A strategy for supraclavicular lymph node dissection using recurrent laryngeal nerve lymph node status in thoracic esophageal squamous cell carcinoma

Clinical outcomes of salvage radiotherapy in patients with supraclavicular lymph node metastases after esophagectomy

Purpose

To evaluate the clinical outcomes of salvage radiotherapy in patients with supraclavicular lymph node (SCLN) metastases after esophagectomy.

Methods

After initial esophagectomy (R0 resection), clinical outcomes in patients with esophageal squamous cell carcinoma with SCLN metastases during follow-up were retrospectively analyzed.

Results

A total of 114 patients were split into two groups: the salvage radiotherapy (SR) (n=89) and the control (NSR) (without salvage radiotherapy, n=25). The overall survival rates of 1 year, 3 years and 5 years were 81.6%, 31.4% and 8.6%, accordingly. The 1-year and 3-year survival after SCLN metastases (SASM) rates were 40.2% and 14.5%, respectively; the median SASM time was 10 months. In the SR group, the SASM rates of 1-year and 3-year were 48.1% and 18.9%, compared to 12.0% and 0% in the NSR group (p<0.001). Patients in the SR group who received combined radiochemotherapy experienced 1-year and 3-year SASM rates of 62.6% and 33.4%, compared to 41.9% and 16.5% with single radiotherapy (p<0.001). The salvage radiation dose revealed that the 1-year and 3-year SASM rates turned out to be 56.5% and 23.4% in group of ≥60 Gy, and 29.2% and 7.5% in group of <60 Gy (p<0.001). According to multivariate analysis, combined visceral metastases (CVM), combined mediastinal failure (CMF), salvage radiotherapy, salvage radiation dose and salvage treatment method possibly were identified as important prognostic variables. After propensity score matching (PSM), the above results were similar to those before PSM, except for that only salvage radiotherapy is possibly independent prognostic variables for survival after SCLN metastases in multivariate analysis.

Conclusion

It is possible that salvage radiotherapy can increase the survival rate of patients who receive SCLN metastases following esophagectomy.

Lymph drainage and cervical fascia anatomy-oriented differential nodal CTV delineation at the supraclavicular region for esophageal cancer and nasopharyngeal cancer

PURPOSE

To determine the differences in supraclavicular lymph node metastasis between esophageal cancer (EC) and nasopharyngeal cancer (NPC) and explore the feasibility of differential supraclavicular clinical target volume (CTV) contouring between these two diseases based on the involvement of different fascial spaces.

MATERIALS AND METHODS

One hundred patients with supraclavicular nodes positive for EC or NPC were enrolled, and their pre-treatment images were reviewed. The distribution patterns of nodes between the two diseases were compared in the context of node levels defined by the 2017 Japanese Esophageal Society and 2013 International Consensus on Cervical Lymph Node Level Classification. Grouping supraclavicular nodes based on sub-compartments formed by the cervical fascia was discussed, and the feasibility of differential CTV contouring based on the differences in the involvement of these sub-compartments between EC and NPC was explored.

RESULTS

The 2013 Consensus on cervical node levels and 2017 Japanese Esophageal Society node station could not practically guide supraclavicular CTV contouring. We divided the supraclavicular space into six sub-compartments: the para-esophageal space (PES), carotid sheath space (CSS), sub-thyroid pre-trachea space (STPTS), pre-vascular space (PVS), and vascular lateral space (VLS) I and II. EC mainly spread to the PES, STPTS, CSS, and VLS I, whereas NPC tended to spread to the CSS, VLS I, and VLS II. These combinations of sub-compartments may help constitute the supraclavicular CTVs for EC and NPC.

CONCLUSIONS

The fascia anatomy-based sub-compartments sufficiently distinguished metastasis to the supraclavicular space between EC and NPC, thus facilitating differential CTV contouring between these two diseases.

Prediction of Individual Lymph Node Metastatic Status in Esophageal Squamous Cell Carcinoma Using Routine Computed Tomography Imaging: Comparison of Size-Based Measurements and Radiomics-Based Models

BACKGROUND

Lymph node status is vital for prognosis and treatment decisions for esophageal squamous cell carcinoma (ESCC). This study aimed to construct and evaluate an optimal radiomics-based method for a more accurate evaluation of individual regional lymph node status in ESCC and to compare it with traditional size-based measurements.

METHODS

The study consecutively collected 3225 regional lymph nodes from 530 ESCC patients receiving upfront surgery from January 2011 to October 2015. Computed tomography (CT) scans for individual lymph nodes were analyzed. The study evaluated the predictive performance of machine-learning models trained on features extracted from two-dimensional (2D) and three-dimensional (3D) radiomics by different contouring methods. Robust and important radiomics features were selected, and classification models were further established and validated.

RESULTS

The lymph node metastasis rate was 13.2% (427/3225). The average short-axis diameter was 6.4 mm for benign lymph nodes and 7.9 mm for metastatic lymph nodes. The division of lymph node stations into five regions according to anatomic lymph node drainage (cervical, upper mediastinal, middle mediastinal, lower mediastinal, and abdominal regions) improved the predictive performance. The 2D radiomics method showed optimal diagnostic results, with more efficient segmentation of nodal lesions. In the test set, this optimal model achieved an area under the receiver operating characteristic curve of 0.841-0.891, an accuracy of 84.2-94.7%, a sensitivity of 65.7-83.3%, and a specificity of 84.4-96.7%.

CONCLUSIONS

The 2D radiomics-based models noninvasively predicted the metastatic status of an individual lymph node in ESCC and outperformed the conventional size-based measurement. The 2D radiomics-based model could be incorporated into the current clinical workflow to enable better decision-making for treatment strategies.

