Sentinel node biopsy during thoracolaparoscopic esophagectomy for advanced esophageal cancer

[Evidence for the extent and oncological benefit of lymphadenectomy for esophageal cancer]

The prognosis for esophageal cancer is determined in particular by the depth of infiltration (T stage) and lymph node metastasis (N status). In patients with locally advanced tumors, surgical resection is the current standard. The extent of the lymphadenectomy depends on the localization of the tumor, analogous to the choice of surgical technique. For adequate tumor staging and achievement of pN0 status, seven lymph nodes without tumor metastases are necessary by definition but the current guidelines recommend 20 lymph nodes as a benchmark in an expert consensus. Despite the importance of the lymph node status for the prognosis of the patient and the already standardized use of targeted imaging of sentinel lymph nodes in other oncological disciplines, there is neither a validated method nor sufficient evidence for the benefit of lymph node mapping in esophageal cancer. The discussion about the prognostic advantage of lymphadenectomy is particularly interesting in T1 early stage cancer. Due to the technical advances of interventional endoscopy in recent years, organ preservation using endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) has not only become possible but also safe to carry out and thus established as the standard with better functional results; however, if one or more risk factors are present, endoscopic ablation is no longer defined as curative and should be supplemented by further treatment, usually non-organ-preserving resection. The step from organ-preserving interventional treatment with a low complication rate to a surgical procedure with significant mortality and morbidity as well as functional limitations seems immense and requires optimization, especially in view of the technical developments of surgery in recent years. This can either aim to identify the risk of lymph node metastases more precisely or to minimize the morbidity/mortality and functional limitations of additive treatment procedures. Approaches to this are currently the subject of research and have already been safely applied in individual pilot projects.

Lymphatic flow mapping using near-infrared fluorescence imaging with indocyanine green helps to predict lymph node metastasis intraoperatively in patients with esophageal or esophagogastric junction cancer not treated with neoadjuvant chemotherapy

BACKGROUND

Lymphatic flow mapping using near-infrared fluorescence (NIR) imaging with indocyanine green (ICG) has been used for the intraoperative prediction of lymph node metastasis in esophageal or esophagogastric junction cancer. However, a consistent method that yields sufficient diagnostic quality is yet to be confirmed. This study explored the diagnostic utility of our newly established lymphatic flow mapping protocol for predicting lymph node metastasis in patients with esophageal or esophagogastric junction cancer.

METHODS

We injected 0.5 mL of ICG (500 μg/mL) into the submucosal layer at four peritumoral points on the day before surgery for 54 patients. We performed lymphatic flow mapping intraoperatively using NIR imaging. After determining the NIR status and presence of metastases, evaluable lymph node stations on in vivo imaging and all resected lymph nodes were divided into four categories: ICG+meta+ (true positive), ICG+meta- (false positive), ICG-meta+ (false negative), and ICG-meta- (true negative).

RESULTS

The distribution of ICG+ and meta+ lymph node stations differed according to the primary tumor site. Sensitivity and specificity for predicting meta+ lymph nodes among ICG+ ones were 50% (95% CI 41-59%) and 75% (73-76%), respectively. Predicting meta+ lymph node stations among ICG+ stations improved these values to 66% (54-77%) and 77% (74-79%), respectively. Undergoing neoadjuvant chemotherapy was an independent risk factor for having meta+ lymph nodes with false-negative diagnoses (odds ratio 4.82; 95% CI 1.28-18.19). The sensitivity of our technique for predicting meta+ lymph nodes and meta+ lymph node stations in patients who did not undergo neoadjuvant chemotherapy was 79% (63-90%) and 83% (61-94%), respectively.

CONCLUSION

Our protocol potentially helps to predict lymph node metastasis intraoperatively in patients with esophageal or esophagogastric junction cancer undergoing esophagectomy who did not undergo neoadjuvant chemotherapy.

Clinical Effect and Postoperative Pain of Laparo-Thoracoscopic Esophagectomy in Patients with Esophageal Cancer

Objective

To investigate the clinical effect and postoperative pain of laparo-thoracoscopic esophagectomy in patients with esophageal cancer.

Methods

A total of 90 patients with esophageal cancer who were admitted and treated in our hospital from August 2020 to November 2021 were randomly selected as the research subjects for prospective analysis, and the patients were assigned to the control group and the experimental group according to the time of admission equally, with 45 cases in each group. Patients in the control group underwent conventional open surgery, and those in the experimental group underwent laparo-thoracoscopic esophagectomy. Then, operation-related indicators, postoperative pain, inflammatory factors, and complications were compared between the two groups.

Results

The operation time, intraoperative blood loss, postoperative drainage, and postoperative length of stays of the experimental group were significantly shorter or less than those of the control group (P < 0.05); there was no significant difference in the number of lymph nodes dissected between the two groups (P > 0.05). The number of patients with moderate and severe pain in the experimental group was significantly smaller than that in the control group, and the number of patients with mild pain was significantly larger than that in the control group (P < 0.05). The level of inflammatory factors (TNF-α, IL-6, IL-8, and IL-10) was significantly lower than that in the control group (P < 0.05); the incidence of surgical complications in the experimental group was significantly lower than that in the control group (P < 0.05).

