred within 36 months. The variables associated with a higher rate of recurrence in the univariate analysis were gender (male), length of tumor (≥5 cm), depth of invasion (deeper), lymph node metastasis (greater), histological grade (higher) and vessel involvement (positive). By multivariate analyses, gender (HR, 1.7; 95% CI, 1.2-2.5; P=0.002), depth of invasion (HR, 1.4; 95% CI, 1.2-1.6; P<0.001) and lymph node involvement (HR, 1.4; 95% CI, 1.3-1.5; P<0.001) were independent predictive factors of recurrence. Post-operative radiotherapy or chemotherapy did not significantly prolong failure-free survival (FFS), particularly in patients with early-stage disease. Information regarding the depth of primary tumor invasion and the number of lymph nodes involved may help in evaluating the recurrence risk in patients with TESCC treated with curative surgery. Further studies are required to clarify the correlation between recurrence and the different multidisciplinary treatment approaches.

The value of ultrasound in the assessment of cervical and abdominal lymph node metastases and selecting surgical strategy in patients with squamous cell carcinoma of the thoracic esophagus treated with neoadjuvant therapy

PURPOSE

To establish the role of ultrasound (US) in the assessment of cervical and abdominal lymph node metastases and its impact on making decision about surgical strategy in patients with squamous cell carcinoma of the thoracic esophagus.

MATERIAL/METHODS

The results of US lymph node assessment before and after a neoadjuvant treatment in 83 patients were compared with the results of histopathological evaluation of lymph nodes harvested during surgery (transthoracic esophagectomy and 2-field extended or 3-field lymph node dissection). A diagnostic value of cervical and abdominal US in terms of sensitivity, specificity, positive and negative predictive value after a neoadjuvant treatment were determined.

RESULTS

The sensitivity, specificity, positive and negative predictive value of the US assessment of cervical lymph node metastases were 100%, 96%, 81% and 100%, respectively. The sensitivity, specificity, positive and negative predictive value of the US assessment of abdominal lymph node metastases were 82%, 94%, 91.5% and 87%, respectively.

CONCLUSIONS

The high sensitivity and specificity of cervical US make this investigational method sufficient in the assessment of cervical nodal involvement. In esophageal cancer patients with negative cervical lymph nodes on US, three-field lymph node dissection could be avoided. In patients with positive cervical lymph nodes on US one should consider to extend lymph node dissection about lymph nodes of the neck to achieve a curative resection. In patients with negative abdominal US this investigation should be supplemented by more detailed diagnostic methods.

Imaging of the cervical and abdominal lymph nodes in a combined treatment of squamous cell oesophageal carcinoma

The presence of lymph node metastases in esophageal cancer is one of the most principle prognostic indicators. The aim of the study was the assessment of cervical and abdominal lymph nodes (N/pN) by ultrasound (US) examination in patients with squamous cell carcinoma of the thoracic esophagus referred to esophagectomy.

MATERIAL AND METHODS

The analyzed study population consisted of 110 patients who underwent a combined-modality treatment (neoadjuvant chemotherapy - 74 patients or chemoradiotherapy - 36 patients). The results of US lymph node assessment were compared to the results of histopathological evaluation of lymph nodes harvested during surgery and diagnostic value of cervical and abdominal US in terms of sensitivity, specificity, positive and negative predictive value were determined.

RESULTS

The complete metastatic regression was shown by US in 14.3-22.2% of patients depending on the node location and mode of neoadjuwant treatment. There was no significant difference in the assessment of lymph nodes between chemotherapy and chemoradiotherapy patients.

CONCLUSIONS

US investigation is a method recommended for the assessment of metastatic lymph nodes in squamous cell oesophageal carcinoma, especially - for cervical nodes, where its specificity amounted to 96% and sensitivity - 100%. When positive nodes are suggested by US of the neck esophagectomy should be combined with 3-field lymphadenectomy.

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

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.

Sentinel lymph node biopsy using intraoperative indocyanine green fluorescence imaging navigated with preoperative CT lymphography for superficial esophageal cancer

BACKGROUND

The sentinel lymph node (SLN) concept has been gaining attention for gastrointestinal neoplasms but remains controversial for esophageal cancer. This study evaluated the feasibility of SLN identification using intraoperative indocyanine green (ICG) fluorescence imaging (IGFI) navigated by preoperative computed tomographic lymphography (CTLG) to treat superficial esophageal cancer.

METHODS

Subjects comprised 20 patients clinically diagnosed with superficial esophageal cancer. Five minutes after endoscopic submucosal injection of iopamidol around the primary lesion using a four-quadrant injection pattern with a 23-gauge endoscopic injection sclerotherapy needle, three-dimensional multidetector computed tomography was performed to identify SLNs and lymphatic routes. ICG solution was injected intraoperatively around the tumor. Fluorescence imaging was obtained by infrared ray electronic endoscopy. Thoracoscope-assisted standard radical esophagectomy with lymphadenectomy was performed to confirm fluorescent lymph nodes detected by CTLG.