Preoperative Clinical Characteristics Predict Recurrent Laryngeal Nerve Lymph Node Metastasis and Overall Survival in Esophageal Squamous Cell Carcinoma: A Retrospective Study With External Validation

Background

Recurrent laryngeal nerve (RLN) lymph node metastasis (LNM) is not rare in patients with esophageal squamous cell carcinoma (ESCC). We aimed to develop and externally validate a preoperative nomogram using clinical characteristics to predict RLN LNM in patients with ESCC and evaluate its prognostic value.

Methods

A total of 430 patients with ESCC who underwent esophagectomy with lymphadenectomy of RLN LNs at two centers between May 2015 and June 2019 were reviewed and divided into training (center 1, n = 283) and external validation cohorts (center 2, n = 147). Independent risk factors for RLN LNM were determined by multivariate logistic regression, and a nomogram was developed. The performance of the nomogram was assessed in terms of discrimination, calibration, clinical usefulness, and prognostic value. The nomogram was internally validated by the bootstrap method and externally validated by the external validation cohort.

Results

Multivariate analysis indicated that clinical T stage (P <0.001), endoscopic tumor length (P = 0.003), bioptic tumor differentiation (P = 0.004), and preoperative carcinoembryonic antigen level (P = 0.001) were significantly associated with RLN LNM. The nomogram had good discrimination with the area under the curve of 0.770 and 0.832 after internal and external validations. The calibration curves and decision curve analysis confirmed the good calibration and clinical usefulness of this model. High-risk of RLN LNM predicted by the nomogram was associated with worse overall survival in the external validation cohort (P <0.001).

Conclusion

A nomogram developed by preoperative clinical characteristics demonstrated a good performance to predict RLN LNM and prognosis for patients with ESCC.

Esophageal cancer with a double aortic arch: a case report and literature review

BACKGROUND

Double aortic arch (DAA) is an extremely rare vascular malformation, even more so when coexisting with esophageal cancer.

METHODS

We report a new case of DAA with esophageal cancer recently seen at our Thoracic Tumor Clinic and review cases of DAA coexisting with esophageal cancer reported in the literature of English language from 2010 to 2020. The purposes of our literature review were to explore how to best achieve radical esophagectomy while reducing postoperative complications. The clinical manifestations, diagnostic method, surgical approach, reconstruction route, and the extent of lymphadenectomy of esophageal cancer with DAA were analyzed in detail.

RESULTS AND CONCLUSION

For such patients, 3D computed tomography is necessary for preoperative diagnosis. The surgical approach should consider factors such as the location of the tumor in the esophagus and whether the tumor is surrounded by DAA, as well as the position of the descending aorta and the requirements for the surgical field for lymphadenectomy. If esophageal reconstruction is required, the retrosternal route is preferred. We recommend that only patients with positive results of intraoperative frozen biopsy of recurrent laryngeal nerve lymph nodes should undergo three-field lymphadenectomy, which may be the best method to achieve radical esophagectomy for middle and lower esophageal cancers with DAA while minimizing postoperative complications.

Clinical significance and outcomes of bilateral and unilateral recurrent laryngeal nerve lymph node dissection in esophageal squamous cell carcinoma: A large-scale retrospective cohort study

Background

The survival benefits of recurrent laryngeal nerve lymph node dissection (RLNLD) in esophageal squamous cell carcinoma (ESCC) are still under debate, and the prognostic value of unilateral RLNLD has been rarely studied. Therefore, the aim of the present study was to investigate the clinical significance and outcomes of RLNLD in ESCC in a large‐scale cohort study, to shed light on the outcomes of unilateral RLNLD, and to identify the factors that affect the prognostic outcome of RLNLD.

Methods

We retrospectively reviewed 1153 patients with thoracic ESCC who underwent right thoracotomy with lymphadenectomy. The impact of RLNLD on disease‐free survival (DFS) and overall survival (OS) was estimated using the Kaplan–Meier method and Cox proportional hazard models. Inverse probability of treatment weighting (IPTW) was performed to adjust for differences in baseline variables in pairwise comparisons. Subgroup analysis of survival and postoperative complications was conducted for selective RLNLD.

Results

RLN lymph node (LN) metastasis was independently associated with tumor location and most other LN station metastases. RLNLD was an independent prognostic factor for DFS and OS. Both patients who underwent unilateral and bilateral RLNLD had significantly better DFS and OS than the non‐RLNLD patients. Furthermore, pairwise comparisons with IPTW confirmed these results, and we found that patients who underwent bilateral RLNLD had better survival than those who underwent unilateral RLNLD. However, subgroup analysis showed that there was no survival benefit and higher morbidity after bilateral RLNLD for patients with cancer in the lower thoracic esophagus, and elderly and female patients.

Conclusion

RLN LN metastasis is very frequent in ESCC, and both unilateral and bilateral RLNLD have considerable survival benefits. Selective RLNLD with better survival and lower morbidity was recommend for some defined subgroups.

Endobronchial Ultrasound Improves Evaluation of Recurrent Laryngeal Nerve Lymph Nodes in Esophageal Squamous Cell Carcinoma Patients

BACKGROUND

The bilateral recurrent laryngeal nerve (RLN) lymph nodes are the most common metastatic site for esophageal squamous cell carcinoma (ESCC); however, the RLNs are susceptible to injury during dissection. Clinically, there is an urgent need to determine an effective diagnostic method for RLN nodes to help achieve selective nodal dissection and avoid potential serious complications by performing more conservative surgery for those with nonmetastatic nodes. Here, we innovatively applied endobronchial ultrasonography (EBUS) and investigated its diagnostic performance for preoperative evaluation of RLN nodes in ESCC patients.

