Thoracoscopic McKeown esophagectomy in a patient with an azygos lobe

BACKGROUND

The azygos lobe is a relatively rare anatomical variation, and there have been no reports, until date, of thoracoscopic McKeown esophagectomy for esophageal cancer in a patient with an azygos lobe. The azygos lobe can be diagnosed by chest X-ray or CT, and is usually not associated with any symptoms. However, surgeons should be aware that transthoracic surgical procedures in patients with an azygos lobe could be associated with a high risk of complications.

CASE PRESENTATION

An 83-years-old man was brought to our emergency room with fever, severe headache, and difficulty in moving. MRI revealed a brain abscess, which was treated by abscess drainage and systemic antibiotic treatment. Further examinations to determine the cause of the brain abscess revealed esophageal cancer. In addition, CT revealed an azygos lobe in the right thoracic cavity. Although intrathoracic adhesions were anticipated on account of a previous history of bacterial pyothorax, we decided to perform esophagectomy via a thoracoscopic approach. Despite the difficulty in dissecting the intrathoracic adhesions, we were able to obtain the surgical field thoracoscopically. Then, we found the azygos lobe, as diagnosed preoperatively, and the azygos vein was supported by the mesentery draining into the superior vena cava. After dividing the mesentery, we clipped and cut the vessel, and both ends were further ligated. After these procedures, we safely performed esophagectomy with 3-field lymph node dissection. The postoperative course was uneventful, and the patient was discharged on the 21st postoperative day.

CONCLUSIONS

Although there was a firm adhesion in the thoracic cavity, preoperative recognition of the azygos lobe could help in preventing intraoperative injury. Especially, esophageal surgeons are required to deal with the azygos lobe safely to avoid serious intraoperative injury.

Effective Postoperative Surveillance Protocol after Thoracoscopic Esophagectomy Focusing on Symptoms in Patients with Esophageal Cancer

BACKGROUND

The optimal postoperative surveillance protocol after esophagectomy for patients with esophageal cancer has still not been established. We investigated the risk factors for recurrence of esophageal cancer to devise an appropriate surveillance protocol. We focused on the appearance and worsening of symptoms to determine if additional imaging examinations should be performed.

STUDY DESIGN

We enrolled 416 patients with esophageal and esophagogastric junctional cancer who had undergone thoracoscopic esophagectomy at Tokai University Hospital. Outpatient visits for the patients are usually scheduled at least 4 times per year with CT imaging and blood biochemical examination. We evaluated the time to recurrence after esophagectomy, especially the correlation of this parameter with the appearance and worsening of symptoms during the postoperative outpatient follow-up.

RESULTS

Of the 416 patients, recurrence occurred in 127 patients (30.5%). The median time to recurrence was 6 months after esophagectomy; recurrence occurred within 24 months in 112 patients (88%), and 51 of these patients (40%) developed some new symptom(s) (symptomatic group) before the diagnosis of recurrence. The number of patients who developed recurrence within 6 months was significantly higher in the symptomatic group compared with that in the asymptomatic group (66.7% vs 46.0%, p = 0.02). The overall survival in the symptomatic group was significantly shorter than that in the asymptomatic group (p < 0.001).

CONCLUSIONS

We advocate an effective surveillance protocol depending on the appearance and worsening of symptoms to diagnose recurrence of esophageal cancer; we recommend routine imaging examinations every 6 months and clinical outpatient follow-up at even shorter intervals for the first 24 months after esophagectomy.

Usefulness of three-dimensional thoracoscope for prone position thoracoscopic esophagectomy improves mediastinal lymph node dissection and prognosis for esophageal cancer

OBJECTIVES

This study aimed to assess the superiority of 3D flexible thoracoscope against 2D thoracoscope for lymph node dissection (LND) and prognosis for prone-position thoracoscopic esophagectomy (TE) in esophageal cancer.

METHODS

Three hundred and sixty-seven esophageal cancer patients who underwent prone-position TE with 3-field LND between 2009 and 2018 were evaluated. 2D and 3D thoracoscope was used in 182 (2D group) and 185 cases (3D group), respectively. Short-term surgical outcomes, numbers of retrieved mediastinal lymph node (LN), and rates of LN recurrence were compared. Risk factors for mediastinal LN recurrence and long-time prognosis were also evaluated.

RESULTS

No differences in postoperative complications were observed between the groups. The numbers of retrieved mediastinal LN were significantly higher, and the rates of LN recurrence were significantly lower in the 3D group compared to 2D group. Use of 2D thoracoscope was a significant independent factor of middle mediastinal LN recurrence by multivariable analysis. Survival was compared by cox regression analysis, and the 3D group had a significantly better prognosis than the 2D group.

CONCLUSIONS

Prone position TE using 3D thoracoscope may improve the accuracy of mediastinal LND and prognosis without increasing postoperative complications for esophageal cancer.

Effectiveness of computed tomography scoring for the early diagnosis of anastomotic leakage after esophagectomy

PURPOSE

Anastomotic leakage after esophagectomy is associated with increased mortality; therefore, early diagnosis is highly important. This study aimed to identify the characteristic computed tomography (CT) findings of cervical anastomotic leakage after esophagectomy for esophageal cancer and evaluate the effectiveness of CT scoring in screening the anastomotic leakage.

METHODS

Overall, 91 patients who underwent thoracoscopic esophagectomy with cervical esophago-gastric anastomosis were included. We investigated the correlation between anastomotic leakage and the presence of the microbubble sign, evident air retention, and fluid collection in the cervical and mediastinal regions. CT findings were scored, and the cutoff value was set to 2 points on the receiver operating characteristic curve. The patients were divided into two groups based on the CT score (≥ 2 points and ≤ 1 point).

RESULTS

CT findings of the microbubble sign (p = 0.01; odds ratio [OR], 8.545; 95% confidence interval [CI], 1.596-45.73), cervical air retention (p < 0.01; OR, 12.43; 95% CI, 2.084-74.17), and cervical fluid collection (p < 0.01; OR, 9.359; 95% CI, 1.753-49.96) significantly correlated with anastomotic leakage. The ≥ 2-point CT score group showed a significantly higher incidence of anastomotic leakage than the ≤ 1-point group (p < 0.01; OR, 16.28; 95% CI [4.704-56.38]). A ≥ 2-point CT score had higher sensitivity (84.2%) than upper gastrointestinal series (36.8%).

CONCLUSION

The presence of microbubble sign, air retention, and fluid collection in the cervical area correlated with anastomotic leakage after cervical anastomosis in thoracoscopic esophagectomy. CT scores are useful early anastomotic leakage detectors.

Current status and future perspectives for the treatment of resectable locally advanced esophagogastric junction cancer: A narrative review

Incidence rates for esophagogastric junction cancer are rising rapidly worldwide possibly due to the economic development and demographic changes. Therefore, increased attention has been paid to the prevention, diagnosis, and the treatment of esophagogastric junction cancer. Although there are discrepancies in the treatment strategy between Asian and Western countries, surgery remains the mainstay of treatment for esophagogastric junction cancer. Recent developments of perioperative multidisciplinary treatment may lead to better therapeutic effect, higher complete resection rate, and better control of the residual diseases, thus result in prolonged prognosis. In this review, we will focus on the treatment of locally advanced resectable esophagogastric junction cancer, and discuss the current status and future perspectives of the perioperative treatment including chemotherapy, radiation therapy, and immunotherapy, as well as the surgical strategy. Better understanding of the latest treatment strategy and future overlook may enable to standardize and individualize the treatment for esophagogastric junction cancer, thus leading to better prognosis for those patients.

