Minimally invasive surgical staging for esophageal cancer

Minimally invasive staging of esophageal cancer

Esophageal cancer is one of the most common malignancies in the world today and the sixth-leading cause of cancer-related mortality. Accurate preoperative staging of esophageal cancer is imperative to the selection of appropriate treatments. Patients with esophageal carcinomas typically undergo a multimodality staging process including noninvasive imaging techniques, such as computed tomography (CT) and positron emission tomography (PET), as well as endoscopic ultrasound (EUS), which is slightly more invasive. Minimally invasive surgical staging, with laparoscopy, occasionally in combination with video-assisted thoracoscopy, is used in the staging process at select institutions and has been shown to be more accurate than noninvasive staging modalities. Two major advantages of minimally invasive surgical staging over conventional techniques are the improved assessment of locoregional disease and enhanced identification of distant metastases. These advantages decrease the likelihood that the patient will undergo a nontherapeutic laparotomy. Currently, no clear consensus exists regarding which patients with esophageal cancer would benefit most from the addition of minimally invasive surgical staging. We have, however, found that minimally invasive surgical staging with laparoscopy is particularly valuable in detection of occult distant metastases. In this article, we summarize the staging modalities for esophageal cancer including minimally invasive surgical staging.

A propensity-matched analysis comparing survival after primary minimally invasive esophagectomy followed by adjuvant therapy to neoadjuvant therapy for esophagogastric adenocarcinoma

OBJECTIVES

Prognosis for patients with locally advanced esophagogastric adenocarcinoma (EAC) is poor with surgery alone, and adjuvant therapy after open esophagectomy is frequently not tolerated. After minimally invasive esophagectomy (MIE); however, earlier return to normal function may render patients better able to receive adjuvant therapy. We examined whether primary MIE followed by adjuvant chemotherapy influenced survival compared with propensity-matched patients treated with neoadjuvant therapy.

METHODS

Patients with stage II or higher EAC treated with MIE (N = 375) were identified. Using 30 pretreatment covariates, propensity for assignment to either neoadjuvant followed by MIE (n = 183; 54%) or MIE as primary therapy (n = 156; 46%) was calculated, generating 97 closely matched pairs. Hazard ratios were adjusted for age, sex, body mass index, smoking, comorbidity, and final pathologic stage.

RESULTS

In propensity-matched pairs, adjusted hazard ratio for death did not differ significantly for primary MIE compared with neoadjuvant (hazard ratio, 0.83; 95% confidence interval, 0.60-1.16). Recurrence patterns were similar between groups and 65% of patients with IIb or greater pathologic stage received adjuvant therapy. Clinical staging was inaccurate in 37 out of 105 patients (35%) who underwent primary MIE (n = 18 upstaged and n = 19 downstaged).

CONCLUSIONS

Primary MIE followed by adjuvant chemotherapy guided by pathologic findings did not negatively influence survival and allowed for accurate staging compared with clinical staging. Our data suggest that primary MIE in patients with resectable EAC may be a reasonable approach, improving stage-based prognostication and potentially minimizing overtreatment in patients with early stage disease through accurate stage assignments. A randomized controlled trial testing this hypothesis is needed.

Phase-contrast X-ray CT imaging of esophagus and esophageal carcinoma

The electron density resolution is 1000 times higher for synchrotron-radiation phase-contrast CT imaging than conventional X-ray absorption imaging in light elements, with which high-resolution X-ray imaging of biological soft tissue can be achieved. In the present study, we used phase-contrast X-ray CT to investigate human resected esophagus and esophageal carcinoma specimens. This technology revealed the three-layer structure of the esophageal wall-- mucous, submucosa and muscular layers. The mucous and muscular layers were clearly separated by a loose submucosa layer with a honeycomb appearance. The surface of the mucous layer was smooth. In esophageal carcinoma, because of tumor tissue infiltration, the submucosa layer was absent, which indicated destruction of the submucosa. The boundary between normal tissue and tumor was comparatively fuzzy, the three-layer structure of the esophageal wall was indistinct. The surface of the mucous layer was rugose. The technology might be helpful in tumor staging of esophageal carcinoma.