PATIENTS AND METHODS

All 81 enrolled ESCC patients underwent preoperative EBUS and CT examinations. The ability of EBUS and CT to detect RLN node metastasis was evaluated based on the resulting sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

The diagnostic performance of EBUS was superior to that of CT; in particular, EBUS of the left RLN (L-RLN) nodes presented the best sensitivity, specificity, PPV, NPV, and accuracy compared with EBUS evaluations of the right RLN (R-RLN) nodes, CT of the L-RLN and R-RLN nodes. Moreover, EBUS combined with CT increased the NPV relative to that of EBUS or CT alone, promoting the ability to identify true-negative RLN nodes. In particular, the NPVs of the combined modality were 100% for both the L- and R-RLN nodes in early-T-stage (T1-T2) ESCC.

CONCLUSIONS

EBUS is an efficient tool for RLN node evaluation, and the combination with CT may provide better guidance for selective RLN node dissection in ESCC patients.

Clinical significance and prognosis of supraclavicular lymph node metastasis in patients with thoracic esophageal cancer

Background

Although most studies proved that thoracic esophageal cancer surgery with supraclavicular lymph nodes (SCLNs) metastasis could benefit, less than 30% of the 5-year survival rate remained controversy on its surgical treatment. In this study, we aimed to analyze the prognosis of SCLNs on the different segments of thoracic esophageal cancer, which will supply a reference for the treatment of this disease.

Methods

Retrospectively collected the clinical data of 163 patients with thoracic esophageal squamous cancer (ESCC) and compared the effects of SCLNs on prognosis in different segments.

Results

Patients with SCLNs metastasis had a worse prognosis than the negative group (P<0.001). In the upper thoracic group, there was no significant difference in OS between SCLNs positive group and negative group (P=0.077); however, in the middle and lower thoracic group, SCLNs positive group had a worse prognosis than the negative group (P<0.001) and lymph nodes positive in other sites (except for SCLNs) (P=0.039). Multivariate analysis found that SCLNs metastasis was an independent risk factor affecting the prognosis of ESCC in the middle and lower thoracic segments (P=0.007).

Conclusions

For patients with upper thoracic ESCC, SCLNs appear to be regional nodes. For the middle and lower thoracic ESCC, SCLNs should be defined as distant metastasis, and neoadjuvant therapy first may be an available therapy.

The clinical significance of the intraoperative pathological examination of bilateral recurrent laryngeal nerve lymph nodes using frozen sections in cervical field lymph node dissection of thoracic esophageal squamous cell carcinoma

Background

The aim of this study was to evaluate intraoperative pathological examination of the left and right recurrent laryngeal nerve lymph nodes (LNs) using frozen section as a predictor of cervical LN metastasis.

Methods

Retrospectively collected data from 69 patients with esophageal squamous cell carcinoma who had undergone intraoperative pathological examination of the left and right recurrent laryngeal nerve LNs using frozen sections and three-field LN dissection in the Fujian Medical University Union Hospital from December 2015 to April 2018, was used to explore the relationship between recurrent laryngeal nerve LN metastasis and cervical LN metastasis and to determine whether cervical-field LN dissection should be performed in patients with thoracic esophageal cancer.

Results

In the entire cohort, 15.9% (11/69) of patients had metastasis in the cervical LNs. We detected 1,195 cervical LN, with an average of 17.3 LN dissections per patient; 28 (2.3%) cases had LN metastasis. Patients with recurrent laryngeal nerve LN metastasis tended to have a high incidence of cervical LN metastasis (P=0.017). Multivariate analysis showed that left recurrent laryngeal nerve LN metastasis was the only independent risk factor for cervical LN metastasis (P=0.02). The incidence of postoperative pulmonary infection was 18.8% (13/69), chylothorax was 2.9% (2/69), anastomotic leakage was 2.9% (2/69), and hoarseness was 8.7% (6/69) for the entire cohort. There was no significant increase in complications compared with patients with 2-field LN dissection in our hospital during the same period. Additional studies are necessary to establish postoperative locoregional recurrence rates and long-term survival.

Conclusions

Intraoperative pathological examination of left recurrent laryngeal nerve LN using frozen sections has some prognostic value in predicting cervical LN metastasis and it can be an indicator for the selection of cervical-field dissection in thoracic esophageal carcinoma.

The impact of cervical lymph node dissection on acid and duodenogastroesophageal reflux after intrathoracic esophagogastrostomy following transthoracic esophagectomy

PURPOSE

The aim of this study was to evaluate the impact of cervical lymph node dissection on acid reflux and duodenogastroesophageal reflux (DGER) in patients undergoing transthoracic esophagectomy with gastric tube reconstruction and intrathoracic esophagogastrostomy.

METHODS

Thirty-one patients receiving transthoracic esophagectomy with gastric tube reconstruction by intrathoracic esophagogastrostomy were divided into the following two groups: a two-field lymph node dissection group (2F group) and a three-field lymph node dissection group (3F group). All patients underwent 24-h pH and bilirubin monitoring and gastrointestinal endoscopy at 1 year after surgery. The 24-h pH and bilirubin monitoring results, endoscopic findings, and reflux symptoms were compared between the 2 groups.

