Esophagectomy Combined With Aortic Segment Replacement for Esophageal Cancer Invading the Aorta

Aorta and tracheobronchial invasion in esophageal cancer: comparing diagnostic performance of 3.0-T MRI and CT

OBJECTIVES

To compare between the diagnostic performance of 3.0-T MRI and CT for aorta and tracheobronchial invasion in patients with esophageal cancer (EC).

METHODS

We prospectively included patients with pathologically confirmed EC from November 2018 to June 2021, who had baseline stage of T3-4N0-2M0 and restaging after neoadjuvant chemotherapy. All patients underwent contrast-enhanced CT and MRI of the thorax. Two independent blinded radiologists scored image quality and the presence of invasion. Agreements between the two readers were calculated using kappa test. The sensitivity, specificity, accuracy, positive predict value (PPV), and negative predict value (NPV) of MRI and CT in evaluating invasion were calculated. The net reclassification index (NRI) was used to evaluate the change in the number of patients correctly classified by MRI and CT.

RESULTS

A total of 70 patients (64.8 ± 9.0 years; 53 men) were enrolled. Inter-reader agreements of image quality scores and presence of invasion by MRI and CT between the two readers were almost perfect (kappa > 0.80). The accuracy of MRI in evaluating thoracic aorta invasion was significantly higher than that of CT (reader 1: 90.0% vs. 71.4%; reader 2: 92.9% vs. 70.0%, respectively), and the accuracy of MRI in evaluating tracheobronchial invasion also was significantly higher than that of CT (reader 1: 92.9% vs. 72.9%; reader 2: 95.7% vs. 70.0%, respectively). NRI values were positive in both the evaluation of aorta and tracheobronchial invasion.

CONCLUSIONS

The accuracy of 3-T MRI in determining thoracic aorta and tracheobronchial invasion is significantly higher than that of CT.

KEY POINTS

• 3.0-T MRI was significantly more accurate than CT in assessing invasion of the thoracic aorta in patients with esophageal cancer. • 3.0-T MRI was also significantly more accurate than CT in assessing tracheobronchial invasion in patients with esophageal cancer. • 3.0-T MRI has a higher diagnostic performance than CT in evaluating patients with suspected aortic or tracheobronchial invasion in esophageal cancer.

The Long-Term Clinical Impact of Thoracic Endovascular Aortic Repair (TEVAR) for Advanced Esophageal Cancer Invading Aorta

Background

Advanced esophageal cancer invading the aorta is considered unsuitable for surgery with definitive chemotherapy or chemoradiation as the treatments of choice. In the current study, we evaluated the long-term clinical impact of combining thoracic endovascular aortic repair (TEVAR) with multimodality treatment in caring for such patients.

Methods

We evaluated 48 patients who had advanced esophageal cancer with aortic invasion. The oncological outcome, including overall survival (OS) and progression-free survival (PFS), after multimodality treatment with or without TEVAR is evaluated for these patients.

Results

Overall, 25/48 patients (52.1%) received a TEVAR procedure. There was no significant difference in OS (p = 0.223) between patients who did or did not receive TEVAR; however, patients who received TEVAR had significantly less local tumor recurrence (p = 0.020) and longer PFS (p = 0.019). This impact was most evident in patients who received both TEVAR and esophagectomy, with an incremental increase in hazard ratio (HR) for disease progression of 2.89 (95% confidence interval [CI] 0.86–9.96) and 4.37 (95% CI 1.33–14.33) observed under multivariable analysis, respectively, in comparison with patients who underwent only one or neither of these procedures (p = 0.005 for trend test).

Conclusion

TEVAR is a feasible procedure for esophageal cancers invading the aorta and can be used for curative-intent resection to improve local tumor control and PFS.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-10081-3.

Survival and prognostic factors of patients with esophageal fistula in advanced esophageal squamous cell carcinoma

The aim of the present study was to investigate the survival and prognostic factors of patients who were with advanced esophageal squamous cell carcinoma (ESCC) and developed an esophageal fistula. The data from 221 patients with advanced ESCC developed esophageal fistula from January 2008 to December 2017 at the Harbin Medical University Cancer Hospital was retrospectively analyzed. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated by the Cox proportional hazard models. The median survival time after a diagnosis of the esophageal fistula was calculated using the Kaplan–Meier method. We found that the pathogens infected by patients are common bacteria in nosocomial infection. Besides, the incidence rate of esophagomediastinal fistula was the highest (54.2%) in the lower third of the esophagus. Kaplan–Meier analysis revealed a median survival time of 11.00 months and a median post-fistula survival time of 3.63 months in patients who developed esophageal fistula in advanced esophageal cancer. In the univariate analysis, gender, therapies for ESCC before the development of fistula, type of esophageal fistula, treatment of esophageal fistula and hemoglobin (Hb) level were the factors with significant prognostic value. Gender, type of esophageal fistula and Hb level were identified as independent prognostic factors in further multivariate analysis. In summary, our study demonstrated that several factors are significantly related to patients with esophageal fistula and should be concerned about in clinical practice.

Robotic esophagectomy

Robotic esophagectomy is an increasingly used modality. Patients who are candidates for traditional, open esophagectomy are typically also candidates for robotic esophagectomy. Knowledge of and training on the robotic platform is critical for success. Patient and port positioning is described. Either a hand-sewn or stapled intrathoracic anastomosis may be performed. Minimally invasive esophagectomy (MIE) appears to be associated with decreased respiratory complications versus open esophagectomy. Robotic esophagectomy may be performed with excellent perioperative outcomes, though long-term oncologic data regarding the operation are not yet available.

Salvage esophagectomy under bilateral thoracotomy after definitive chemoradiotherapy for aorta T4 thoracic esophageal squamous cell carcinoma: Report of a case

INTRODUCTION

The surgical technique for esophagectomy to treat esophageal malignancies has been improved over the past several decades. Nevertheless, it remains extremely difficult to surgically treat patients with locally advanced T4b tumors invading the aorta or respiratory tract.

PRESENTAION OF CASE

A 37-year-old Japanese man was diagnosed with T4b (descending aorta) N2M0, Stage IIIC middle thoracic esophageal squamous cell carcinoma. He was initially treated with definitive CRT followed by 3 courses of DCF. After the DCF, CT showed that the main tumor had shrunk and appeared to have separated from the descending aorta. Therefore we decided to perform a salvage esophagectomy. Because we needed the ability to closely observe the site of invasion to determine whether aortic invasion was still present, half the esophageal resection was performed under right thoracotomy, but the final resection at the invasion site was performed under left thoracotomy. Consequently, the thoracic esophagus was safely removed and aortic replacement was avoided. The patient has now survived more than 30 months after the salvage esophagectomy with no additional treatment for esophageal cancer and no evidence of recurrent disease.

DISCUSSION

Because this and the previously reported procedures, each have particular advantages and disadvantages, one must contemplate and select an approach based on the situation for each individual patient.

CONCLUSION

Salvage esophagectomy through a right thoracotomy followed by careful observation of the invasion site for possible aortic replacement through a left thoracotomy is an optional procedure for these patients.