Modified McKeown minimally invasive esophagectomy for esophageal cancer: a 5-year retrospective study of 142 patients in a single institution

Background

To achieve decreased invasiveness and lower morbidity, minimally invasive esophagectomy (MIE) was introduced in 1997 for localized esophageal cancer. The combined thoracoscopic-laparoscopic esophagectomy (left neck anastomosis, defined as the McKeown MIE procedure) has been performed since 2007 at our institution. From 2007 to 2011, our institution subsequently evolved as a high-volume MIE center in China. We aim to share our experience with MIE, and have evaluated the outcomes of 142 patients.

Methods

We retrospectively reviewed 142 consecutive patients who had presented with esophageal cancer undergoing McKeown MIE from July 2007 to December 2011. The procedure, surgical outcomes, disease-free and overall survival of these cases were assessed.

Results

The average total procedure time was 270.5±28.1 min. The median operation time for thoracoscopy was 81.5±14.6 min and for laparoscopy was 63.8±9.1 min. The average blood loss associated with thoracoscopy was 123.8±39.2 ml, and for laparoscopic procedures was 49.9±14.3 ml. The median number of lymph nodes retrieved was 22.8. The 30 day mortality rate was 0.7%. Major surgical complications occurred in 24.6% and major non-surgical complications occurred in 18.3% of these patients. The median DFS and OS were 36.0±2.6 months and 43.0±3.4 months respectively.

Conclusions

Surgical and oncological outcomes following McKeown MIE for esophageal cancer were acceptable and comparable with those of open-McKeown esophagectomy. The procedure was both feasible and safe – properties that can be consolidated by experience.

Distance between the esophageal tumor and the aorta measured by using the contrast-enhanced attenuation on computed tomography for predicting this tumor invading aorta

BACKGROUND AND AIM

Despite remarkable advances in diagnostic modalities, preoperative assessment of the local tumor extent in esophageal cancer is still very difficult. The aim of this study was to evaluate the predictive value of the computed tomography (CT) attenuation value between the tumor and the aorta for esophageal cancer.

METHODS

Consecutive CT values were determined between the center of the tumor and the center of the aorta. The distance between the intersection of the average CT attenuation value of the tumor using the lower CT attenuation value of the inclusion tissues (T-A distance) was determined. The minimal CT attenuation value and the overall circumference of contact area (Picus' angle) were also determined. This study included 101 patients suspected of having a tumor invading the adventitia and evaluated the capacity of these parameters for predicting the aortic invasion.

RESULTS

The T-A distance in patients who were diagnosed without aortic invasion was significantly longer than patients who were pathologically confirmed to have invasion to the aortic wall [pT4(Ao)] (P < 0.05). The minimal CT attenuation value in patients without aortic invasion was significantly lower than pT4(Ao) patients (P < 0.05), although such a difference was not observed for the Picus' angle. The T-A distance (1.3 mm >) is the most reliable feature for predicting the aortic invasion, according to the results of the area under the receiver operating characteristic curve.

CONCLUSIONS

The assessment of the T-A distance is simple and objective, and it can help prevent unnecessary surgery in patients with inoperable tumors.

Role of photodynamic therapy in the palliation of obstructing esophageal cancer

BACKGROUND/AIMS

The aim of this non-randomized study was to determine the role of photodynamic therapy (PDT) in a multimodal approach for the palliation of advanced esophageal carcinoma.

METHODS

Twenty consecutive patients with obstructing esophageal cancer were enrolled in this study. Each subject had dysphagia, and nine could not swallow fluid. External beam radiotherapy or a self-expandable metal stent was used following PDT for dysphagia due to recurrence of the malignancy.

RESULTS

At 4 weeks post-PDT, a significant improvement in the dysphagia score was observed in 90% of patients, from 2.75 ± 0.91 to 1.05 ± 0.83 (p < 0.05). Patients with recurrent dysphagia underwent stent insertion at an average of 63 days (range, 37 to 90). The rate of major complications was 10%. Two esophageal strictures occurred, which were treated by placement of a modified expandable stent across the stricture. The median survival in these cases was 7.0 ± 0.6 months. One patient that was treated with PDT and radiotherapy is alive and showed a complete tumor response.