RESULTS

No acid reflux was observed in the 2F group, whereas it was observed in 6 (40%) patients in the 3F group (p = 0.007). DGER was found in 2 patients (13%) in the 2F group and in 8 (53%) in the 3F group (p = 0.023). Four patients (25%) in the 2F group and 9 (60%) in the 3F group (p = 0.048) had reflux esophagitis.

CONCLUSION

Cervical lymph node dissection increases acid reflux and DGER and can lead to an increase in the incidence of reflux esophagitis in patients undergoing intrathoracic esophagogastrostomy.

Reliability and safety of minimally invasive esophagectomy after neoadjuvant chemoradiation: a retrospective study

Background

Thoracic surgeons have recognized the advantages of minimally invasive esophagectomy (MIE). However, MIE for locally advanced esophageal cancer after neoadjuvant chemoradiotherapy (NCRT) is controversial. This study aimed to nvestigate and summarise the reliability and safety of MIE after NCRT.

Methods

We retrospectively analyzed the perioperative outcomes of patients with locally advanced esophageal cancer who underwent minimally invasive esophagectomy after neoadjuvant chemoradiotherapy from January 2016 to January 2018, and compared them with patients who underwent MIE alone during the same period.

Results

In total, 107 patients were eligible for the study. Forty-four patients underwent MIE after NCRT (CRM), and 63 patients underwent MIE alone (MA). The surgical duration (253.59 ± 47.51 vs. 222.86 ± 42.86 min), intraoperative blood loss (164.55 ± 109.09 vs. 146.19 ± 112.89 ml), number of lymph nodes resected (18.36 ± 8.01 vs. 22.10 ± 12.03), duration of the postoperative hospital stay (12.84 ± 6.57 vs. 14.60 ± 8.48 days), postoperative intubation time (5.68 ± 3.08 vs. 6.54 ± 4.97 days), total incidence of complications (34.10% vs. 31.7%), and R0 resection rate (95.45% vs. 96.83%) had no significant difference. The incidence of arrhythmia was higher in CRM (P < 0.02). No mortality occurred postoperatively within 30 days in either group.

Conclusion

Minimally invasive esophagectomy after neoadjuvant chemoradiotherapy is a feasible, safe, and beneficial for postoperative recovery of patients.

Electronic supplementary material

The online version of this article (10.1186/s13019-019-0920-0) contains supplementary material, which is available to authorized users.

Comparison of minimally invasive Ivor Lewis esophagectomy and left transthoracic esophagectomy in esophageal squamous cell carcinoma patients: a propensity score-matched analysis

Background

To investigate the long-term efficacy of the minimally invasive Ivor Lewis esophagectomy (MIILE) in esophageal squamous cell carcinoma (ESCC) patients, a retrospective comparison of the quality of life (QOL) and survival between patients who underwent MIILE and left transthoracic esophagectomy (Sweet approach) was conducted.

Methods

A detailed database search identified 614 patients who underwent MIILE and 243 patients who underwent Sweet esophagectomy between January 2011 and December 2017. After propensity score matching, 216 paired cases were selected for statistical analysis. Survival was evaluated with Kaplan-Meier curves or Cox models.

Results

MIILE was associated with a longer duration, less blood loss and more lymph node dissected than Sweet esophagectomy. MIILE patients suffered from less pain, less frequently developed pneumonia, and had fewer postoperative complications. Additionally, MIILE patients began oral intake earlier and had a shorter postoperative hospital stay, and enhanced recovery of QOL. There was no significant difference between the approaches regarding the recurrence pattern, 2-year and 5-year overall survival (OS) or disease-free survival (DFS), except that patients with tumor-node-metastasis (TNM) stage I in the MIILE group demonstrated superior OS and DFS. Pathological TNM stage and postoperative complications were determined to be independent prognostic factors based on the multivariate analysis.

Conclusion

MIILE is a safe and feasible approach for treating ESCC patients. MIILE approach may provide more postoperative advantages, enhanced QOL improvement, and more favorable long-term survival in early stage patients than the Sweet procedure.

Proposed modifications of supraclavicular lymph node metastasis in the esophageal squamous cell carcinoma staging system for improved survival stratification

The present study aims to investigate the clinical implication of supraclavicular lymph nodes (SCLNs) in thoracic esophageal squamous cell carcinoma (ESCC). A total of 1156 ESCC patients who underwent three-field lymphadenectomy with node metastasis were analyzed retrospectively. SCLNs were defined as regional nodes in the current system or as distant nodes in the modified system. Survival was analyzed using the Kaplan-Meier method, and values were compared using the log-rank test. Multivariate analysis was performed using the Cox proportional hazard model. The Akaike information criterion (AIC) and the concordance index (c-index) were applied to compare the two prognostic systems. Among 1156 patients, 183 (15.8%) patients were diagnosed with SCLN metastasis. Higher rate of SCLN metastasis was associated with upper tumor location, metastasis involving seven or more nodes, and positive recurrent laryngeal nerve node status. The current staging system was unable to stratify overall survival well in patients with N2, N3, and M1 status using a univariate analysis. In both the current staging system and the modified version, age, gender, pathological T status, and nodal status were independent prognostic factors in a multivariate analysis. The AIC value for the modified version was smaller than that for the current staging system; the c-index value for the modified version was larger than that for the current staging system. Based on the data from our single center, SCLNs should be reclassified as regional lymph nodes in thoracic ESCC for better stratification of overall survival.

Predicting prognosis in resected esophageal squamous cell carcinoma using a clinical nomogram and recursive partitioning analysis

BACKGROUND

Development demand of precise medicine in resectable esophageal squamous cell carcinoma (ESCC) require to recognize patients at high risk treated by surgery alone. Thus, our aim was to construct a clinical nomogram and recursive partitioning analysis (RPA) to predict long-term survival in ESCC treated by surgery alone.