RESULTS

Lymphatic vessels and SLNs were identified preoperatively using CTLG in all cases. Intraoperative detection rates were 100% using CTLG and 95% using IGFI. Lymph node metastases were found in four cases, including one false-negative case with SLNs occupied by bulky metastatic tumor that were not enhanced with both methods. The other 19 cases, including three cases of metastatic lymph nodes, were accurately identified by both procedures.

CONCLUSIONS

Preoperative CTLG visualized the correct number and site of SLNs in surrounding anatomy during routine computed tomography to evaluate distant metastases. Referring to CTLG, SLNs were identified using IGFI, resulting in successful SLN navigation and saving time and cost. This method appears clinically applicable as a less-invasive method for treating superficial esophageal cancer.

Patterns of lymph node metastasis and survival for upper esophageal squamous cell carcinoma

BACKGROUND

This study evaluated the clinical results, nodal metastatic patterns, and overall efficacy of esophagectomy with three-field lymph node dissection for upper esophageal squamous cell carcinoma (SCC).

METHODS

Between 2001 and 2008, esophagectomy was performed in 497 esophageal cancer patients, of whom 93 underwent esophagectomy with three-field lymph node dissection, without neoadjuvant treatment for upper esophageal SCC.

RESULTS

Of these 93 patients, 91 (97.8%) were men, the median age was 65.0 years, and 82 (88.2%) underwent R0 resection with curative intent. In-hospital mortality was 4.3%. Pathologic T N M stages were stage I, 8.6%; stage II, 16.1%; stage III, 75.3%; and stage IV, 0%. The mean numbers of total lymph nodes dissected and, of those, total metastatic lymph nodes per patient were 61.7±18.2 and 4.7±7.0, respectively. Metastases occurred to the recurrent laryngeal lymph nodes in 43.3%, to the cervical lymph nodes in 46.2%, and to abdominal lymph nodes in 24.7% of patients. Overall 5-year and disease-free survival rates were 43.5% and 34.3%, respectively, and were 50.1% and 37.6%, respectively, for R0 resection.

CONCLUSIONS

Recurrent laryngeal lymph node chains are those most commonly affected by nodal metastasis, and the prevalence of cervical lymph node involvement is high, at more than 40%. Esophagectomy with three-field lymph node dissection in patients with upper esophageal SCC can be performed with acceptable morbidity and mortality. Curative R0 resection for upper esophageal SCC achieved a satisfactory 5-year survival rate.

Current trends in extended lymph node dissection for esophageal carcinoma

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

Factors predictive of prognosis after esophagectomy for squamous cell cancer

OBJECTIVE

To evaluate the prognosis after esophagectomy for squamous cell carcinoma of the thoracic esophagus and its prognostic factors.

METHODS

Six hundred five patients with primary squamous cell carcinoma of the thoracic esophagus who underwent curative esophagectomy between June 1997 and June 1998 were collected from 3 medical centers. Among them, 26 patients died from the operation and 26 patients did not complete adjuvant treatment owing to toxicity. Univariate and multivariate analysis was performed to identify prognostic factors for survival. The effect of adjuvant treatment on survival was also evaluated.

RESULTS

The 1-, 3-, 5-, and 10-year overall survivals of 605 patients were 90%, 65%, 36%, and 8%, respectively. Multivariate analysis identified the following as independent prognostic factors: number of lymph node metastases (P < .001), histologic differentiation (P < .001), tumor location (P = .002), depth of invasion (P = .020), and vascular invasion (P = .023).

CONCLUSIONS

Several pathologic characteristics of the primary tumor are correlated with the outcome of esophagectomy for squamous carcinoma of the thoracic esophagus. Patients with fewer than 2 metastatic nodes after curative esophagectomy have a better prognosis than those with multiple involved nodes (>2). To stratify patients appropriately for prognosis, it is necessary to refine the current 6th edition TNM staging system.

Esofagogastrectomia com linfadenectomia em dois campos no câncer do esôfago torácico

OBJETIVO: Avaliar as indicações, sobrevida e fatores prognósticos da esofagogastrectomia com linfadenectomia em dois campos no câncer do esôfago torácico. MÉTODOS: Foram avaliados 111 pacientes retrospectivamente no período de janeiro de 1990 a dezembro de 2001 sendo 83 homens e 29 mulheres. A idade média dos pacientes foi 55,1 anos (variando entre 35-79). A linfadenectomia em dois campos foi parcial (Standard) em 34 pacientes(30,6%) e ampliada em 77(69,4%). RESULTADOS: A média de linfonodos dissecados foi de 22,6(variando entre 4 e 50). A doença R0 ocorreu em 53 pacientes(47,7%) a doença residual microscópica (R1) em 57 (52,3%) e a doença residual R2 em um paciente(0,9%). A recidiva ocorreu em 32 pacientes (28,8%) sendo em sete (6,3%) cervical, 17 (15,3%) locorregional e 19 (17,1%) sistêmica. A morbidade e mortalidade pós-operatória foram de 31,5% e 9% respectivamente, sem diferença significativa em relação á extensão da linfadenectomia mediastinal. A sobrevida global dos 111 pacientes em cinco anos foi de 48,4%, sem diferença significativa na sobrevida em relação á extensão da linfadenectomia, porém, houve aumento significativo na sobrevida livre de doença a favor dos paciente submetidos a linfadenectomia mediastinal ampliada(p=0,01). A ausência de doença residual (R0), comprometimento linfonodal (pN0) e o número de linfonodos comprometidos inferior a quatro, indicaram bom prognóstico. CONCLUSÃO: A esofagogastrectomia com linfadenectomia em dois campos apresentou um impacto positivo na taxa de sobrevida em cinco anos nos pacientes com câncer do esôfago torácico, particularmente em relação aos pacientes com ECIII. A linfadenectomia mediastinal ampliada aumentou significativamente a sobrevida livre de doença.