Usefulness of skeletal muscle measurement by computed tomography in patients with esophageal cancer: changes in skeletal muscle mass due to neoadjuvant therapy and the effect on the prognosis

PURPOSE

This analysis was performed to clarify the usefulness of skeletal muscle measurements using computed tomography (CT) in patients with esophageal cancer and the effect of treatment-induced changes in the skeletal muscle mass on the prognosis.

METHODS

Ninety-seven male patients who underwent thoracoscopic esophagectomy for esophageal squamous cell carcinoma were included in the study. The preoperative CT images were analyzed retrospectively.

RESULTS

In a survival analysis performed according to the preoperative data of skeletal muscle, the low-skeletal muscle index (l-SMI) group had a poorer outcome than the normal skeletal muscle index (n-SMI) group in terms of both the overall survival (OS) and the relapse-free survival (RFS) (OS: P < 0.01, RFS: P = 0.01). In the multivariate analysis for the OS, preoperative l-SMI was an independent predictor (hazard ratio: 3.68, 95% confidence interval 1.32-10.2, P = 0.01). In patients who underwent neoadjuvant therapy (NAT), the SMI was significantly reduced after NAT (P < 0.01). The preoperative skeletal muscle area on CT was strongly correlated with the results of a bioelectrical impedance analysis (BIA) (ρ = 0.77, P < 0.01).

CONCLUSIONS

A decreased preoperative skeletal muscle mass was associated with a poor outcome. In patients who underwent NAT, the SMI was significantly reduced after NAT. An analysis of the skeletal muscle mass using CT images was found to be useful for providing data that corresponded with BIA data.

Thoracoscopic esophagectomy for stenosis of thoracic esophagus due to acute esophageal necrosis associated with alcoholic ketoacidosis

Acute esophageal necrosis (AEN) is a rare disease characterized by the appearance of diffuse black mucosa on upper gastrointestinal endoscopy; the condition often progresses to esophageal stenosis in the chronic phase. A 70-year-old man was admitted to a neighborhood hospital with the diagnosis of alcoholic ketoacidosis and an upper gastrointestinal endoscopy performed to investigate the symptom of esophageal tightness revealed AEN. The patient developed esophageal stenosis with scarring in the chronic phase and was referred to our hospital for surgery 6 months after the diagnosis of AEN. We performed thoracoscopic esophagectomy with the patient in the prone position. Although the esophagus was thickened and strong adhesions were present around the esophagus due to inflammation, we were able to complete the surgical procedure thoracoscopically. In patients presenting with benign esophageal stenosis developing after AEN, thoracoscopic esophagectomy may be a useful treatment option, even in the presence of severe fibrosis.

Multimodal Treatment Strategies to Improve the Prognosis of Locally Advanced Thoracic Esophageal Squamous Cell Carcinoma: A Narrative Review

Esophageal cancer is the seventh most common malignancy and sixth most common cause of cancer-related death globally. Esophageal squamous cell carcinoma (ESCC) with aortic or tracheal invasion is considered unresectable, and has an extremely poor prognosis; its standard treatment is definitive chemoradiotherapy (dCRT). In recent years, induction chemotherapy (ICT) has been reported to yield high response rates for locally advanced ESCC, and the efficacy and safety of ICT followed by conversion surgery (CS) have been investigated. Multimodal treatment, combining surgery with induction chemoradiotherapy (ICRT) or ICT, is necessary to improve ESCC prognosis. CS is generally performed for locally advanced ECC after ICRT or ICT when tumor downstaging is achieved, although its prognostic benefit remains controversial. The Japan Clinical Oncology Group (JCOG) has conducted a three-arm phase III randomized controlled trial (JCOG1510) to confirm the superiority of DCF (docetaxel, cisplatin, and 5-fluorouracil) ICT, over conventional dCRT, among patients with initially unresectable ESCC. In recent years, researchers have reported favorable outcomes of induction therapy followed by CS and salvage surgery, after dCRT or systemic immunochemotherapy. In this review, we will describe the latest developments in the multimodal treatment including chemotherapy, CRT, surgery, and immunotherapy, which may improve oncological and survival outcomes for patients with cT4 ESCC.

Preventive procedure for stenosis after esophagojejunostomy using a circular stapler and transorally inserted anvil (OrVil™) following laparoscopic proximal gastrectomy and total gastrectomy involving reduction of anastomotic tension

Background

Recently, due to increasing reports of stenosis after esophagojejunostomy created using circular staplers and a transorally inserted anvil (OrVil™) following laparoscopic proximal gastrectomy (LPG) and total gastrectomy (LTG), linear staplers are being used instead. We investigated our preventive procedure for esophagojejunostomy stenosis following use of circular staplers.

Methods

Since the anastomotic stenosis is considered to be mainly caused by tension in the esophageal and jejunal stumps at the anastomotic site, we have been performing procedures to relieve this tension, by cutting off the rubber band and pushing the shaft of the circular stapler toward the esophageal side, since July 2015. We retrospectively compared the incidence of anastomotic stenosis in cases of LPG and LTG performed before July 2015 (early phase, 30 cases) versus those performed after this period (later phase, 22 cases).

Results

Comparison of the incidence of anastomotic stenosis according to the type of surgery, LPG or LTG, and between the two time periods versus all cases, indicated a significantly lower incidence in the later phase than in the early phase (4.5 vs. 26.7%, p < 0.05), especially for LPG (0 vs. 38.5%, p < 0.05).

Conclusions

It is possible to use a circular stapler during laparoscopic esophagojejunostomy, as with open surgery, if steps to reduce tension on the anastomotic site are undertaken. These procedures will contribute to the spread of safe and simple laparoscopic anastomotic techniques.

Thoracoscopic esophagectomy with left recurrent laryngeal nerve monitoring for thoracic esophageal cancer in a patient with a right aortic arch: a case report

Background

Surgery for cases of thoracic esophageal cancer with a right aortic arch is rare, and the anatomic abnormalities in such patients necessitate a different surgical approach. Since the position of the recurrent laryngeal nerve often differs from the usual in these cases, the lymph node dissection around the recurrent laryngeal nerve, which is an important step in surgery for thoracic esophageal cancer, requires careful attention. There are some reports on the usefulness of intraoperative recurrent laryngeal nerve monitoring during esophageal cancer surgery. Herein, we report a case of successful thoracoscopic esophagectomy for esophageal cancer in a patient with a right aortic arch using intraoperative recurrent laryngeal nerve monitoring.