METHODS

Based on the patients with ESCC who treated by three-incisional esophagectomy and two-field lymphadenectomy alone, we identified and integrated significant prognostic factors for survival to build a nomogram. The nomogram was calibrated for overall survival (OS) and the predictive accuracy and discriminative ability was measured by concordance index (c-index) and Akaike information criterion (AIC). Based on the nomogram, the RPA was performed for risk stratification.

RESULTS

A total of 747 patients were included for analysis. Five independent prognostic factors were identified and entered into the nomogram. The calibration curves for probability of 1-, 3-, and 5-year OS showed optimal agreement between nomogram prediction and actual observation. The AIC value of the nomogram was lower than that of the 7th edition staging system, whereas the c-index of the nomogram was higher than that of the 7th edition staging system. The risk groups stratified by RPA allowed significant distinction between survival curves within respective TNM categories.

CONCLUSION

The RPA based on a clinical nomogram appears to be suitable for risk stratification in OS for resected ESCC. This practical system may help clinicians in decision making and design of clinical studies.

Identification of risk factors and the pattern of lower cervical lymph node metastasis in esophageal cancer: implications for radiotherapy target delineation

Radiotherapy remains the important therapeutic strategy for patients with esophageal cancer (EC). At present, there is no uniform opinion or standard care on the range of radiotherapy in the treatment of EC patients. This study aimed to investigate the risk factors associated with lower cervical lymph node metastasis (LNM) and to explore the distribution pattern of lower cervical metastatic lymph nodes. It could provide useful information regarding accurate target volume delineation for EC. We identified 239 patients who initial diagnosed with esophageal squamous cell carcinoma. The clinicopathological factors related to LNM were analyzed and the locations of the lower cervical metastatic lymph nodes were transferred onto computed tomography images. The lower cervical area was further divided into four subgroups areas. The results showed that the incidence of lower cervical LNM was 37.2 % (89 of 239) and 94.4 % (84 of 89 patients) patients had subgroup II and/or subgroup III region LNM. Of those patients, 151 nodes were considered to be clinical metastatic in the lower cervical region and 96% nodes were located in group II and group III. Based on the present study, prophylactic irradiating to lower cervical areas is recommended for patients with deeper tumor invasion, the mediastinal level 1, 2, and 4 station LNM and the more number of LNM. The atlas showed that, for the lower cervical area, the subgroup II and III region should be precisely covered in the target volume and the subgroup I and IV may be spared for minimizing the toxicity.

Efficacy comparison of transcervical video-assisted mediastinoscopic lymphadenectomy combined with left transthoracic esophagectomy versus right transthoracic esophagectomy for esophageal cancer treatment

Background

This study aimed to propose a new surgical strategy, i.e., the transcervical video-assisted mediastinoscopic lymphadenectomy (VAMLA) with esophagectomy via the left transthoracic approach for patients with esophageal cancer (EC), and to compare the outcomes with those of esophagectomy via the right thoracic approach.

Methods

From December 2014 to March 2016, 49 cases were enrolled in this non-randomized concurrent control study. Twenty-eight patients with EC who underwent transcervical VAMLA with esophagectomy via the left transthoracic approach were assigned into the study group, while 21 EC patients undergoing esophagectomy via the right transthoracic approach during the same period were enrolled into the control group. Operative outcomes including operative time, the numbers of removed lymph nodes, intraoperative blood loss, the length of hospital stay, and postoperative complications in both groups were evaluated and compared.

Results

There were no significant differences in the baseline profiles between the two groups, and all patients in the two groups successfully underwent the surgery. There was a significant difference between transcervical VAMLA with esophagectomy via the left thoracic approach and esophagectomy via the right thoracic approach with regard to the number of all dissected lymph nodes [(29.0 ± 8.7) vs. (17.8 ± 8.1), p < 0.05], dissected superior mediastinal lymph nodes [(11.2 ± 5.0) vs. (3.7 ± 2.9), p < 0.05], and dissected in the recurrent laryngeal nerve lymph nodes [(5.6 ± 3.5) vs. (2.3 ± 2.1), p < 0.05]. No significant differences were observed in the operative time, intraoperative blood loss, length of postoperative hospital stay, number of dissected abdominal lymph nodes, postoperative pulmonary complications (pneumonia and atelectasis), anastomotic fistula, chylothorax, and vocal cord paralysis (p > 0.05).

Conclusion

Transcervical VAMLA combined with esophagectomy via the left thoracic approach appears technically feasible and safe and shows advantages in the number of dissected superior mediastinal lymph nodes, suggesting that it may serve as a new treatment option for patients with esophageal carcinoma.

Patterns of failure and clinical outcomes of definitive radiotherapy for cervical esophageal cancer

Purpose

Because of the scarcity of cervical esophageal cancer (CEC), data for this disease entity is limited. We aim to evaluate the outcomes, prognostic factors and failure patterns of CEC treated by contemporary radiotherapy (RT).

Methods

We retrospectively analyzed 86 CEC patients consecutively treated between 2007 and 2015 by definitive RT with or without concurrent chemotherapy. RT was mainly delivered with Intensity Modulated Irradiation Therapy (IMRT) or Volumetric-Modulated Arc Therapy (VMAT). Statistical analyses were performed on survival, prognostic factors and failure patterns.