Esofagogastrectomia com linfadenectomia em dois campos no câncer do esôfago torácico

OBJETIVO: Avaliar as indicações, sobrevida e fatores prognósticos da esofagogastrectomia com linfadenectomia em dois campos no câncer do esôfago torácico. MÉTODOS: Foram avaliados 111 pacientes retrospectivamente no período de janeiro de 1990 a dezembro de 2001 sendo 83 homens e 29 mulheres. A idade média dos pacientes foi 55,1 anos (variando entre 35-79). A linfadenectomia em dois campos foi parcial (Standard) em 34 pacientes(30,6%) e ampliada em 77(69,4%). RESULTADOS: A média de linfonodos dissecados foi de 22,6(variando entre 4 e 50). A doença R0 ocorreu em 53 pacientes(47,7%) a doença residual microscópica (R1) em 57 (52,3%) e a doença residual R2 em um paciente(0,9%). A recidiva ocorreu em 32 pacientes (28,8%) sendo em sete (6,3%) cervical, 17 (15,3%) locorregional e 19 (17,1%) sistêmica. A morbidade e mortalidade pós-operatória foram de 31,5% e 9% respectivamente, sem diferença significativa em relação á extensão da linfadenectomia mediastinal. A sobrevida global dos 111 pacientes em cinco anos foi de 48,4%, sem diferença significativa na sobrevida em relação á extensão da linfadenectomia, porém, houve aumento significativo na sobrevida livre de doença a favor dos paciente submetidos a linfadenectomia mediastinal ampliada(p=0,01). A ausência de doença residual (R0), comprometimento linfonodal (pN0) e o número de linfonodos comprometidos inferior a quatro, indicaram bom prognóstico. CONCLUSÃO: A esofagogastrectomia com linfadenectomia em dois campos apresentou um impacto positivo na taxa de sobrevida em cinco anos nos pacientes com câncer do esôfago torácico, particularmente em relação aos pacientes com ECIII. A linfadenectomia mediastinal ampliada aumentou significativamente a sobrevida livre de doença.

Appraisal of a revised lymph node classification system for esophageal squamous cell cancer

BACKGROUND

Node-positive patients with esophageal carcinoma constitute a heterogeneous population with a variable prognosis, which the current staging system insufficiently addresses. To that end, 863 patients with a curative resection for esophageal squamous cell carcinoma were analyzed to evaluate a useful and simple nodal classification system.

METHODS

Along with standard conventional clinicopathologic factors, data for metastatic lymph node (MLN) number, metastatic to examined LN ratio (MLN ratio), and MLN size were evaluated. The greatest microscopic dimension of the metastatic tumor inside the largest MLN (MLN size) was measured on histopathologic slides. Patients with MLNs were classified into n1 (< 9 mm) and n2 (> or = 9 mm) groups, according to size of MLNs (n-stage).

RESULTS

The paratracheal LNs most frequently contained the largest MLN and among them the right recurrent laryngeal LNs were the most common site (81.8%). Patients were stratified into significant groups by all the nodal criteria. In multivariable analysis, MLN size n-stage and MLN ratio N-stage were the best independent predictors for disease-free and overall survival, respectively. In the disease-free survival, MLN ratio N-stage subcategories were divided into prognostic groups according to the n-stage. A combined nodal staging strategy combining the n-stage and N-stage had the strongest prognostic value and was used for the tumor-node-metastasis classification with distinct separation of patients into prognostic groups.

CONCLUSIONS

Results of this study indicate that the MLN size may serve as an accurate metric to classify node-positive patients and a combination of the MLN ratio and size may have synergism in classifying node-positive patients into prognostically homogenous groups.