Case presentation

A 70-year-old man was diagnosed as having esophageal cancer (Ut, type 0-IIc, T1b/MtLt, type 0-IIc, T1b, N2, M0, cStage II) and was treated by neoadjuvant chemoradiotherapy followed by radical surgery. Preoperative CT examination revealed a right aortic arch, and based on the findings of 3D-CT, we classified the right aortic arch as type IIIB1 (Edwards classification), which is the most frequent type of right aortic arch. We performed thoracoscopic esophagectomy via a left thoracic approach with the patient placed in the prone position, cervical esophagogastric conduit reconstruction via the retrosternal route, and three-field lymph node dissection. Although Kommerell’s diverticulum could be easily confirmed, the descending aorta took a meandering course, making it difficult for the esophagus to be mobilized and detached and therefore also to identify the ductus arteriosus and left recurrent laryngeal nerve. Intraoperative recurrent laryngeal nerve monitoring using NIM-RESPONSE® 3.0 (Medtronic Japan, Tokyo, Japan) allowed the position of the left recurrent laryngeal nerve to be accurately determined, and upper mediastinal lymph node dissection and mobilization of the upper thoracic esophagus were performed safely. Postoperatively, the patient showed no evidence of recurrent laryngeal nerve palsy, but needed conservative treatment for anastomotic leakage. The patient was discharged 46 days after the surgery.

Conclusion

It was suggested that intraoperative recurrent laryngeal nerve monitoring is useful in esophageal cancer with a right aortic arch undergoing surgery, in whom anatomic abnormalities of the recurrent laryngeal nerve can be expected.

Prognostic impact of lymphovascular invasion in lymph node-negative superficial esophageal squamous cell carcinoma

The relationship between lymphovascular invasion (LVI) and prognosis in patients with superficial esophageal squamous cell carcinoma (SESCC) is unclear. The aim of this study is to evaluate prognostic factors in patients with lymph node-negative SESCC. A total of 195 patients with pathologically confirmed T1a-MM, T1b, and lymph node-negative SESCC were retrospectively reviewed in this study. Overall, the disease-free survival (DFS) rate was poorer in the lymphatic invasion-positive group than in the lymphatic invasion-negative group (p = 0.002) and a multivariate analysis suggested that lymphatic invasion was the only independent prognostic factor of DFS in patients with lymph node-negative SESCC (HR = 4.075, p = 0.005). Distant organ recurrence occurred in one patient (1/52, 1.9%) in the T1b-SM2 group and in six patients (6/61, 9.7%) in the T1b-SM3 group; all of these patients had LVI. LVI-positive patients had a poorer DFS than invasion-negative patients in the T1b-SM2 and SM3 groups (p = 0.026), and a multivariate analysis suggested that LVI was the only independent prognostic factor of DFS in patients with lymph node-negative SM2 and SM3 SESCC (HR = 5.165, p = 0.031). Lymph node-positive patients had a significantly poorer DFS rate than lymph node negative and LVI positive patients among the SM2 and SM3 SESCC patients (p = 0.018). The present results suggested that LVI was an independent prognostic factor in patients with SM2 and SM3 lymph node-negative SESCC; however their prognosis was not worse than that of patients with lymph node-positive SM2 and SM3 SESCC, for whom adjuvant therapy is indicated as a standard treatment.

Prognostic significance of pathological tumor response and residual nodal metastasis in patients with esophageal squamous cell carcinoma after neoadjuvant chemotherapy followed by surgery

BACKGROUND

The present study investigated prognostic factors in patients with resectable locally advanced esophageal squamous cell carcinoma (ESCC) among various clinicopathological features related to neoadjuvant chemotherapy (NAC) and surgery, and the indications for additional treatment after surgery were considered.

METHODS

A total of 113 patients with clinical stage II or III ESCC, who had undergone NAC followed by a thoracic esophagectomy with a three-field lymphadenectomy were retrospectively reviewed. NAC consisted of either two courses of cisplatin and 5-fluorouracil or three courses of docetaxel, cisplatin and 5-fluorouracil, with a new course beginning every 3 weeks.

RESULTS

The overall survival (OS) rate was poorer in the pN-positive group than in the pN-negative group (P < 0.001). In terms of the histological therapeutic effect, the OS rate was poorer in the worse pathological responder group than in the better pathological responder group (P = 0.001). A multivariate analysis examining overall survival suggested that only pN (HR 3.204, P = 0.007) and worse pathological responder (HR 2.347, P = 0.041) were independent prognostic factors. The OS rate was compared among four groups classified according to the different combinations of pN and pathological response. A group of patients with pN-positive and worse pathological response had a significantly poorer outcome than the other groups.

CONCLUSIONS

The present study suggested that patients with resectable advanced ESCC undergoing NAC followed by surgery, who have both pN and worse pathological response, have a poor prognosis.

A thoracoscopically resected case of the diverticulum in the middle esophagus

Background

Approximately 65% of esophageal diverticulum cases are asymptomatic and are found by endoscopic examination. Symptomatic middle esophageal diverticulum requiring surgery is rare. In recent years, endoscopic surgery for middle esophageal diverticulum has been reported, but cases remain few in number, and the surgical indication, surgical procedure, and postoperative results are unknown.

Case presentation

A 41-year-old man had been diagnosed as having a middle esophageal diverticulum based on an upper gastrointestinal contrast examination performed when he was 30 years old. He had not received treatment because he was asymptomatic. Eight months earlier, he experienced chest discomfort after eating and visited our hospital. The diameter of his middle esophageal diverticulum was 47 mm. A gastrointestinal endoscopy revealed a diverticulum in the right wall located 30 cm from the incisor row. The pathological findings of the endoscopic biopsy were atypical epithelium and no malignant findings. We confirmed the function of the lower esophageal sphincter, and the esophageal body peristaltic wave was observed to be normal using high-resolution manometry. We decided to perform a thoracoscopic diverticulectomy based on his symptoms and the possibility of malignancy suggested by the atypical epithelium. Surgery was performed with the patient in a prone position via 4 ports, and intraoperative endoscopy was performed during the surgery. To achieve a complete resection of the diverticulum, threads were placed on the oral and anal sides of the diverticulum, the threads were pulled, and the diverticulum was resected using an automatic suturing device.

A postoperative upper gastrointestinal contrast examination revealed no abnormalities. He was discharged on postoperative day 12.

Conclusions

During thoracoscopic surgery for middle esophageal diverticulum, we think that pulling and separating the diverticulum and confirming the lumen using endoscopy are useful for reducing the risk of postoperative recurrence and stenosis. Few reports of long-term performance after surgery have been made for this procedure. Therefore, we believe that long-term follow-up is necessary.

Prognostic significance of sarcopenia in patients undergoing esophagectomy for superficial esophageal squamous cell carcinoma

Nononcological prognostic factors in superficial esophageal squamous cell carcinoma (SESCC) patients remain unclear. The aim of this study is to evaluate the relationship between sarcopenia and surgical outcome in patients with SESCC who had undergone definitive surgery. A total of 194 SESCC patients who had undergone thoracic esophagectomy with three-field lymphadenectomy without neoadjuvant therapy at Tokai University Hospital between January 2006 and December 2015 were analyzed retrospectively. Manual tracing using CT imaging was used to measure the cross-sectional areas of the skeletal muscle mass. The cutoff values for the skeletal muscle index used to define sarcopenia were based on the results of a previous study. Twenty-eight patients (14.4%) had sarcopenia, while the remaining 166 patients (85.6%) did not. A multivariate analysis suggested that sarcopenia was an independent risk factor for postoperative pulmonary complications (OR = 3.232, P = 0.026). The overall survival rate and the disease-free survival rate were both significantly worse in the sarcopenia group than in the nonsarcopenia group (P < 0.001). In a multivariate analysis, sarcopenia was an independent prognostic factor affecting overall survival (HR = 7.121, P < 0.001) and disease-free survival (HR = 6.000, P < 0.001). Patients with sarcopenia and lymph node metastasis (n = 18) had a worse outcome than the other patients (P < 0.001). This study suggests that the alleviation of sarcopenia through nutritional support and rehabilitation in SESCC patients scheduled to undergo surgery might help to prevent postoperative pulmonary complications and to improve the long-term outcome.