CONCLUSIONS

PDT as a multimodality treatment is safe and effective for relieving malignant esophageal obstruction with minimal complications.

Minimally invasive surgery and cancer: controversies part 1

Perhaps there is no more important issue in the care of surgical patients than the appropriate use of minimally invasive surgery (MIS) for patients with cancer. Important advances in surgical technique have an impact on early perioperative morbidity, length of hospital stay, pain management, and quality of life issues, as clearly proved with MIS. However, for oncology patients, historically, the most important clinical questions have been answered in the context of prospective randomized trials. Important considerations for MIS and cancer have been addressed, such as what are the important immunologic consequences of MIS versus open surgery and what is the role of laparoscopy in the staging of gastrointestinal cancers? This review article discusses many of the key controversies in the minimally invasive treatment of cancer using the pro-con debate format.

Integrated FDG-PET/CT compared with intravenous contrast-enhanced CT for evaluation of metastatic regional lymph nodes in patients with resectable early stage esophageal cancer

OBJECTIVE

To assess whether integrated fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) can improve the diagnostic accuracy of metastatic regional lymph nodes (LNs) in esophageal cancer compared with contrast enhanced CT (CECT).

METHODS

We examined 180 consecutive patients with esophageal cancer by integrated PET/CT between April 2006 and March 2007. Eighteen patients (M:F 14:4) underwent radical esophagectomy after evaluations by PET/CT and CECT of 5-7-mm-thick slices 70-80 s after injection. Regional LNs of esophageal cancer were retrospectively reviewed on CECT images by two blinded evaluators on the basis of the following cutoff sizes: 7 mm for all regional LNs (Protocol A), 10 mm for paratracheal LNs (Protocol B), and 7 mm for others. In addition, the maximum standardized uptake value (SUVmax) on PET/CT was evaluated for positive uptake by LNs.

RESULTS

Of 210 LNs excised at surgery, 25 were positive and 185 were negative for metastasis at pathology. The PET/CT images identified 15 true-positive and 184 true-negative LNs, whereas CECT identified 15 true positives and 176 true negatives in Protocol A, and 14 true positives and 180 true negative in Protocol B. The sensitivity, specificity, accuracy, positive, and negative predictive values of PET/CT were respectively 60.0%, 99.5%, 94.8%, 93.8%, and 94.8%, whereas those of CECT were 60.0%, 95.1%, 91.0%, 62.5%, and 94.6% (Protocol A) and 56.0%, 97.3%, 92.4%, 73.7%, and 94.2% (Protocol B). A comparison of the two CECT protocols revealed fewer false-positive LNs in Protocol B, but slightly lower sensitivity in Protocol B than in Protocol A. Substantial numbers of false-positive LNs were determined by CECT in the paratracheal regions (6 of 9, 66.7%) and CECT revealed central necrosis in 4 of 15 (26.7%) true-positive LNs > 1.8 cm. The mean SUVmax on PET/CT was 2.9 (range 1.7-5.5) in true-positive LNs. The smallest LN metastasis detectable by PET/CT was 6 mm.

CONCLUSIONS

Integrated PET/CT improves the PPV of regional LNs when compared with CECT.

[Laparoscopic transhiatal esophagectomy: outcomes]

BACKGROUND

The laparoscopic transhiatal esophagectomy for benign or malignant disease is a complex operation associated with a high rate of morbidity and mortality. In the last decade this procedure gained popularity and acceptance for treatment of the esophagus cancer and other benign diseases.

AIM

To perform a retrospective analysis in patients with esophageal cancer that was underwent a laparoscopic transhiatal esophagectomy, demonstrated pre and post operative complications and immediate result.