Prognostic and Clinical Evaluation of Axillary Lymph Node Metastasis in Esophageal Cancer

Axillary lymph node metastasis (ALNM) from esophageal cancer is rare. Its prognosis and effective treatments remain unknown. Between 1997 and 2005, esophagectomy was performed in 361 patients with esophageal cancer in our hospital. ALNM was identified in four patients (1.1%). All patients had left ALNM with ipsilateral left supraclavicular lymph node metastasis. In two patients ALNM developed after radical esophagectomy with regional lymphadenectomy and in the other two patients after chemoradiotherapy of primary lesions. Axillary lymphadenectomy with chemoradiotherapy was given to all patients. Median survival time and disease-free survival (DFS) after initial treatment for primary esophageal cancer were 30.5 months and 11.5 months, respectively. One patient, who had a small number of regional lymph node metastases (two lymph nodes) at esophagectomy and prolonged DFS (22 months) until axillary node recurrence, is still alive, 67 months after axillary lymphadenectomy. The other three patients, who had larger numbers of regional lymph node metastases (average, 8.3) and shorter DFS (average, 9.7 months), died of recurrence an average of 13.3 months after axillary lymphadenectomy. In conclusion, although ALNM is considered a type of distant organ metastasis, if it is a solitary recurrence, good survival may be obtained after appropriate loco-regional therapy. The number of metastatic regional lymph nodes at initial esophagectomy and the duration of DFS until axillary node recurrence can help to guide the decision whether aggressive treatments are warranted.

Impact of prediagnosis smoking, alcohol, obesity, and insulin resistance on survival in male cancer patients: National Health Insurance Corporation Study

PURPOSE

Although many studies have demonstrated that smoking, alcohol, obesity, and insulin resistance are risk factors for cancer, the role of those factors on cancer survival has been less studied.

PATIENTS AND METHODS

The study participants were 14,578 men with a first cancer derived from a cohort of 901,979 male government employees and teachers who participated in a national health examination program in 1996. We obtained mortality data for those years from the Korean Statistical Office. We used a standard Poisson regression model to estimate the hazard ratio (HR) for survival in relation to smoking, alcohol, obesity, and insulin resistance before diagnosis.

RESULTS

Poor survival of all cancer combined (HR, 1.24; 95% CI, 1.16 to 1.33), cancer of the lung (HR, 1.45; 95% CI, 1.15 to 1.82), and cancer of the liver (HR, 1.36; 95% CI, 1.21 to 1.53) were significantly associated with smoking. Compared with the nondrinker, heavy drinkers had worse outcomes for head and neck (HR, 1.85; 95% CI, 1.23 to 2.79) and liver (HR, 1.25; 95% CI, 1.11 to 1.41) cancer, with dose-dependent relationships. Patients with a fasting serum glucose level above 126 mg/dL had a higher mortality rate for stomach (HR, 1.52; 95% CI, 1.25 to 1.84) and lung (HR, 1.48; 95% CI, 1.18 to 1.87) cancer. Higher body mass index was significantly associated with longer survival in head and neck (HR, 0.54; 95% CI, 0.39 to 0.74) and esophagus (HR, 0.44; 95% CI, 0.28 to 0.68) cancer.

CONCLUSION

Prediagnosis risk factors for cancer development (smoking, alcohol consumption, obesity, and insulin resistance) had a statistically significant effect on survival among male cancer patients.

Prognostic factors in adenocarcinoma of the esophagus or gastroesophageal junction

The incidence of adenocarcinoma of the esophagus is rising rapidly in Western Europe and North America. It is an aggressive disease with early lymphatic and hematogenous dissemination. TNM cancer staging systems predict survival on the basis of the anatomic extent of the tumor. However, the adequacy of the current TNM staging system for adenocarcinoma of the esophagus or gastroesophageal junction (GEJ) is questioned repeatedly. Numerous prognostic factors have been described, but are not included in the TNM system. This review describes clinical parameters, aspects of operative technique, response to preoperative chemoradiotherapy therapy, complications and established pathologic determinants found in the resection specimen that have a prognostic impact. Furthermore, their potential application in the clinical setting in patients with adenocarcinoma of the esophagus or GEJ is discussed. Future directions to improve staging systems are given.

Oblique view of preoperative lymphoscintigraphy improves detection of sentinel lymph nodes in esophageal cancer

Because sentinel lymph nodes (SLNs) of esophageal cancer can be widely located between the neck and the upper abdomen, lymphoscintigraphy plays an important role in their detection, but some modifications are required to clearly visualize their locations. Recently, we applied the stereoscopic imaging method by adding the 10-degree oblique view to the conventional lymphoscintigraphy for SLNs, so that we could better determine SLN locations on the basis of depth information. In this report, we describe a case in which the oblique view of the lymphoscintigram contributed to improving the visualization of a mediastinal SLN of esophageal cancer. Evaluation of the patient's chest CT image validated the notion that gamma rays from SLN are less absorbed by the surrounding soft tissues and the sternum in acquisition from the oblique view than from the true anterior view. The additional oblique view of the lymphoscintigram is useful for evaluation of the SLNs of esophageal cancer.

Prediction of lymph node status in patients with superficial esophageal carcinoma: analysis of 160 surgically resected cancers

BACKGROUND

The ability to predict lymph node metastasis in cases of superficial esophageal carcinoma before surgery would allow the identification of specific patients who do not require additional surgical resection after endoscopic local resection.

METHODS

From 1980 to 2002 a total of 160 patients with superficial esophageal carcinoma, Tis or T1 tumors, underwent subtotal esophagectomy with lymph node dissection. On the basis of clinicopathologic data the risk factors for lymph node metastases are discussed.