Regeneration of Transected Recurrent Laryngeal Nerve Using Hybrid-Transplantation of Skeletal Muscle-Derived Stem Cells and Bioabsorbable Scaffold

Hybrid transplantation of skeletal muscle-derived multipotent stem cells (Sk-MSCs) and bioabsorbable polyglyconate (PGA) felt was studied as a novel regeneration therapy for the transected recurrent laryngeal nerve (RLN). Sk-MSCs were isolated from green fluorescence protein transgenic mice and then expanded and transplanted with PGA felt for the hybrid transplantation (HY group) into the RLN transected mouse model. Transplantation of culture medium (M group) and PGA + medium (PGA group) were examined as controls. After eight weeks, trans-oral video laryngoscopy demonstrated 80% recovery of spontaneous vocal-fold movement during breathing in the HY group, whereas the M and PGA groups showed wholly no recoveries. The Sk-MSCs showed active engraftment confined to the damaged RLN portion, representing favorable prevention of cell diffusion on PGA, with an enhanced expression of nerve growth factor mRNAs. Axonal re-connection in the HY group was confirmed by histological serial sections. Immunohistochemical analysis revealed the differentiation of Sk-MSCs into Schwann cells and perineurial/endoneurial cells and axonal growth supportive of perineurium/endoneurium. The number of axons recovered was over 86%. These results showed that the stem cell and cytokine delivery system using hybrid transplantation of Sk-MSCs/PGA-felt is a potentially practical and useful approach for the recovery of transected RLN.

Expression of vasohibin-1 and -2 predicts poor prognosis among patients with squamous cell carcinoma of the esophagus

Vasohibin (VASH) -1 and -2 are novel angiogenic regulators. The aim of the present study was to assess the prognostic values of VASH1 expression and VASH2 expression in esophageal squamous cell carcinoma (ESCC). A total of 209 patients with ESCC were investigated. Resected tumor specimens were immunostained using anti-CD34 antibody, anti-VASH1 antibody and anti-VASH2 antibody. The ratio of the microvessels density and the VASH1 density as the VASH1-positive ratio were defined and the patients were divided into two groups (a high VASH1 group and a low VASH1 group) according to the average value. The patients were also divided into two groups (a high VASH2 group and a low VASH2 group) according to VASH2 expression upon immunostaining. The clinical outcomes of these two groups were then evaluated. The high VASH1 group contained 106 patients (50.7%). The high VASH2 group contained 48 patients (23.0%). Long-term survival was significantly poorer in the high VASH1 group compared with that in the low VASH1 group. A slight correlation between VASH1 expression and VASH2 expression was observed. The low VASH1/low VASH2 group had a better prognosis than the other three groups with different combinations of VASH1 and VASH2 expression levels. The present study showed that high VASH1 expression and high VASH2 expression may be novel independent predictors of a poor prognosis in patients with ESCC and that a slight correlation between VASH1 and VASH2 expression existed. The present findings suggest that combined evaluation of VASH1 and VASH2 expression should provide an improved understanding of their clinicopathological features.

Metabolome analysis of esophageal cancer tissues using capillary electrophoresis-time-of-flight mass spectrometry

Reports of the metabolomic characteristics of esophageal cancer are limited. In the present study, we thus conducted metabolome analysis of paired tumor tissues (Ts) and non-tumor esophageal tissues (NTs) using capillary electrophoresis time-of-flight mass spectrometry (CE-TOFMS). The Ts and surrounding NTs were surgically excised pair-wise from 35 patients with esophageal cancer. Following tissue homogenization and metabolite extraction, a total of 110 compounds were absolutely quantified by CE-TOFMS. We compared the concentrations of the metabolites between Ts and NTs, between pT1 or pT2 (pT1-2) and pT3 or pT4 (pT3-4) stage, and between node-negative (pN-) and node-positive (pN+) samples. Principal component analysis and hierarchical clustering analysis revealed clear metabolomic differences between Ts and NTs. Lactate and citrate levels in Ts were significantly higher (P=0.001) and lower (P<0.001), respectively, than those in NTs, which corroborated with the Warburg effect in Ts. The concentrations of most amino acids apart from glutamine were higher in Ts than in NTs, presumably due to hyperactive glutaminolysis in Ts. The concentrations of malic acid (P=0.015) and citric acid (P=0.008) were significantly lower in pT3-4 than in pT1-2, suggesting the downregulation of tricarboxylic acid (TCA) cycle activity in pT3-4. On the whole, in this study, we demonstrate significantly different metabolomic characteristics between tumor and non-tumor tissues and identified a novel set of metabolites that were strongly associated with the degree of tumor progression. A further understanding of cancer metabolomics may enable the selection of more appropriate treatment strategies, thereby contributing to individualized medicine.

Wnt3a expression is associated with poor prognosis of esophageal squamous cell carcinoma

The Wnt signaling pathway is widely implicated in various types of cancer. Canonical Wnt signaling, including Wnt3a, may be a key component of cancer progression or chemoresistance. Consequently, it was hypothesized that Wnt3a expression may be a prognostic factor of esophageal squamous cell carcinoma (ESCC) due to its roles in chemoresistance and tumor progression. The aim of the present study was to investigate the association between Wnt3a expression and prognosis in patients with ESCC. Wnt3a expression was evaluated in resected specimens from 139 patients with thoracic ESCC who were subjected to curative surgery without neoadjuvant therapy in Tokai University Hospital between 2007 and 2009. Samples were assessed using immnohistochemistry. Patients with ESCC were divided into two groups according to the expression of Wnt3a in tumor tissue. The influence of Wnt3a expression on clinicopathological findings and prognosis of ESCC were subsequently investigated. Immnohistologically, 68 cases were Wnt3a-positive in the cytoplasm of cancer cells, whereas 71 cases were negative. Multivariate analysis by Cox proportional hazard model showed the association between pN (HR=3.539, P=0.001), venous invasion (HR=2.798, P=0.012), Wnt3a expression (HR=1.691, P=0.046) and overall survival (OS). OS rate and disease-free survival rate were poorer in Wnt3a-positive group compared with those in the Wnt3a-negative group as indicated by the log-rank test (P=0.012 and P=0.023, respectively). In pathological stages I and II, there was no significant difference in the OS rate between Wnt3a-positive and Wnt3a-negative groups; however, the OS rate of the Wnt3a-positive group was significantly worse than that of Wnt3a-negative group in pathological stage III (log rank test; P=0.017). Wnt3a-positive patients with recurrence had a significantly poorer prognosis compared with Wnt3a-negative patients (log-rank test; P=0.023). The present findings suggested that Wnt3a may be a prognostic factor of ESCC.