METHODS

From November 1993 to June 2005, 72 patients underwent laparoscopic transhiatal esophagectomy. Sixty-four with malignant neoplasm of esophagus. The males are predominant, and the mean age was 56.5 years. The abdominal part of the operation was totally laparoscopic and the cervical one was made the conventional way. The stomach was pulled up to the neck by the posterior mediastinum.

RESULTS

The laparoscopic transhiatal esophagectomy was initiated in 64 patients. Four patients were converted to open surgery. The mean operation time was 153 minutes. The incidence of cervical fistula was 14.06%. The mortality rate 5.6%.

CONCLUSION

Laparoscopic transhiatal esophagectomy is a secure option in experience centers. The morbility is low, with a faster return to normal activity. Maybe in fact this procedure may be reminded and ponder in the treatment of esophageal disease.

Laparoscopic Gastric Ischemic Conditioning Prior to Esophagogastrectomy: Technique and Review

Esophagectomy can be associated with significant peri-operative morbidity such as leaks and strictures. Gastric ischemia as a result of gastric devascularization is one of the several contributing factors that may play a role in development of these complications. In an attempt to improve gastric tissue perfusion, a technique of gastric ischemic conditioning was proposed. For patients with esophageal cancer and at the time of laparoscopic staging, partial gastric devascularization is achieved by division of the left gastric vessels. Esophagectomy is subsequently performed several days after the gastric ischemic conditioning procedure. Our experience showed that preoperative ligation of left gastric vessels prior to esophagogastrectomy is technically feasible and safe and may decrease ischemic complications such as leaks and strictures.

Laparoscopic transhiatal esophagectomy: outcomes

BACKGROUND

Laparoscopic transhiatal esophagectomy, indicated for benign and malignant esophageal diseases, is a complex operation, often associated with a high rate of morbidity and mortality. During the past decade this technique has became well accepted among specialized surgeons for the treatment of esophageal cancer, avoiding thoracotomy and reducing open access complications. The aim of the present study was to retrospectively analyze patients with esophageal cancer who underwent laparoscopic transhiatal esophagectomy.

METHODS

From November 1993 to August 2006, 78 patients underwent laparoscopic transhiatal esophagectomy. There were 68 cases of esophageal cancer (57 males and 21 females, age range = 28-73 years) with a predominant rate of squamous cell carcinoma (60.2%).

RESULTS

The conversion rate was 6.4%. The mean operative time was 153 min with a 12.8% rate of cervical leak and a postoperative (30-day) mortality rate of 5.1%. The four-year survival rate was 19% as determined within a subgroup of 21 patients whose followup during the period was possible.

CONCLUSIONS

Laparoscopic transhiatal esophagectomy is a safe alternative for experienced professionals. This access can improve mortality, hospital stay, and other outcomes when compared with open methods.

Significant clinical impact and prognostic stratification provided by FDG-PET in the staging of oesophageal cancer

PURPOSE

To evaluate the clinical impact of FDG-PET in staging oesophageal cancer and whether this information improves prognostic stratification.

METHODS

Impact was based on comparison of a prospectively recorded pre-PET plan with post-PET treatment in 68 consecutive patients undergoing primary staging. Survival was analysed using the Kaplan-Meier product limit method and the Cox proportional hazards regression model.

RESULTS

FDG-PET findings impacted on the management of 27/68 patients (40%): in 12 therapy was changed from curative to palliative and in three from palliative to curative, while in 12 other patients there was a change in the treatment modality or delivery but not in the treatment intent. The median survival was 21 months, with post-PET stage and treatment intent both strongly associated with survival (p<0.001). Conventional stage was not able to clearly stratify this population.

CONCLUSION

The use of FDG-PET for primary staging of oesophageal cancer changed the clinical management of more than one-third of patients and provided superior prognostic stratification compared with conventional investigations.