Conclusion

Laparo-thoracoscopic esophagectomy can significantly improve the clinical effect in patients with esophageal cancer. Thoracic-laparoscopic esophagectomy can significantly improve the clinical results of patients with esophageal cancer. With better performance in surgery-related indicators, lower inflammatory factor levels and postoperative pain, and fewer postoperative complications, it will speed up patients' recovery and is worthy of clinical promotion and application.

Robotic-assisted minimally invasive esophagectomy: past, present and future

Esophagectomy for cancer of the esophagus is increasingly performed using minimally invasive techniques. After the introduction of minimally invasive esophagectomy (MIE) in the early 1990's, robotic-assisted techniques followed after the turn of the millennium. The advent of robotic platforms has allowed the development of robotic-assisted minimally invasive esophagectomy (RAMIE) over the past 15 years. Although recent trials have shown superior peri-operative morbidity and quality of life compared to open esophagectomy, no randomized trials have compared RAMIE to conventional MIE. This paper summarizes the current literature on RAMIE and provides an overview of expected future developments in robotic surgery.

Sentinel node navigation surgery in esophageal cancer

Over the last 20 years, the sentinel node (SN) concept has been widely applied to the surgical staging of both breast cancer and melanoma. However, the validity of this concept has been controversial for esophageal cancer, because SN mapping for esophageal cancer is not considered to be technically easy because of the complicated multidirectional lymphatic networks of the esophagus and mediastinum. Nevertheless, studies including meta-analyses indicated that SN mapping may be feasible in early esophageal cancer. Transthoracic esophagectomy with three-field lymphadenectomy was developed as a potential curative procedure for thoracic esophageal cancer. However, this highly invasive procedure might increase morbidity and reduce patients' quality of life (QOL) after esophagectomy. Although further validation based on multicenter trials using the standard protocol of SN mapping for esophageal cancer is required, SN navigation surgery would enable us to carry out personalized and limited lymph node dissection which might reduce morbidity and maintain patients' QOL.

The extent of lymphadenectomy in esophageal resection for cancer should be standardized

The incidence of esophageal cancer increases, with approximately 482,000 patients diagnosed with esophageal cancer each year. Despite the growing incidence of esophageal carcinoma, the extent of the lymphadenectomy is still under discussion. Lymph node status is an important prognostic parameter in esophageal cancer and an independent predictor of survival. Surgical strategy depends on the distribution pattern of nodal metastases but consensus on the extent of lymphadenectomy differs worldwide. For squamous cell cancer, Japanese surgeons have standardized the 2- or 3-field lymphadenectomy according to the location of the tumor. For adenocarcinoma, in the Western World accounting for 85% of all esophageal cancers, the type of lymphadenectomy to perform is not clear. Moreover, the use of neoadjuvant therapy may influence the mediastinal lymph nodes and the significance of the lymphadenectomy for survival. These aspects have challenged the traditional policy concerning lymphadenectomy, at least in the Western World. Furthermore, an extensive lymphadenectomy may improve survival but, on the other hand, may cause significant more morbidity. An overview of the literature on the extent of lymphadenectomy for esophageal cancer with respect to the supposed lymph node distribution patterns for squamous cell carcinoma and adenocarcinoma, the different lymph node classification systems, the commonly used surgical techniques and outcomes, and the proposal of observational cohort study to standardize the type of lymphadenectomy according to the type of tumor, location and use of neoadjuvant therapy will be provided.

Identification of the Lymphatic Drainage Pattern of Esophageal Cancer with Near-Infrared Fluorescent Imaging

OBJECTIVE

Nodal status is one of the most important long-term prognostic factors for esophageal cancer. The aim of this study was to evaluate the ability of near-infrared (NIR) light fluorescent imaging to identify the lymphatic drainage pattern of esophageal cancer.

METHODS

Patients with distal esophageal cancer or esophagogastric junction cancer scheduled for esophagectomy were enrolled in this study. Before surgery, an endoscopy was performed with submucosal injection of 2 cc of indocyanine green (ICG) around the tumor. Real-time NIR images from the surgical field were obtained for each patient to visualize the lymphatic ICG drainage.

RESULTS

A total of nine patients were included in this study. Ivor Lewis esophagectomy was performed in all cases. ICG drainage was visualized to first drain along the left gastric nodes in eight patients (88.9%) and toward the diaphragmatic nodes in one patient (11.1%). The median number of resected nodes was 32. Three patients (33.3%) presented nodal involvement. All of them had positive nodes in the first nodal station identified with ICG.

CONCLUSIONS

Evaluation of the lymphatic drainage pattern with real-time NIR light fluorescent technique is feasible. Distal and esophagogastric junction tumors showed to drain first in the left gastric nodes in most of the cases.