Late esophageal wall injury after mesh repair for large esophageal hiatal hernia: a case report

Background

Plication of an esophageal hiatus during surgery for esophageal hiatal hernia is a common practice; however, a mesh may be used if the hiatus is markedly enlarged. Recently, various late complications occurring as a result of mesh-induced esophageal and/or gastric wall injuries have been reported.

Case presentation

A 71-year-old woman presented at a neighborhood clinic in November 2010 with chief complaints of respiratory distress on exertion and heartburn. She was diagnosed as having a large esophageal hiatal hernia and was treated at our hospital using a laparoscopic Toupet fundoplication with mesh repair of the esophageal hiatus. Two years and 1 month after the operation, the patient complained of a bowel obstruction. An upper gastrointestinal endoscopy revealed that part of the mesh had extruded into the esophageal lumen, resulting in ulceration and stricture of the esophageal wall. Endoscopic balloon dilatation failed to improve the esophageal stricture. In July 2012, the patient underwent a lower esophagectomy with proximal gastrectomy and was discharged on the 25th hospital day.

Conclusions

We experienced a rare case requiring surgical treatment for a mesh-induced esophageal wall injury after surgery for a giant esophageal hiatal hernia. The selection of a soft, durable mash and its firm securement at a position distant from the gastrointestinal wall may be important to avoid late esophageal wall injury.

Clinicopahological features of superficial basaloid squamous cell carcinoma of the esophagus

Basaloid squamous cell carcinoma (BSC) of the esophagus is classified as an epithelial malignant tumor and is a rare variant of squamous cell carcinoma (SCC). Most previous reports have suggested that advanced BSC has a poorer prognosis than typical SCC because of its high biological malignancy, but the biological activity of superficial BSC remains unclear. Twenty cases of superficial BSC, which underwent surgical resection in Tokai University Hospital between January 2004 and December 2013, were analyzed retrospectively. Among these cases, 19 cases with a T1 depth of invasion (BSC group) were compared with 180 cases of SCC that were resected during the same period and were pathologically diagnosed as T1 (SCC group). The frequency of lymph node metastasis in the T1 BSC group was significantly lower (2 patients, 11%) than that in the SCC group (84 patients, 47%) (P = 0.005). The frequency of lymphatic invasion in the BSC group was also lower (9 patients, 47%) than that in the SCC group (131 patients, 73%) (P = 0.021). The pathological type of the metastatic lymph node was BSC in all the superficial BSC cases with lymph node metastasis. This study demonstrated that lymph node metastasis was less likely to occur in cases with superficial BSC than in cases with superficial SCC.

Pulmonary artery hypoplasia associated with posterior mediastinal hematoma accompanied by a ruptured pseudoaneurysm of the esophageal branch of the left gastric artery

A 65-year-old woman with no significant medical history visited the emergency department complaining of epigastric discomfort. A computed tomography of the thorax and abdomen showed the attenuation of the pulmonary artery and a posterior mediastinal hematoma. Angiography showed a tortuous esophageal branch of the left gastric artery and a pseudoaneurysm, and during the later phase, the left lower lobe of the lung was enhanced, and finally, the left pulmonary vein was enhanced. We considered that the patient was exhibiting hypoperfusion of the left pulmonary artery arising from left pulmonary artery hypoplasia, since the left lung was supplying the systemic circulation. Transcatheter arterial embolization was performed. The patient has not experienced any recurrence of a ruptured pseudoaneurysm or epigastric discomfort. Here, we report the first documented case of pulmonary artery hypoplasia associated with posterior mediastinal hematoma accompanied by a ruptured aneurysm of the left gastric artery.

Laparoscopic mesh repair of adult diaphragmatic hernia: A report of two cases

Congenital diaphragmatic hernia is very rare in adults. The first choice of treatment is surgery, but the optimal surgical method remains unclear. We performed laparoscopic surgeries for two types of congenital diaphragmatic hernias using a novel mesh coated with a chemically modified substance. The first patient was a 65-year-old man with a Bochdalek hernia without a hernial sac, and the other patient was an 80-year-old woman with a Morgagni hernia with a hernial sac. The short-term outcomes of both cases were good, and laparoscopic repair seems to be a useful strategy regardless of the presence or absence of a hernial sac.

Two-year follow-up period showing the natural history of a superficial esophageal adenocarcinoma arising in a long segment of Barrett's esophagus

A 55-year-old woman experienced gastrointestinal dysfunction caused by scleroderma. An initial endoscopy revealed an erosive lesion in a long segment of Barrett's esophagus, and a biopsy led to a diagnosis of ectopic gastric mucosa. Two years later, an irregular, elevated tumor developed at the same site. This tumor was suspected of having invaded the submucosal layer. A second biopsy led to a diagnosis of adenocarcinoma. The patient subsequently underwent a thoracoscopic esophagectomy. The resected specimen revealed an invasive tumor front that had invaded the deep layer of a duplicated muscularis mucosae. Intraepithelial neoplasia partially surrounded the tumor. This lesion was thought to have developed into an adenocarcinoma according to the orderly sequence of metaplasia, intraepithelial neoplasia and finally adenocarcinoma over a 2-year period. The present case suggests that erosive lesions in Barrett's esophagus should be strictly followed up by endoscopy, even if a biopsy does not reveal any neoplastic findings.

Blood flow speed of the gastric conduit assessed by indocyanine green fluorescence: New predictive evaluation of anastomotic leakage after esophagectomy

Anastomotic leakage is considered as an independent risk factor for postoperative mortality after esophagectomy, and an insufficient blood flow in the reconstructed conduit may be a risk factor of anastomotic leakage. We investigated the clinical significance of blood flow visualization by indocyanine green (ICG) fluorescence in the gastric conduit as a means of predicting the leakage of esophagogastric anastomosis after esophagectomy.Forty patients who underwent an esophagectomy with gastric conduit reconstruction were prospectively investigated. ICG fluorescence imaging of the gastric conduit was detected by a near-infrared camera system during esophagectomy and correlated with clinical parameters or surgical outcomes.In 25 patients, the flow speed of ICG fluorescence in the gastric conduit wall was simultaneous with that of the greater curvature vessels (simultaneous group), whereas in 15 patients this was slower than that of the greater curvature vessels (delayed group). The reduced speed of ICG fluorescence stream in the gastric conduit wall was associated with intraoperative blood loss (P = 0.008). Although anastomotic leakage was not found in the simultaneous group, it occurred in 7 patients of the delayed group (P < 0.001). A flow speed of ICG fluorescence in the gastric conduit wall of 1.76 cm/s or less was determined by a receiver operating characteristic (ROC) curve, identified as a significant independent predictor of anastomotic leakage after esophagectomy (P = 0.004).This preliminary study demonstrates that intraoperative evaluation of blood flow speed by ICG fluorescence in the gastric conduit wall is a useful means to predict the risk of anastomotic leakage after esophagectomy.

Long peptic strictures of the esophagus due to reflux esophagitis: a case report

Background

Most of benign esophageal strictures caused by gastroesophageal reflux are short segments and can be treated by an endoscopic dilatation, but cases of long-segment stenosis requiring an esophagectomy are rare.