Minimally invasive techniques for oesophageal cancer surgery

Innovative minimally invasive surgical (MIS) techniques have been explored for the purpose of oesophagectomy since the early 1990s, including various combinations of thoracoscopy, laparoscopy or laparoscopic-assisted methods, mediastinoscopy and open thoracotomy and laparotomy. The myriad of surgical approaches implies a lack of consensus on which is superior. Like open surgery, it is perhaps more important to have a tailored approach for the individual patient. MIS oesophagectomy has been shown to be feasible, and at least equivalent postoperative morbidity and mortality rates to open surgical resection have been demonstrated. Selected series have achieved less blood loss, reduction in some postoperative complications, decrease in intensive care and hospital stay, and better preservation of pulmonary function. Clear proof of superiority over conventional oesophagectomy methods however is not forthcoming since comparisons were often made with unmatched patient cohorts, and a well conducted randomized controlled trial has not been carried out. It is expected that with further improvements in instrumentation and experience, these difficult procedures may become more accessible and widely practised.

Immediate preoperative laparoscopic staging for squamous cell carcinoma of the esophagus

BACKGROUND

Conventional preoperative staging for esophageal carcinoma could be inaccurate. Laparoscopy has been applied for the staging of various upper gastrointestinal malignancies. It can identify peritoneal and liver deposits not shown by imaging, and could reduce the number of nontherapeutic laparotomies. This study aimed to evaluate the efficacy of laparoscopic staging for the management of squamous cell carcinoma involving the mid and distal esophagus.

METHODS

A retrospective review was performed for all patients with esophageal cancer evaluated for surgical resection from January 1998 to January 2004. Laparoscopy was performed for all the patients with mid and distal esophageal cancer immediately before open gastric mobilization. The efficacy of laparoscopy for the management of squamous cell carcinoma of the esophagus was evaluated.

RESULTS

Among the 63 patients with potentially resectable disease shown on conventional imaging, 54 (84%) underwent esophagectomy with curative intent after laparoscopic staging. Seven patients (11%) underwent laparoscopy alone because of abdominal metastases (n = 5) or other medical conditions (n = 2) that precluded esophagectomy. Two patients (3%) had exploratory right thoracotomy without esophagectomy despite normal laparoscopic findings. The sensitivity and specificity of laparoscopic staging were 100% in this series of patients (100% sensitivity and specificity means no false-positives or -negatives).

CONCLUSION

Laparoscopic staging is valuable for the management of patients with mid and distal squamous cell carcinoma of the esophagus. Patients with metastatic disease and those with prohibitive surgical risk can thus avoid unnecessary laparotomy and be offered other treatment methods.

Endoluminal palliation

Endoluminal palliation involves the application of endoscopic techniques or devices to relieve the symptoms of malignant gastrointestinal obstruction. This is most often achieved with the use of self-expandable metal stents (SEMS). SEMS can be deployed as far distally or proximally in the gastrointestinal tract as the reach of an adult colonoscope. This article outlines the use of endoscopic techniques to provide endoluminal palliation.

Transhiatal Esophagectomy

Controversy still remains regarding the appropriateness of THE asa cancer operation. Critics argue that without an en bloc mediastinal lymphadenectomy, THE does not provide accurate staging or the potential for a curative procedure; however, operative margins are similar after transthoracic and transhiatal esophagectomy, and van Sandick and co-workers reported that 73% of margins were microscopically negative. In many cases, esophageal carcinoma appears to be a systemic disease at the time of diagnosis. According to Orringer and colleagues, 46% of patients have Stage III or IV disease at the time of operation, and Altorki and co-authors found that 35% of patients thought to be potentially curable were found to have occult cervical lymph node disease after three-field lymph node dissection. In addition, survival after THE is similar to that reported after transthoracic esophagectomy as well as radical esophagectomy with mediastinal lymphadenectomy. The most important determinants of survival appear to be the biologic behavior of the tumor and the stage at the time of resection rather than the operative approach, and esophageal carcinoma will likely require systemic therapy for a cure. Transhiatal esophagectomy has been used increasingly in the resection of benign and malignant disease, and has several potential advantages over transthoracic esophagectomy, including significantly decreased respiratory complications and mediastinitis due to the avoidance of thoracotomy and intrathoracic anastomosis. In a meta-analysis of fifty studies comparing transthoracic and transhiatal resection, Hulscher et al found significantly higher early morbidity and mortality rates after transthoracic resections, which was confirmed in a later randomized study of 220 patients(Table 2). Survival after THE is also equivalent to or better than that seen after transthoracic esophagectomy, and transhiatal esophagectomy should be considered in all patients requiring esophagectomy for benign or malignant disease.