RESULTS

Patients with tumors that showed submucosal invasion, a nonflat shape, and lymphatic invasion had a higher risk for lymph node metastasis than the other patients. Multivariate analysis showed that the tumor depth and the macroscopic shape of the tumor were independent risk factors for lymph node metastases.

CONCLUSIONS

Esophagectomy with lymph node dissection is recommended for patients with submucosal cancer. Local tumor resection can be recommended for patients with mucosal cancer without lymphatic invasion.

Histopathological criteria for additional treatment after endoscopic mucosal resection for esophageal cancer: analysis of 464 surgically resected cases

No previous reports on lymph-node metastasis (LNM) from superficial squamous cell carcinoma of the esophagus have proposed definite criteria for additional treatment after endoscopic mucosal resection (EMR). We investigated the association between histopathological factors and LNM in 464 consecutive patients with superficial squamous cell carcinoma of the esophagus who had undergone a radical esophagectomy with lymph-node dissection (14 'M1' lesions: intraepithelial tumors, 36 'M2' lesions: tumors invading the lamina propria, 50 'M3' lesions: tumors in contact with or invading the muscularis mucosa, 32 'SM1' lesions: tumors invading the most superficial 1/3 of the submucosa and 332 'SM2/3' lesions: tumors invading deeper than SM1 level). Histopathological factors including invasion depth, size, lymphatic invasion (LY), venous invasion, tumor differentiation, growth pattern, degree of nuclear atypia and histological grade were assessed for their association with LNM in 82 M3 or SM1 lesions to determine which patients need additional treatment after EMR. LNM was found in 0.0, 5.6, 18.0, 53.1 and 53.9% of the M1, M2, M3, SM1 and SM2/3 lesions, respectively. A univariate analysis showed that each of the following histopathological factors had a significant influence on LNM: invasion depth (M3 vs SM1), LY, venous invasion and histological grade. Invasion depth and LY were significantly associated with LNM in a multivariate analysis. Four out of 38 patients (10.3%) with M3 lesions without LY had LNM, whereas five out of 12 patients (41.7%) with M3 lesions and LY had LNM. Only patients with M1/2 lesions are good candidates for EMR. Invading the muscularis mucosa (M3) is a high-risk condition for LNM the same as submucosal invasion, but M3 lesions without LY can be followed up after EMR without any additional treatment.

A prospective trial for avoiding cervical lymph node dissection for thoracic esophageal cancers, based on intra-operative genetic diagnosis of micrometastasis in recurrent laryngeal nerve chain nodes

BACKGROUND AND OBJECTIVES

The aim of this study was to evaluate the usefulness of intra-operative genetic diagnosis of RN node micrometastasis in the decision-making of 3FL for thoracic esophageal cancers.

METHODS

Eighty-nine patients with middle and lower thoracic esophageal cancer were enrolled in a prospective study, in which 3FL was performed when RN node metastasis was revealed by intra-operative histological examination and/or genetic analysis using real-time RT-PCR assay. For other cases, 2FL was performed.

RESULTS

Of the 89 patients, 3FL was performed for 33 patients and 2FL for 56 patients. In the 3FL group, RN node metastasis was both histologically and genetically positive in 19 patients, histologically negative and genetically positive in 11, and histologically positive and genetically negative in 3, with cervical node metastasis being detected in 7, 3, and 0 patients, respectively. In the 2FL group, only one patient had cervical node recurrence during the follow-up period. The post-operative survival in this study was equivalent to that of the historical controls (3-year survival rates 63.9% vs. 52.3%, P = 0.1513) of 66 3FL patients when 3FL was the first choice for thoracic esophageal cancers.

CONCLUSIONS

Intra-operative histological and genetic diagnosis of RN node metastasis may help avoid unnecessary cervical node resection. A Phase III trial should be done.

Two-field lymph-node dissection may be enough to treat patients with submucosal squamous cell carcinoma of the thoracic esophagus

Significance of extended radical surgical treatment including three-field lymph node dissection for squamous cell carcinoma (SCC) of the esophagus remains debatable. The aim of the current study was to reconsider the merits and demerits obtained by three-field lymph node dissection for esophageal carcinoma and also to attempt to elucidate an appropriate surgical strategy for submucosal SCC of the thoracic esophagus. Thirty-one patients with SCC of the thoracic esophagus who had been treated with esophagectomy and two-field (thoracic and abdominal) lymph node dissection without preoperative therapies were enrolled. Five-year survival rate was 75.0% and the incidence proportion of postoperative complication was 9.7%. These data regarding postoperative outcome of patients were by no means inferior to those in the previous reports referring the prognosis of patients with esophageal carcinoma who had been treated with three-field lymph node dissection. Authors would like to mention that two-field lymph node dissection associated with reduced incidence of postoperative complications might be enough to treat the submucosal SCC of the thoracic esophagus.

En-bloc esophagectomy--the three-field dissection

The treatment of esophageal cancer remains controversial. Standard techniques of surgical resection are associated with a local recurrence rate of 30% to 60% and 5-year survival of 20% to 25%. The addition of induction therapy of any kind does not significantly alter these survival rates. This article examines the rationale,technique, and results of radical esophagectomy, including two-field and three-field lymph node dissection.