Results

The median follow-up time was 19.4 months. The 3-year overall survival (OS), local regional failure free survival (LRFFS), distant metastatic free survival (DMFS), and progression free survival (PFS) were 53.6%, 57.9%, 81.5% and 41.5%, respectively. Independent predictors for poorer OS were N stage, hoarseness and recurrent laryngeal nerve lymph node (RLN) involvement, and predictors for LRFFS were N stage and EQD2 (equivalent dose in 2 Gy fraction) to gross tumor volume (GTV), with ≥ 66Gy achieving local control of 94.7%. Patients receiving elective nodal irradiation (ENI) had better nodal regional control than those receiving involved field irradiation (IFI). 31 (36%) patients had treatment failure and 15 (17.4%), 8 (9.3%) and 14 (16.2%) patients had local, regional, and distant failure, respectively. 86.7% (13/15) local failures were within GTV, and supraclavicular region (62.5%, 5/8) was the most common regional failure site. No severe toxicities were observed.

Conclusions

Our results seem to indicate that good locoregional control might be achieved for CEC with adequate radiation dose and treatment planning approaches.

Prognostic value of supraclavicular nodes and upper abdominal nodes metastasis after definitive chemoradiotherapy for patients with thoracic esophageal squamous cell carcinoma

The purpose of this study is to assess the prognostic value of supraclavicular nodes, left gastric nodes, celiac nodes and common hepatic nodes metastasis in esophageal squamous cell carcinoma (ESCC) treated with definitive radiotherapy. A total of 293 ESCC patients treated with radiotherapy or chemoradiotherapy entered the study. The results showed that the presence of supraclavicular nodes (χ² = 0.075, P = 0.785) and left gastric nodes (χ² = 3.603, P = 0.058) metastasis had no significant influence on survival, while celiac nodes (χ² = 33.775, P < 0.001) and common hepatic nodes (χ² = 42.350, P < 0.001) metastasis were associated with significantly shorter survival, regardless of the sites of primary tumor. Multivariate analysis showed that celiac nodes (HR: 0.457, 95% CI: 0.256-0.816; P = 0.008) and common hepatic nodes (HR: 0.241, 95% CI: 0.092-0.630; P = 0.004) metastasis were independently adverse indicator of survival in upper ESCC. While in the middle and lower ESCC, only the common hepatic nodes (middle ESCC: HR: 0.345, 95% CI: 0.161-0.738, P = 0.006; lower ESCC: HR: 0.377, 95% CI: 0.160-0.890, P = 0.026) metastasis was an independently adverse indicator of survival. In conclusion, our study demonstrated that in ESCC treated with definitive radiotherapy, both of celiac nodes and common hepatic nodes metastasis were adverse indicator of survival in upper ESCC, and common hepatic nodes metastasis were adverse indicator of survival in middle and lower ESCC. Supraclavicular nodes an left gastric nodes metastasis is not associated with patients survival in ESCC.

Recurrent laryngeal nerve lymph node dissection may not be suitable for all early stage esophageal squamous cell carcinoma patients: an 8-year experience

BACKGROUND

Recurrent laryngeal nerve (RLN) injury is one of the most frequent postoperative complications of esophageal squamous cell carcinoma (ESCC) radical resection. This study aims to develop a novel scoring system to predict recurrent laryngeal nerve lymph node (RLNLN) metastases in early ESCC and explore the indications for precise RLN lymphadenectomy.

METHODS

Early stage ESCC patients from 2006 to 2014 were analyzed. Patient and pathologic characteristics were compared between patients with RLNLN metastases and those without. Univariate and multivariate analyses were performed to establish a scoring system that estimates the risks of RLNLN metastases. The indications for RLNLN dissection were validated by survival rate, postoperative complications, and metastases rate.

RESULTS

A total of 311 cases selected from 1,466 ESCC patients were divided into the dissection group and the control group. Age, tumor length, macroscopic tumor type, T stage, tumor location and tumor differentiation were independent predictors of RLNLN metastases. The weighted scoring system included age (+2 for <56 years), tumor length (+2 for over 4.45 cm), tumor location (+4 for upper thoracic, +2 for mid-thoracic) and macroscopic tumor type (+1 for advanced type). The total number of points estimated the probability of RLNLN metastases [low-risk (0-2 point), 0%; moderate-risk (3-4 points), 9.8%; and high-risk (>4 points), 43.4%]. Besides, the dissection group had more complications and similar survival rate when compared with the control group.

CONCLUSIONS

We developed a novel scoring system that accurately estimated the risk of RLNLN metastases in early ESCC patients. RLN lymphadenectomy may be safely omitted for the patients in the low-risk subgroup.

Risk Factors and Clinical Outcomes of Recurrent Laryngeal Nerve Paralysis After Esophagectomy for Thoracic Esophageal Carcinoma

BACKGROUND

The objectives of this study were to assess the incidence of recurrent laryngeal nerve paralysis (RLNP) using laryngoscopy after esophagectomy for thoracic esophageal carcinoma and to clarify the risk factors influencing postoperative RLNP.

METHODS

A total of 299 patients who underwent laryngoscopic examination after esophagectomy were retrospectively reviewed. Patients who were found to have postoperative RLNP were followed up every 1–3 months, with a median follow-up period of 3 months. Recovery from paralysis was also evaluated on the basis of each affected nerve. Multivariate analyses using logistic regression were used to identify independent risk factors for RLNP. Cumulative recovery rate was calculated using Kaplan–Meier method.