Case presentation

A 62-year-old woman had undergone emergency surgery for a giant ovarian tumor rupture at another hospital. A duodenal perforation occurred after surgery but improved with conservative treatment. She had undergone long-term nasogastric tube placement for 4 months because she was on a mechanical ventilator and did not receive proton pump inhibitors (PPIs). Thereafter, the patient experienced dysphagia. An esophagogastroduodenoscopy (EGD) revealed circumferential reflux esophagitis (grade D) and a stricture located 25 to 40 cm from the incisor teeth. She received medical treatment with fasting and PPIs. The second EGD revealed that the reflux esophagitis had improved somewhat, but that the esophageal stricture had worsened. Thereafter, balloon dilatation was attempted, but the stricture did not improve and she was referred to our hospital. Finally, she was diagnosed as having a benign esophageal stricture caused by reflux esophagitis. She underwent a thoracoscopic esophagectomy with gastric tube reconstruction through the antethoracic route. Her postoperative course was uneventful. Pathologically, a circumferential stricture with white scar formation and no malignant cells were observed.

Conclusions

We experienced a rare case requiring esophagectomy for long-segment stenosis caused by reflux esophagitis. It is suggested that the possibility of esophageal stricture needs to be kept in mind when treating GERD patients with long-term nasogastric tube placement.

Impact of body mass index on postoperative complications and long-term survival in patients with esophageal squamous cell cancer

Undernutrition and cachexia have been suggested to be risk factors for postoperative complications and survival in cancer patients. The aim of this study was to investigate whether body mass index (BMI) is related to the short-term and long-term outcomes in patients who undergo an esophagectomy for the resection of esophageal squamous cell cancer (ESCC). Three hundred forty patients who underwent an esophagectomy for the resection of ESCC between 2003 and 2008 were retrospectively reviewed. The patients were divided into two groups: an L-BMI group characterized by a BMI < 18.5 kg/m(2) and an N-BMI group characterized by a BMI ≥ 18.5 kg/m(2). Clinical and pathological outcome were compared between groups. The study included 40 patients in the L-BMI group and 300 patients in the N-BMI group. A clinicopathological assessment showed that nodal involvement was seen more frequently in the L-BMI group (P = 0.016). Pulmonary complications seemed to occur more frequently in the L-BMI group (P = 0.006). The 5-year overall survival rate was higher in the N-BMI group (63.6%) than in the L-BMI group (32.3%) (P < 0.001). The 5-year disease-free survival rate was also higher in the N-BMI group (58.0%) than in the L-BMI group (33.6%) (P = 0.001). In multivariate analysis, the BMI (hazard ratio, 2.154; 95% CI, 1.349-3.440, P = 0.001) was found to be an independent prognostic factor for overall survival. Our data suggested that a lower BMI not only increased pulmonary complications but also impaired overall and disease-free survival after an esophagectomy for the resection of ESCC.

Sentinel node navigation surgery with indocyanine green fluorescence-guided method for metachronous early gastric carcinoma arising from reconstructed gastric tube after esophagectomy

A 67-year-old man who had undergone a thoracoscopic esophagectomy and posterior mediastinal gastric tube reconstruction for thoracic esophageal cancer 9 years previously was endoscopically diagnosed as having gastric carcinoma arising from the reconstructed gastric tube. No evidence of metastasis was seen in imaging examinations, and the depth of tumor invasion was suspected to be the submucosal layer. Based on these results, we decided that surgery, rather than endoscopic resection, was indicated. The tumor was located in the upper abdomen. Therefore, we performed a partial resection of the gastric tube. Sentinel nodes (SN) were identified using the Hyper Eye Medical System II. Metastasis was not observed in any of the selected SN. While the treatment strategy for gastric tube cancer after an esophagectomy remains controversial, minimally invasive surgery with sentinel node navigation surgery appears to be clinically useful. However, the method of SN dissection should be investigated with due consideration given to arterial preservation.

Resection of a Submucosal Tumor-Like Superficial Carcinoma in Middle Thoracic Esophagus Concomitant with Mucosal Adenocarcinoma and Submucosal Squamous Cell Carcinoma: A Case Report and Review of Literature

A 67-year-old man was pointed out mucosal irregularity on health check-up and was referred to our institution. Diagnostic examinations were performed and an aggregated type 0-IIa lesion having 3 small protrusions was recognized in the middle thoracic esophagus. Endoscopic biopsy led to diagnosis of esophageal cancer concomitant with adenocarcinoma and squamous cell carcinoma. Thoracic esophagectomy with 3-fields lymph node dissection was performed via a right thoracoabdominal approach and reconstructed with stomach roll. Three submucosal tumors like small protrusions were recognized in resected specimen. One of them was well differentiated tubular adenocarcinoma which occupied in mucosal layer. The other two were moderately differentiated squamous cell carcinoma. They existed very near but no connection was recognized by serial section. The adenocarcinoma existing in middle esophagus is very rare. Almost all of them were submucosal or advanced cancers. When we searched with the ICHUSHI database (a domestic medical literature database service provided by the NPO Japan Medical Abstracts Society) and the PubMed database, there was no report of mucosal adenocarcinoma occurred in middle thoracic esophagus in the past 10 years. Then this report was thought to be the first report of mucosal adenocarcinoma in middle thoracic esophagus in the world.

A Long Surviving Case of Multiple Early Stage Primary Malignant Melanoma of the Esophagus and a Review of the Literature

We report a 75 year old man in whom primary malignant melanoma of the esophagus (PMME) was detected on an upper gastrointestinal radiographic contrast study and upper gastrointestinal endoscopy during a regular medical checkup. An extensive black lesion with a 1.5 x 1.0 cm protrusion and diffuse 1 cm flat lesions were recognized. The results of radical surgery were PMME pT1a-MM ly1 v0 pN0 (0/86) multiple lesions (+). Adjuvant chemotherapy was not employed and he has survived almost 7 years with no evidence of recurrence. PMME is a very rare lesion and in the PubMed database only 85 cases in 73 reports accumulated in a 10 year period from 2005 to 2014. Until 2014 a total of 369 cases were reported. In the ICHUSHI database (a domestic medical literature database service provided by the NPO Japan Medical Abstracts Society), 65 lesions in 62 cases were reported in the same period. Also until 2014, 301 cases were reported. At present, surgery is the first choice of treatment for PMME extending to the submucosa or deeper, but with developments in molecular targeting agents, PMME is thought to likely become an expanded indication of this technique.