Intraoperative identification of esophageal sentinel lymph nodes with near-infrared fluorescence imaging

OBJECTIVE

In esophageal cancer, selective removal of involved lymph nodes could improve survival and limit complications from extended lymphadenectomy. Mapping with vital blue dyes or technetium Tc-99m often fails to identify intrathoracic sentinel lymph nodes. Our purpose was to develop an intraoperative method for identifying sentinel lymph nodes of the esophagus with high-sensitivity near-infrared fluorescence imaging.

METHODS

Six Yorkshire pigs underwent thoracotomy and received submucosal, esophageal injection of quantum dots, a novel near-infrared fluorescent lymph tracer designed for retention in sentinel lymph nodes. Six additional pigs underwent thoracotomy and received submucosal esophageal injection of CW800 conjugated to human serum albumin, another novel lymph tracer designed for uptake into distant lymph nodes. Finally, 6 pigs received submucosal injection of the fluorophore-conjugated albumin with an endoscopic needle through an esophagascope. These lymph tracers fluoresce in the near-infrared, permitting visualization of migration to sentinel lymph nodes with a custom intraoperative imaging system.

RESULTS

Injection of the near-infrared fluorescent lymph tracers into the esophagus revealed communicating lymph nodes within 5 minutes of injection. In all 6 pigs that received quantum dot injection, only a single sentinel lymph node was identified. Among pigs that received fluorophore-conjugated albumin injection, in 5 of 12 a single sentinel lymph node was revealed, but in 7 of 12 two sentinel lymph nodes were identified. There was no dominant pattern in the appearance of the sentinel lymph nodes either cranial or caudal to the injection site.

CONCLUSION

Near-infrared fluorescence imaging of sentinel lymph nodes is a novel and reliable intraoperative technique with the power to assist with identification and resection of esophageal sentinel lymph nodes.

Surgical resection for esophageal carcinoma: Speaking the language

The terminology used to describe esophagectomy for carcinoma can be confusing, even for specialists in gastrointestinal disease. As a result, specific terms are often used out of their intended context. To simplify the nomenclature, two points regarding procedures for surgical resection of the esophagus are critical: the extent of resection (radical vs standard) and the operative approach (choice of incisions). It is important to understand that the radicality of the resection may have little to do with the operative approach, with the exception of esophagectomy without thoracotomy (transhiatal esophagectomy), which mandates the performance of a standard or non-radical resection. Esophagectomy has emerged as the standard curative treatment option for patients with esophageal carcinoma; however, unlike the surgical resection of other types of solid tumors, many different surgical options and/or approaches exist for these patients. This heterogeneity of care may result from the fact that the esophagus is accessible through more than one body cavity (left hemithorax, right hemithorax, abdomen). In addition, and partially as a result of its accessibility, different types of surgical specialists harbor this operation in their armamentarium, including general surgeons, thoracic surgeons, and surgical oncologists. Despite this enthusiasm amongst surgeons, little consensus exists as to which option is most oncologically sound. Further, the details of the various surgical approaches and procedures for resection of the esophagus are often difficult to comprehend, even for specialists in gastrointestinal disease, with much of the relevant terminology used out of its intended context. To facilitate the understanding of the surgical options for esophageal carcinoma, it is useful to view the operation from two angles: the extent of resection (Aradical@ vs Astandard@) and the operative approach (choice of incisions).

Laparoscopic esophagectomy in the palliative treatment of advanced esophageal cancer after radiochemotherapy

BACKGROUND

Esophageal cancer is associated with a poor long-term prognosis. Only a 10% 5-year survival rate is reported. This article aims to evaluate the feasibility and efficacy of laparoscopic esophagectomy for the palliative treatment of advanced esophageal cancer (T3-T4 Nx-N1) after neoadjuvant therapy.

METHODS

From March 1998 to July 2002, 35 patients (mean age, 64.6 years; range, 35-72 years) affected by advanced cancer of the middle lower third of the esophagus came to the authors' observation. All received neoadjuvant radiochemotherapy. Of the 35 patients, 22 (62.9%) showed a positive response to treatment (>or=50% reduction of maximal cross-sectional area of the tumor), and surgical intervention was performed 4 weeks after the end of the therapy. The operations were accomplished through the laparoscopic approach and left lateral cervicotomy.

RESULTS

The mean operative time was 160 min (range, 120-260 min). One patient (4.5%) experienced a cervical anastomotic leak. Three patients (13.6%) died in the postoperative period: one of myocardial infarction and two of acute respiratory failure. The mean postoperative hospital stay was 12.1 days (range, 9-23 days). After a mean follow-up period of 20.2 months (range, 10-40 months), 13 patients (68.4%) were alive.

CONCLUSIONS

The laparoscopic approach seems to be effective for the palliative treatment of advanced esophageal cancer. Further trials will be necessary to evaluate the advantages of this technique.