RESULTS

A total of 178 (59.5%) patients were diagnosed with RLNP by first laryngoscopy [bilateral in 59 (33.1%) patients, right in 15 (8.4%), and left in 104 (58.4%)]. In 206 patients who underwent transthoracic and thoracoscopic esophagectomy, independent risk factors for RLNP were lymph node dissection along the right RLN (odds ratio [OR] 3.01, 95% confidence interval [CI] 1.06–8.54, P = 0.04) and cervical anastomosis (OR 5.94, 95% CI 1.78–19.80, P < 0.01). Cumulative recovery rate from RLNP was 61.7% at 12 months after esophagectomy with 91 nerves eventually recovering from paralysis. Median recovery time was 6 months.

CONCLUSIONS

RLNP developed in 60 % of patients after esophagectomy and may be associated with lymphadenectomy around the right RLN and cervical esophageal mobilization. Although 62% of affected nerves recovered within 12 months, great attention should be given when performing these procedures.

Correlation between para-recurrent laryngeal nerve lymph node metastasis and cervical lymph node metastasis in patients with esophageal cancer

AIM: To analyze the correlation between para-recurrent laryngeal nerve lymph node metastasis and cervical lymph node metastasis in patients with esophageal squamous cell carcinoma (ESCC) and discuss their predictive value, in order to find the indications for three field lymphadenectomy.

METHODS: Two hundred patients with ESCC who underwent three field lymphadenectomy at Department of Thoracic Surgery of Ningbo Lihuili Hospital from January 2015 to December 2015 were included. The relationship between para-recurrent laryngeal nerve lymph node metastasis and cervical lymph node metastasis was analyzed statistically, and risk factors for cervical lymph node metastasis were analyzed.

RESULTS: With the increase in T stage, the rates of cervical, mediastinal, abdominal and para-recurrent laryngeal nerve lymph node metastasis increased gradually. The abdominal lymph node metastasis rate in patients with upper thoracic ESCC was 0%, and the lymph node metastasis rate in patients with ESCC at other parts was more than 40%. The cervical lymph node metastasis rate was 69.23% in upper thoracic ESCC patients with para-recurrent laryngeal nerve lymph node metastasis and 44.44% in those without para-recurrent laryngeal nerve lymph node metastasis, and there was no significant difference between the two groups. The cervical lymph node metastasis rates were 46.81%, 66.67%, and 50.85%, respectively, in middle, lower, and middle + lower thoracic ESCC patients with para-recurrent laryngeal nerve lymph node metastasis, and 28.89%, 25%, and 28.18%, respectively, in those without para-recurrent laryngeal nerve lymph node metastasis, and there were significant difference between the two groups, suggesting that para-recurrent laryngeal nerve lymph node metastasis closely correlates with cervical lymph node metastasis in patients with middle, lower, and middle + lower thoracic ESCC. In patients who had ≤ 4 metastatic thoracic abdominal lymph nodes, 53 (31.18%) had cervical lymph node metastasis, while in patients who had > 4 metastatic thoracic abdominal lymph nodes, 25 (83.33%) had cervical lymph node metastasis, and there was a significant difference between the two groups. In patients who had para-recurrent laryngeal nerve lymph node metastasis and ≤ 4 metastatic thoracic abdominal lymph nodes, 20 (40%) had cervical lymph node metastasis, while in patients who had para-recurrent laryngeal nerve lymph node metastasis and > 4 metastatic thoracic abdominal lymph nodes, 21 (95.45%) had para-recurrent laryngeal nerve lymph node metastasis, and there was a significant difference between the two groups. Multivariate analysis demonstrated that para-recurrent laryngeal nerve lymph node metastasis and > 4 metastatic thoracic abdominal lymph nodes were independent risk factors for cervical lymph node metastasis.

CONCLUSION: Para-recurrent laryngeal nerve lymph node metastasis closely correlates with cervical lymph node metastasis in patients with middle, lower, and middle + lower thoracic ESCC. Para-recurrent laryngeal nerve lymph node metastasis and > 4 metastatic thoracic abdominal lymph nodes are independent risk factors for cervical lymph node metastasis.

Application of Endobronchial Ultrasonography for the Preoperative Detecting Recurrent Laryngeal Nerve Lymph Node Metastasis of Esophageal Cancer

Background

The preoperative detection of recurrent laryngeal nerve lymph node (RLN LN) metastasis provides important information for the treatment of esophageal cancer. We investigated the possibility of applying endobronchial ultrasonography (EBUS) with conventional preoperative endoscopic ultrasonography (EUS) and computerized tomography (CT) examination to evaluate RLN LN metastasis in patients with esophageal cancer.

Methods

A total of 115 patients with advanced thoracic esophageal cancer underwent EBUS examinations. Patients also underwent EUS and CT imaging as reference diagnostic methods. Positron emission tomography /computed tomography (PET/CT) was also introduced in partial patients as reference method. The preoperative evaluation of RLN LN metastasis was compared with the surgical and pathological staging in 94 patients who underwent radical surgery.

Results

The sensitivities of the preoperative evaluations of RLN LN metastasis by EBUS, EUS and CT were 67.6%, 32.4% and 29.4%, respectively. The sensitivity of EBUS was significantly different from that of EUS or CT, especially in the detection of right RLN LNs. In addition, according to the extra data from reference method, PET/CT was not superior to EBUS or EUS in detecting RLN LN metastasis. Among all 115 patients, 21 patients who were diagnosed with tracheal invasions by EUS or EBUS avoided radical surgery. Another 94 patients who were diagnosed as negative for tracheobronchial tree invasion by EUS and EBUS had no positive findings in radical surgery.