Reconstruction of Multiple Facial Nerve Branches Using Skeletal Muscle-Derived Multipotent Stem Cell Sheet-Pellet Transplantation

Head and neck cancer is often diagnosed at advanced stages, and surgical resection with wide margins is generally indicated, despite this treatment being associated with poor postoperative quality of life (QOL). We have previously reported on the therapeutic effects of skeletal muscle-derived multipotent stem cells (Sk-MSCs), which exert reconstitution capacity for muscle-nerve-blood vessel units. Recently, we further developed a 3D patch-transplantation system using Sk-MSC sheet-pellets. The aim of this study is the application of the 3D Sk-MSC transplantation system to the reconstitution of facial complex nerve-vascular networks after severe damage. Mouse experiments were performed for histological analysis and rats were used for functional examinations. The Sk-MSC sheet-pellets were prepared from GFP-Tg mice and SD rats, and were transplanted into the facial resection model (ST). Culture medium was transplanted as a control (NT). In the mouse experiment, facial-nerve-palsy (FNP) scoring was performed weekly during the recovery period, and immunohistochemistry was used for the evaluation of histological recovery after 8 weeks. In rats, contractility of facial muscles was measured via electrical stimulation of facial nerves root, as the marker of total functional recovery at 8 weeks after transplantation. The ST-group showed significantly higher FNP (about three fold) scores when compared to the NT-group after 2–8 weeks. Similarly, significant functional recovery of whisker movement muscles was confirmed in the ST-group at 8 weeks after transplantation. In addition, engrafted GFP⁺ cells formed complex branches of nerve-vascular networks, with differentiation into Schwann cells and perineurial/endoneurial cells, as well as vascular endothelial and smooth muscle cells. Thus, Sk-MSC sheet-pellet transplantation is potentially useful for functional reconstitution therapy of large defects in facial nerve-vascular networks.

Small Cell Type of Esophageal Neuroendocrine Carcinoma Resembling a Submucosal Tumor

We report a rare case of primary small cell type esophageal neuroendocrine carcinoma with a unusual endoscopic form similar to a submucosal tumor with the results of the histological and immunohistochemical analyses. A 57-year-old woman with dysphagia was referred to our hospital for further examination and treatment, and was diagnosed as type 1s esophageal carcinoma in the middle thoracic esophagus. Endoscopy revealed a protruding esophageal carcinoma resembling a submucosal tumor with an irregular and nodular surface covered by non-neoplastic epithelium stained with iodine. Analysis of the esophageal biopsy specimen revealed poorly differentiated squamous cell carcinoma. Based on a diagnosis of type 1s carcinoma in the middle thoracic esophagus that was 5 cm in size longitudinally, a radical esophagectomy with three-field lymph node dissection was performed. The pathological examination with histological and immunohistochemical analysis of the resected specimen revealed a small cell type neuroendocrine carcinoma overlaid by a non-neoplastic epithelium, extending into the adventitia without lymph node metastasis (T3, N0, M0, Stage II). However, multiple metastases in the brain and lung developed 3 months postoperatively, and the patient died of the cancer 7 months after the operation. This was a rare case of a highly malignant primary small cell type esophageal neuroendocrine carcinoma showing extremely rare form.

Small Intestinal Metastasis from Esophageal Squamous Cell Carcinoma Presenting with Perforated Peritonitis

Metastatic tumors of the small intestinal tract from extra-abdominal sites are rare. We report herein a rare case of small intestinal metastasis from esophageal carcinoma that presented with perforated peritonitis. A 71-year-old man with dysphagia was referred to our hospital for further examination and treatment, and was diagnosed with type 3 advanced esophageal squamous cell carcinoma of the lower thoracic esophagus. Based on a diagnosis of Stage II cancer, a radical esophagectomy with three-field lymph node dissection was performed after neoadjuvant chemotherapy composed of 5-fluorouracil plus cisplatin. Pathological examination of the resected specimen revealed a moderately differentiated squamous cell carcinoma, extending into the adventitia with lymph node metastasis (T3, N2, M0, Stage III). During postoperative adjuvant chemotherapy, the patient complained of abdominal pain and was found to have perforated peritonitis. Emergency laparotomy was performed. A jejunal perforation with a submucosal nodule approximately 80 cm distal from the ligament of Treitz was detected, and completely resected by jejunal partial resection. Histopathology of the specimen showed a perforation of the small intestine due to metastasis of esophageal squamous cell carcinoma with mesenteric lymph node metastasis. The patient died of cancer 9 months after surgery. An extremely rare case of small intestinal metastasis from esophageal carcinoma presenting with perforated peritonitis was described.

Impact of preoperative neutrophil to lymphocyte ratio on long-term survival in patients with esophageal squamous cell carcinoma

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Background: Elevated neutrophil to lymphocyte ratio (NLR) reflects patients’ inflammation status and closely relates to tumor progression. The aim of this study was to evaluate the clinical significance of the preoperative NLR in patients who undergo an esophagectomy for esophageal squamous cell carcinoma. Methods: A total of 340 patients who underwent an esophagectomy for esophageal squamous cell carcinoma between 2003 and 2008 were retrospectively reviewed. The NLR ≥ 3 was considered to be elevated and the patients were divided into two groups. The overall and disease-free survival curves of the two NLR groups were determined using the Kaplan-Meier method and were compared using a log-rank test. A cox proportional hazards regression analysis was used for the univariate and multivariate analyses. Results: The study included 306 males and 34 females. Seventy-two patients (21%) had an elevated NLR. The 5-year overall survival for patients with high NLR was significantly worse than that for patients with normal NLR (41% vs 69%, p < 0.001). The 5-year disease-free survival for patients with high NLR was significantly worse than that for patients with normal NLR (41% vs 59%, p < 0.001). In multivariate analysis, a high NLR (HR 1.76, 95% CI 1.19-2.60, p = 0.005), an upper tumor location (HR 1.97, 95% CI 1.18-3.30, p = 0.010), an advanced T stage (HR 2.71, 95% CI 1.70-4.31, p < 0.001), and a larger number of metastatic lymph nodes (HR 4.38, 95% CI 1.18-3.30, p < 0.001) were independent predictors of poor overall survival. Conclusions: Our results suggested that the elevated preoperative NLR predicts poor overall and disease-free survival after an esophagectomy for esophageal squamous cell carcinoma.

Clinicopathological significance of laminin-5γ2 chain expression in superficial esophageal cancer

The glycoprotein laminin 5γ2 chain (LN-5γ2) has recently become a focus of increased interest and investigation as a marker of invasion in gastrointestinal malignancies. We investigated the significance of LN-5γ2 expression as a prognostic factor in superficial esophageal cancer. The study population consisted of 87 patients who had undergone a transthoracic esophagectomy and three-field lymphadenectomy for the treatment of superficial esophageal cancer at Tokai University Hospital. Formalin-fixed, paraffin-embedded sections of the resected specimens were examined using immunohistochemical staining and hematoxylin and eosin staining to assess the correlations between the LN-5γ2 expression pattern and the clinicopathological factors (age, sex, T-factor, N-factor, ly-factor, v-factor, degree of differentiation, infiltrative growth pattern, tumor node metastasis classification of malignant tumors [TNM] stage, etc.) and the patient outcome. The expression pattern of LN-5γ2 was classified into an extracellular type (E type), characterized by the staining of extracellular matrix such as the basement membrane and the stroma (31 cases, 35.6%), and a cytoplasmic type (C type), characterized by the staining of the cytoplasm in the cancer cells (56 cases, 64.6%). The expression pattern was not correlated with any of the clinicopathological factors that were assessed. However, univariate analyses of the survival analysis data showed that the N-factor (P = 0.011), TNM stage (P = 0.011), and LN-5γ2 C type (P = 0.017) were prognostic factors. A multivariate analysis revealed that the N-factor (P = 0.049) and LN-5γ2 C type (P = 0.048) were prognostic factors. In the survival analysis, a univariate analysis of the 75 T1b cases also showed that the N-factor (P = 0.048), TNM stage (P = 0.048), and LN-5γ2 C type (P = 0.029) were prognostic factors, while a multivariate analysis showed that the LN-5γ2 C type (P = 0.035) was a prognostic factor. The C type expression of LN-5γ2, i.e. confined to the cytoplasm, was correlated with an unfavorable outcome among the patients with superficial esophageal cancer in the present series. Observation of the LN-5γ2 expression pattern may be useful for the diagnosis of highly malignant tumors.