Diagnostic radiology and nuclear medicine

The diagnosis and accurate staging of esophageal adenocarcinoma remains one of the greatest challenges for non-invasive imaging techniques. All modalities have limitations and require a rational application of combined tools in order to assess the extent of loco-regional tumor and distant metastatic disease. The fundamental role remains defining organ-confined disease and mapping non-organ confined disease. Endoscopic ultrasound combined with multislice computed tomography (CT) is the mainstay of morphologic loco-regional staging. In recent years, functional metabolic 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET) has emerged as a particularly useful adjunct to detect occult metastatic disease, to predict response to neoadjuvant therapy and to document recurrent disease. The current imaging algorithm and new developments in imaging assessment will be reviewed.

Preoperative TN staging of esophageal cancer: Comparison of miniprobe ultrasonography, spiral CT and MRI

AIM: To evaluate the value of miniprobe sonography (MPS), spiral CT and MR imaging (MRI) in the tumor and regional lymph node staging of esophageal cancer.

METHODS: Eight-six patients (56 men and 30 women; age range of 39-73 years, mean 62 years) with esophageal carcinoma were staged preoperatively with imaging modalities. Of them, 81 (94%) had squamous cell carcinoma, 4 (5%) adenocarcinoma, and 1 (1%) adenoacanthoma. Eleven patients (12%) had malignancy of the upper one third, 41 (48%) of the mid-esophagus and 34 (40%) of the distal one third. Forty-one were examined by spiral CT in whom 13 were co-examined by MPS, and forty-five by MRI in whom 18 were also co-examined by MPS. These imaging results were compared with the findings of the histopathologic examination for resected specimens.

RESULTS: In staging the depth of tumor growth, MPS was significantly more accurate (84%) than spiral CT and MRI (68% and 60%, respectively, P < 0.05). The specificity and sensitivity were 82% and 85% for MPS; 60% and 69% for spiral CT; and 40% and 63% for MRI, respectively. In staging regional lymph nodes, spiral CT was more accurate (78%) than MPS and MRI (71% and 64%, respectively), but the difference was not statistically significant. The specificity and sensitivity were 79% and 77% for spiral CT; 75% and 68% for MPS; and 68% and 62% for MRI, respectively.

CONCLUSION: MPS is superior to spiral CT or MRI for T staging, especially in early esophageal cancer. However, the three modalities have the similar accuracy in N staging. Spiral CT or MRI is helpful for the detection of far-distance metastasis in esophageal cancer.

New techniques for staging esophageal cancer

Correct staging is essential for treatment selection, discussion of prognosis, and scientific communication. The CT scan has long been the essential tool for staging esophageal cancer and still remains valuable for initial screening for distant metastases. The development of endoscopic ultrasonography (EUS), with EUS fine-needle aspiration, positron emission tomography, and minimally invasive surgical staging via thoracoscopy and laparoscopy has resulted in more precise staging. These new tools will allow better definition of patient subsets that may benefit from selected therapies and clinical investigations.

A review of endoscopic methods of esophageal dilation

Esophageal strictures from a variety of benign and malignant causes require dilation therapy when patients develop symptoms of dysphagia. Dilation can be accomplished using a variety of dilating devices and adjunctive techniques. The approach to management of esophageal strictures is reviewed with a focus on dilation technique and special considerations for various stricture types.

Endoscopic therapeutic esophageal interventions

In Western countries, many esophageal diseases result from uncontrolled gastroesophageal reflux. Treatments for Barrett esophagus, peptic strictures, and esophageal adenocarcinoma still account for a large portion of the esophageal interventions performed by therapeutic endoscopists. In addition to continued refinements in the treatment of these sequelae, new endoscopic therapies have emerged to treat gastroesophageal reflux disease itself. This article reviews the available literature on new endoscopic antireflux procedures along with other advances that give the endoscopist unprecedented options in the treatment of esophageal diseases.