Multiple management modalities in esophageal cancer: epidemiology, presentation and progression, work-up, and surgical approaches

Annually, approximately 13,200 people in the U.S. are diagnosed with esophageal cancer and 12,500 die of this malignancy. Of new cases, 9,900 occur in men and 3,300 occur in women. In part I of this two-part series, we explore the epidemiology, presentation and progression, work-up, and surgical approaches for esophageal cancer. In the 1960s, squamous cell cancers made up greater than 90% of all esophageal tumors. The incidence of esophageal adenocarcinomas has risen considerably over the past two decades, such that they are now more prevalent than squamous cell cancer in the western hemisphere. Despite advances in therapeutic modalities for this disease, half the patients are incurable at presentation, and overall survival after diagnosis is grim. Evolving knowledge regarding the etiology of esophageal carcinoma may lead to better preventive methods and treatment options for early stage superficial cancers of the esophagus. The use of endoscopic ultrasound and the developing role of positron emission tomography have led to better diagnostic accuracy in this disease. For years, the standard of care for esophageal cancer has been surgery; there are several variants of the surgical approach. We will discuss combined modality approaches in part II of this series.

Survival results of a multicentre phase II study to evaluate D2 gastrectomy for gastric cancer

Curative resection is the treatment of choice for potentially curable gastric cancer. Two major Western studies in the 1990s failed to show a benefit from D2 dissection. They showed extremely high postoperative mortality after D2 dissection, and were criticised for the potential inadequacy of the pretrial training in the new technique of D2 dissection, prior to the phase III studies being initiated. The inclusion of pancreatectomy and splenectomy in D2 dissection was associated with increased morbidity and mortality. Following these results, we started a phase II trial to evaluate the safety and efficacy of pancreas-preserving D2 dissection. The results of this trial regarding the safety of pancreas preserving D2 dissection were published in 1998. In this paper, we present the survival results of this phase II trial to confirm the rationale of carrying out a phase III study comparing D1 vs D2 dissection for curable gastric cancer. Italian patients with histologically proven gastric adenocarcinoma were registered in the Italian Gastric Cancer Study Group Multicenter trial. The study was carried out based on the General Rules of the Japanese Research Society for Gastric Cancer. A strict quality control system was achieved by a supervising surgeon of the reference centre who had stayed at the National Cancer Center Hospital, Tokyo, to learn the standard D2 gastrectomy and the postoperative management. The standard procedure entailed removal of the first and second tier lymph nodes. During total gastrectomy, the pancreas was preserved according to the Maruyama technique. Complete follow-up was available to death or 5 years in 100% of patients and the median follow-up time was 4.38 years. Out of 297 consecutive patients registered, 191 patients were enrolled in the study between May 1994 and December 1996. The overall morbidity rate was 20.9%. The postoperative in-hospital mortality was 3.1%. The overall 5-year survival rate among all eligible patients was 55%. Survival was strictly related to stage, depth of wall invasion, lymph node involvement and type of gastrectomy (distal vs total). Our results suggest a survival benefit for pancreas-preserving D2 dissection in Italian patients with gastric cancer if performed in experienced centres. A phase III trial among exclusively experienced centres is urgently needed.

Two-step three-field lymph node dissection is beneficial for thoracic esophageal carcinoma

Aggressive surgery including extensive lymph node dissection is considered necessary to improve the long-term survival of patients with esophageal carcinoma. While three-field lymph node dissection is widely performed for patients with thoracic esophageal carcinoma, cervical lymph node metastasis is uncommon. In order to reduce surgical stress, we have developed a two-step three-field lymph node dissection procedure for thoracic esophageal carcinoma. In the first-step operation, total thoracic esophagectomy through a right thoracotomy is performed. Mediastinal and abdominal lymph node dissection is performed synchronously. When recurrent nerve lymph node metastasis is pathologically positive, cervical lymph node dissection is performed about 3 weeks after the first operation (second step). Of 343 patients with carcinoma of the esophagus surgically treated in our department between 1990 and 2001, 146 underwent the operation described above. Three-field dissection was performed in 68 patients (group A), while two-field dissection was performed in 78 patients (group B). In the 68 group A patients, cervical lymph node metastasis was positive in 15 patients (22%). There was no marked difference in the onset of major complications between the two groups. The 5-year survival rate was 58% for group A and 61% for group B, not a statistically significant difference. In 78 of the 146 patients, it was possible to avoid cervical lymph node dissection without negatively affecting therapeutic outcomes. Two-step three-field lymph node dissection can reduce surgical stress of patients with good clinical outcome.

Development of less invasive surgical procedures for thoracic esophageal cancer

In order to minimize the invasiveness of the operative procedure for thoracic esophageal cancer, several procedures have been introduced since January 1997. They included: (i) perioperative use of steroids; (ii) muscle-sparing thoracotomy without costectomy; (iii) preparation of the gastric tube with preservation of sufficient blood supply; (iv) reconstruction of the alimentary tract via posterior-mediastinal route; and (v) formation of anastomosis between the remaining esophagus and the gastric tube at a location between the gastroepiploic arteries of the gastric greater curvature. Twenty-one patients who did not receive preoperative chemoradiotherapy underwent the newly developed procedure, and were compared with those receiving the original procedure. Hospital mortality was zero, and postoperative systemic inflammatory response syndrome was suppressed. The mean postoperative hospital stay was 21.5 days, and the actuarial 3-year survival rate was 76.2%. From the comparison with those receiving the original procedure, it can be concluded that the newly developed procedures were effective in minimizing surgical invasiveness and were sufficiently curative in terms of cancer treatment.