Impact of sarcopenia on long-term prognosis of patients with esophageal cancer after surgery

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Background: Emerging evidence suggests that sarcopenia might have an adverse impact on the survival of patients with cancer. We herein investigated the impact of sarcopenia on the long-term outcome of patients with esophageal cancer after curative surgery by analyzing the muscle cross-sectional area using computed tomography (CT). Methods: Sarcopenia was assessed in 204 patients undergoing a macroscopic curative esophagectomy for the resection of esophageal cancer between January 2005, and December 2008 at Tokai University Hospital by measuring the cross-sectional area of the psoas muscle at the level of the third lumbar vertebra on CT images obtained before surgery. The measured total psoas area (TPA) was normalized according to the patient’s height. Sarcopenia was defined as a TPA of ≤525 mm/m2 for men, and ≤375 mm/m2 for women. The impact of sarcopenia was assessed after controlling for clinical factors using multivariate modeling. Results: The median follow-up period was 60 months. The median patient age was 64 years; 184 (90%) patients were male and 20 (10%) were female. The median TPA was 580 mm/m2 for the men and 386 mm/m2 for the women. Sixty-nine (34%) patients had sarcopenia (TPA ≤525 mm/m2 for men, 375 mm/m2 for women ). The overall five-year survival rates were 33% for the patients with sarcopenia, and 66% for those without sarcopenia. In a multivariate analysis, a low body mass index (BMI ≤ 18.5 kg/m2; hazard ratio [HR], 1.87 [P = 0.028]), pathological stage of disease (HR for stage I, 1.587 in stage II [P = 0.219], 4.146 in stage III [P < 0.001], and 6.712 in stage IV [P < 0.001]), tumor location (HR of upper thoracic for middle and lower thoracic, 2.350 [P = 0.002]), and sarcopenia (HR, 1.858 [P= 0.006]) were independently associated with the overall mortality. Conclusions: Sarcopenia is associated with an increased risk of overall mortality in esophageal cancer after curative surgery independent of tumor-specific factors and the BMI. The development of effective interventions for sarcopenia warrants further study to improve the prognosis of patients with esophageal cancer.

Impact of body mass index on postoperative complications and long-term survival in patients with esophageal squamous cell carcinoma

37

Background: Chachexia and undernutrition have been suggested to be risk factors for postoperative complications and survival in cancer patients. The aim of this study was to investigate whether body mass index (BMI) is related to the short-term and long-term outcomes in patients who undergo an esophagectomy for the resection of esophageal squamous cell cancer. Methods: Three hundred forty patients who underwent an esophagectomy for the resection of esophageal squamous cell cancer between 2003 and 2008 were retrospectively reviewed. The patients were divided into two groups: an L-BMI group characterized by a BMI < 18.5 kg/m2, and an N-BMI group characterized by a BMI ≥ 18.5 kg/m2. The overall and disease-free survival curves of the two BMI groups were determined using the Kaplan-Meier method and were compared using a log-rank test. A Cox proportional hazards regression analysis was used for the univariate and multivariate analyses. Results: The study included 40 patients in the L-BMI group and 300 patients in the N-BMI group. Pulmonary complications seemed to occur more frequently in the L-BMI group (P = 0.006). A histopathological assessment showed that nodal involvement was seen more frequently in the L-BMI group (P = 0.016). The 5-year overall survival rate was higher in the N-BMI group (63.6%) than in the L-BMI group (32.3%) (P < 0.001). The 5-year disease-free survival rate was also higher in the N-BMI group (64.2%) than in the L-BMI group (32.3%) (P = 0.014). In a multivariate analysis, a lower BMI, an upper tumor location, an advanced pathological T stage, and a larger number of metastatic lymph nodes were independent prognostic factors for overall survival (P < 0.05). Conclusions: Our data suggested that a lower BMI not only increased pulmonary complications but also impaired overall and disease-free survival after an esophagectomy for the resection of esophageal squamous cell cancer.

[Recent advances in endoscopic resection for esophageal cancer]

The indications for endoscopic resection (ER) in esophageal cancer are limited to cases without lymph node metastasis because it is a local therapy. The relationship between cancer depth and lymph node metastasis has been clarified according to the pathologic analysis of lymph nodes removed during esophagectomy for early esophageal cancer. Cancer invasion remaining in the lamina propria mucosa rarely metastasizes to the lymph nodes, and ER is thus indicated. ER allows the esophagus to be preserved and is less invasive, enabling the specimen to be examined pathologically. Lesions extending to a large area can be resected by repeated endoscopic mucosal resection (EMR), but have recently been resected en bloc in the endoscopic submucosal dissection (ESD) procedure, which is also indicated for the treatment of gastric cancer. The selection of EMR or ESD depends on the size of the lesion, the technique of the surgeon, the time the patient can safely spend under anesthesia, and economic management. ER is now employed in T1a-MM, SM1 cases without lymph node metastasis, although some require additional treatment including surgery after pathologic examination of the resected lesions.

Altered pain responses in mice lacking alpha 1E subunit of the voltage-dependent Ca2+ channel

alpha(1) subunit of the voltage-dependent Ca(2+) channel is essential for channel function and determines the functional specificity of various channel types. alpha(1E) subunit was originally identified as a neuron-specific one, but the physiological function of the Ca(2+) channel containing this subunit (alpha(1E) Ca(2+) channel) was not clear compared with other types of Ca(2+) channels because of the limited availability of specific blockers. To clarify the physiological roles of the alpha(1E) Ca(2+) channel, we have generated alpha(1E) mutant (alpha(1E)-/-) mice by gene targeting. The lacZ gene was inserted in-frame and used as a marker for alpha(1E) subunit expression. alpha(1E)-/- mice showed reduced spontaneous locomotor activities and signs of timidness, but other general behaviors were apparently normal. As involvement of alpha(1E) in pain transmission was suggested by localization analyses with 5-bromo-4-chloro-3-indolyl beta-d-galactopyranoside staining, we conducted several pain-related behavioral tests using the mutant mice. Although alpha(1E)+/- and alpha(1E)-/- mice exhibited normal pain behaviors against acute mechanical, thermal, and chemical stimuli, they both showed reduced responses to somatic inflammatory pain. alpha(1E)+/- mice showed reduced response to visceral inflammatory pain, whereas alpha(1E)-/- mice showed apparently normal response compared with that of wild-type mice. Furthermore, alpha(1E)-/- mice that had been presensitized with a visceral noxious conditioning stimulus showed increased responses to a somatic inflammatory pain, in marked contrast with the wild-type mice in which long-lasting effects of descending antinociceptive pathway were predominant. These results suggest that the alpha(1E) Ca(2 +) channel controls pain behaviors by both spinal and supraspinal mechanisms.