Helical CT versus EUS with fine needle aspiration for celiac nodal assessment in patients with esophageal cancer

BACKGROUND

Conventional CT is insensitive for detection of metastatic involvement of celiac lymph nodes in esophageal cancer. Helical CT has theoretical advantages over "slice" CT in this regard, but its performance has not yet been prospectively studied.

METHODS

Consecutive patients with untreated esophageal cancer were recruited after obtaining informed consent. Helical CT was performed on all patients and TNM staging was performed by a single radiologist. Subsequently, all patients underwent esophageal radial and, as needed, curvilinear array EUS with fine needle aspiration (FNA), for evaluation of celiac lymph nodes and TNM staging. Test performance characteristics with 95% confidence intervals were calculated, assuming EUS with FNA as the reference standard.

RESULTS

Forty-eight patients were recruited, of whom 37 (77%) were men. The mean (SD) age was 63.6 (10) years. Excluding 5 patients in whom a confirmatory FNA was not available (n = 43), helical CT identified celiac lymph nodes in 12 (28%) patients. The reference standard of EUS with FNA identified 15 (35%) patients with metastatic celiac lymph nodes, giving a sensitivity, specificity, and positive and negative predictive values for helical CT of 53% (95% CI [28%, 79%]), 86% (95% CI [73%, 99%]), 67% (95% CI [40%, 93%]), and 77% (95% CI [63%, 92%]), respectively, for assessing celiac lymph nodal involvement. The sensitivity and specificity of helical CT in detecting T4 disease were 25% (95% CI [3.8%, 46%]) and 94% (95% CI [85%, 100%]), respectively. There were 12 patients (25%; 95% CI [13%, 37%]) who were felt to have resectable disease by helical CT but had either metastatic involvement of celiac lymph nodes or T4 disease by EUS/FNA.

CONCLUSIONS

Despite technological advances, helical CT still appears unreliable, mainly because of insensitivity, for the identification of inoperable T4 or metastatic involvement of celiac lymph node disease in esophageal cancer.

Evaluation of minimally invasive surgical staging for esophageal cancer

BACKGROUND

Conventional imaging studies (computed tomography and endoscopic esophageal ultrasonography) used for preoperative evaluation of patients with esophageal cancer can be inaccurate for detection of small metastatic deposits. We evaluated the efficacy of minimally invasive surgical (MIS) staging as an additional modality for evaluation of patients with esophageal cancer.

METHODS

Between December 1998 and February 2001, 33 patients with esophageal cancer were evaluated for surgical resection. Conventional imaging studies demonstrated operable disease in 31 patients and equivocal findings in 2 patients. All patients then underwent MIS staging (laparoscopy, bronchoscopy, and ultrasonography of the liver). We compared the results from surgical resection and MIS staging with those from conventional imaging.

RESULTS

MIS staging altered the treatment plan in 12 (36%) of 33 patients; MIS staging upstaged 10 patients with operable disease and downstaged 2 patients with equivocal findings. MIS staging accurately determined resectability in 97% of patients compared with 61% of patients staged by conventional imaging. The specificity and negative predictive value for detection of unsuspected metastatic disease in MIS staging were 100% and 96%, respectively, compared with 91% and 65%, respectively, for conventional imaging studies.

CONCLUSION

In addition to conventional imaging studies, MIS staging should be included routinely in the preoperative work-up of patients with esophageal cancer.

Distant metastases from cervical esophagus cancer

Cancer of the cervical esophagus has a poor prognosis in relation to stage. Correct staging is thus essential in order to establish the prognosis and the treatment program. Distant metastases can involve the lymph nodes (mediastinal and celiac lymph nodes) or they can be extranodal visceral types. Correct lymph node staging can be performed with esophageal endoscopic ultrasonography, computed tomography (CT) scan and, currently, with positron emission tomography (PET) and minimally invasive surgery. For hematogenous metastases, CT scan and PET are mainly used, as well as minimally invasive surgery, with the eventual aid of intraoperative ultrasonography.