Conclusions

EBUS can enhance the preoperative sensitivity of the detection of RLN LN metastasis in cases of thoracic esophageal cancer and is a useful complementary examination to conventional preoperative EUS and CT, which can alert thoracic surgeons to the possibility of a greater range of preoperative lymph node dissection. EBUS may also indicate tracheal invasion in cases of esophageal stricture.

Comparison of short-term outcomes between prone and lateral decubitus positions for thoracoscopic esophagectomy

BACKGROUND

Prone thoracoscopic esophagectomy was introduced at our institution from 2012. This study describes our experiences of the main differences between thoracoscopic esophagectomy in the prone and traditional left lateral decubitus positions together with an analysis of the short-term surgical outcomes.

METHOD

In total, 87 patients undergoing thoracoscopic esophagectomy between January 2012 and October 2013 at Tohoku University Hospital were enrolled; of these, 54 and 33 patients were operated in the prone (Group P) and lateral decubitus (Group L) positions, respectively.

RESULTS

The background of the patients was similar, and there was no in-hospital mortality. There were no significant differences between the groups in terms of whole surgical duration, thoracic duration, and number of dissected lymph nodes. Total blood loss and thoracic estimated blood loss were significantly lower in Group P than Group L. Furthermore, postoperative pulmonary complications, intensive care unit stay, and hospital stay were significantly lower in Group P.

CONCLUSION

Thoracoscopic esophagectomy in the prone position is feasible and safe. The prone position technique may be superior to conventional lateral decubitus position esophagectomy.

[Clinical value of ultrasound in the diagnosis of supraclavicular lymph node metastasis of primary lung cancer]

背景与目的

原发性肺癌是常见的恶性肿瘤之一，术前准确的局部淋巴结（N）分期可避免不必要的手术创伤，N3期已非手术治疗指征。本研究旨在探讨超声在诊断原发性肺癌锁骨上淋巴结转移及确定其分期中的应用价值。

方法

回顾性分析2012年10月-2013年11月经病理确诊为肺癌患者131例，所有患者均在术前行锁骨上区域的超声和增强计算机断层扫描（computed tomography, CT），对检查结果为阳性的患者行超声引导下穿刺活检，将组织病理学诊断作为淋巴结转移的诊断标准，对比两种检查方法与病理结果的一致性。

结果

131例肺癌患者中经病理证实共有50例为锁骨上淋巴结转移，经超声检查阳性者54例，转移者50例；增强CT检查阳性者41例，其中36例为恶性。超声的灵敏度、特异度、正确指数、阳性预测值及阴性预测值（分别为100%、95.06%、95.06%、92.59%、100%）明显高于增强CT（分别为72%、93.83%、65.83%、87.80%、84.44%）。两种方法在确定肺癌TNM分期准确性的差异存在统计学意义（P < 0.01）。

结论

与增强CT相比，超声在原发性肺癌锁骨上淋巴结转移方面具有较高的准确性、敏感性和特异性，并且能够更加准确地确定原发性肺癌的TNM分期。

Thoracoscopic and laparoscopic radical esophagectomy with lateral-prone position

With 20 years of development, minimally-invasive treatment for esophageal cancer has been widely spread. However, surgeons have not reached consensus about the optimal minimally-invasive operation method, or whether the effect of radical lymph nodes dissection is comparable to the traditional open procedure. Thoracoscopic esophagectomy with lateral-prone position combines the advantages of both lateral position (allowing quick conversion to open procedure) and prone position (good visual area and complete lymphadenectomy). Together with laparoscopic abdominal lymphadenectomy, gastric tube formation and jejunostomy, this approach provides an easier way for minimally-invasive radical esophagectomy. In this article, approaches for thoracoscopic esophagectomy with lateral-prone position and total mediastinal lymphadenectomy, combined with totally laparoscopic gastric mobilization, abdominal lymphadenectomy, gastric tube formation and jejunostomy, will be presented by video instructions. All the procedures were under the rule of radical lymphadenectomy. Cervical lymph nodes dissection and esophago-gastrostomy were the same as those in open procedure, which will not be discussed here.

Supraclavicular node metastasis from thoracic esophageal carcinoma: A surgical series from a Japanese multi-institutional nationwide registry of esophageal cancer

OBJECTIVES

In the present TNM classification, involvement of supraclavicular nodes is defined as distant metastases. However, the therapeutic value of supraclavicular node dissection remains controversial. The purpose of this study was to evaluate the survival benefit of dissection of metastases to the supraclavicular lymph nodes in patients with thoracic esophageal carcinoma by using a large nationwide registry of esophageal cancer maintained by the Japanese Esophageal Society.

METHODS

The study group comprised 1309 patients with thoracic esophageal carcinoma treated in 2001, 2002, and 2003, who underwent esophagectomy with 3-field dissection for curative intent, and in whom the locations of pathologic metastatic lymph nodes and outcome evaluations were available.

RESULTS

Of 1309 patients, 559 (42.7%) had no nodal metastases, 560 (42.8%) had at least 1 positive node but were supraclavicular node-negative, and 190 (14.5%) had supraclavicular node metastases. The 5-year survival was 73.7% for patients with N0, 40.4% for node-positive patients without supraclavicular node disease, and 24.1% for patients with supraclavicular node metastasis. In a multivariate analysis, male sex (P<.001), deeper T category (P<.001), and more positive nodes (P<.001) retained statistical significance as adverse prognostic factors for overall survival. Supraclavicular node metastasis was not significant (P=.062).

CONCLUSIONS

The survival benefit of dissection of metastases to the supraclavicular lymph nodes was indicated in patients with thoracic esophageal carcinoma. Supraclavicular nodes appear to be regional nodes similar to other regional nodes.