Extended surgery for cancer of the esophagus and gastroesophageal junction

The overall prognosis of patients with carcinoma of the esophagus and gastroesophageal junction (GEJ) remains poor mainly because of the advanced stage of the disease at the time of presentation. As a result, controversy persists over the appropriate extent of surgery. This article reviews the impact of aggressive surgery on staging, disease-free survival, and cure rate. Despite recent advances in staging including positron emission tomography (PET), the findings after aggressive surgery indicate that the overall accuracy, sensitivity, and specificity of clinical staging are still too low. These shortcomings in clinical staging therefore question the value of the indications, results, and interpretation of outcomes in multimodality treatment regimens. Extended surgery increases the R(0) resection rate, which seems to have an undeniable beneficial effect on the incidence of locoregional recurrence and which should be considered as a parameter of surgical quality, especially within the context of multimodality trials. As to the effect on cure rate, the only randomized trial with published results did not indicate a significant difference between extended and more limited resections for adenocarcinoma of the esophagus and GEJ, albeit that a subsequent subanalysis did show a significant survival benefit favoring more extended surgery in distal third adenocarcinomas. However, the bulk of current literature suggests that better survival is achieved by more aggressive surgery. For three-field lymphadenectomy the available data suggest a potential survival benefit. It appears that positive cervical lymph nodes in patients with middle or proximal third carcinoma should no longer be considered as M(1a/b) distant lymph node metastasis but rather as N(1) regional disease.

Recurrence pattern of squamous cell carcinoma of the thoracic esophagus after extended radical esophagectomy with three-field lymphadenectomy

BACKGROUND

Extended radical esophagectomy with three-field lymphadenectomy for patients with thoracic esophageal cancer has been shown to be effective. But even if this operation is performed, some patients still experience relapse of the disease. The purpose of this study was to clarify the pattern and timing of recurrence after extended radical esophagectomy.

STUDY DESIGN

Recurrence of esophageal squamous cell carcinoma was examined in 171 of 174 patients who underwent extended radical esophagectomy with three-field lymphadenectomy. Recurrence patterns were classified as locoregional (at the site of the primary tumor, the anastomotic site, or the lymph nodes), hematogenous, and other (pleura or site of gastrostomy). Factors associated with recurrence were identified using univariate and multivariate statistical methods for survival analysis.

RESULTS

The overall 5-year survival rate was 55.6%. Recurrence was recognized in 74 patients (43.3%). The median disease-free interval until recurrence was 11 months. Thirty patients (17.5%) developed a locoregional recurrence, and 24 (14.0%) developed a hematogenous recurrence. Five patients (2.9%) developed both recurrences simultaneously and were classified as hematogenous recurrences. Of 30 patients with cervical lymph node metastasis, recurrent disease was recognized in 19 patients (63.3%). In multivariate analysis of 160 patients, the depth of invasion and pM-lym (cervical or celiac lymph node metastasis) were significant factors for locoregional recurrence; the depth of invasion and number of lymph node metastases at operation were significant factors for hematogenous recurrence. Survival time for patients with hematogenous recurrence (median 16 months) was significantly shorter than that of patients with locoregional recurrence (median 25.5 months).

CONCLUSIONS

Locoregional recurrence is associated mainly with the extent of the local tumor and lymph node metastasis; hematogenous recurrence is not only associated with tumor stage but also with the tumor's oncologic behavior.

Validity of intraoperative pathological diagnosis of paratracheal lymph node as a strategy for selection of patients for cervical lymph node dissection during esophagectomy

The aim of this paper is to examine whether intraoperative examination of paratracheal nodes can indicate cervical node dissection and whether this approach is valid. From 1988 to 1997, 76 patients with thoracic esophageal squamous cell carcinoma received esophagectomies with and without cervical lymph node (LN) dissection based on the results of intraoperative pathological diagnosis from selective checking of paratracheal LN. We retrospectively examined the outcomes for the patients and the micro metastasis in the dissected lymph node using cytokeratin staining. Three of the seven patients with cervical LN dissection were detected as having cervical LN metastasis by postoperative hematoxylin-eosin or cytokeratin staining. Five (7%) of the 69 patients without cervical LN dissection had cervical LN recurrence after the operation. Four of the seven patients who were diagnosed as having metastasis or micro metastasis in paratracheal LN by postoperative examination had cervical LN recurrence after the operation. In conclusion, the esophagectomy with and without cervical LN dissection for thoracic esophageal squamous cell carcinoma based on the results of intraoperative pathological diagnosis from selective checking of paratracheal LN was not fully acceptable. The reliability of intraoperative pathological diagnosis of selective checking may improve by increasing the number of checked LN and the detection of micro metastasis.