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Vagliasindi A, Franco FD, Degiuli M, Papis D, Migliore M. Extension of lymph node dissection in the surgical treatment of esophageal and gastroesophageal junction cancer: seven questions and answers. Future Oncol 2023; 19:327-339. [PMID: 36942741 DOI: 10.2217/fon-2021-0545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
The role of two- or three-field nodal dissection in the surgical treatment of esophageal and gastroesophageal junction cancer in the minimally invasive era is still controversial. This review aims to clarify the extension of nodal dissection in esophageal and gastroesophageal junctional cancer. A basic evidence-based analysis was designed, and seven research questions were formulated and answered with a narrative review. Reports with little or no data, single cases, small series and review articles were not included. Three-field lymph node dissection improves staging accuracy, enhances locoregional disease control and might improve survival in the group of patients with cervical and upper mediastinal metastatic lymph nodal involvement from middle and proximal-third esophageal cancer.
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Affiliation(s)
- Alessio Vagliasindi
- Department of General Surgery & Emergency Unit, S. Maria delle Croci Hospital, Ravenna, Italy
- Unit of abdominal Oncological Surgery, IRCS CROB, Rionero del Vulture(PZ), ITALY
| | - Filippo Di Franco
- Department of Surgery, North West Anglia NHS Foundation Trust, Huntingdon, PE29 6NT, UK
| | - Maurizio Degiuli
- Department of Oncology, Surgical Oncology & Digestive Surgery, San Luigi University Hospital, University of Torino, Orbassano Torino, Italy
| | - Davide Papis
- Department of General Surgery, Sant'Anna Hospital, ASST Lariana, Como
| | - Marcello Migliore
- Department of Surgery & Medical Specialties, Section of Thoracic Surgery, University of Catania, Catania, Italy
- Thoracic Surgery & Lung Transplant, Lung Health Centre, Organ Transplant Center of Excellence (OTCoE), King Faisal Specialist Hospital & Research Center, Riyadh, KSA
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Integrating Preoperative Computed Tomography and Clinical Factors for Lymph Node Metastasis Prediction in Esophageal Squamous Cell Carcinoma by Feature-Wise Attentional Graph Neural Network. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)00002-0. [PMID: 36641040 DOI: 10.1016/j.ijrobp.2022.12.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 12/26/2022] [Accepted: 12/29/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE This study aimed to propose a regional lymph node (LN) metastasis prediction model for patients with esophageal squamous cell carcinoma (ESCC) that can learn and adaptively integrate preoperative computed tomography (CT) image features and nonimaging clinical parameters. METHODS AND MATERIALS Contrast-enhanced CT scans taken 2 weeks before surgery and 20 clinical factors, including general, pathologic, hematological, and diagnostic information, were collected from 357 patients with ESCC between October 2013 and November 2018. There were 999 regional LNs (857 negative, 142 positive) with pathologically confirmed status after surgery. All LNs were randomly divided into a training set (n = 738) and a validation set (n = 261) for testing. The feature-wise attentional graph neural network (FAGNN) was composed of (1) deep image feature extraction by the encoder of 3-dimensional UNet and high-level nonimaging factor representation by the clinical parameter encoder; (2) a feature-wise attention module for feature embedding with learnable adaptive weights; and (3) a graph attention layer to integrate the embedded features for final LN level metastasis prediction. RESULTS Among the 4 models we constructed, FAGNN using both CT and clinical parameters as input is the model with the best performance, and the area under the curve (AUC) reaches 0.872, which is better than manual CT diagnosis method, multivariable model using CT only (AUC = 0.797), multivariable model with combined CT and clinical parameters (AUC = 0.846), and our FAGNN using CT only (AUC = 0.853). CONCLUSIONS Our adaptive integration model improved the metastatic LN prediction performance based on CT and clinical parameters. Our model has the potential to foster effective fusion of multisourced parameters and to support early prognosis and personalized surgery or radiation therapy planning in patients with ESCC.
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Schlottmann F, Angeramo CA, Bras Harriott C, Casas MA, Herbella FAM, Patti MG. Transthoracic Esophagectomy: Hand-sewn Versus Side-to-side Linear-stapled Versus Circular-stapled Anastomosis: A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2022; 32:380-392. [PMID: 35583556 DOI: 10.1097/sle.0000000000001050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/12/2021] [Indexed: 12/08/2022]
Abstract
BACKGROUND Three anastomotic techniques are mostly used to create an esophagogastric anastomosis in a transthoracic esophagectomy: hand-sewn (HS), side-to-side linear-stapled (SSLS), and circular-stapled (CS). The aim of this study was to compare surgical outcomes after HS, SSLS, and CS intrathoracic esophagogastric anastomosis. MATERIALS AND METHODS A systematic review using the MEDLINE database was performed to identify original articles analyzing outcomes after HS, SSLS, and CS esophagogastric anastomosis. The main outcome was an anastomotic leakage rate. Secondary outcomes included overall morbidity, major morbidity, and mortality. A meta-analysis of proportions and linear regression models were used to assess the effect of each anastomotic technique on the different outcomes. RESULTS A total of 101 studies comprising 12,595 patients were included; 8835 (70.1%) with CS, 2532 (20.1%) with HS, and 1228 (9.8%) with SSLS anastomosis. Anastomotic leak occurred in 10% [95% confidence interval (CI), 6%-15%], 9% (95% CI, 6%-13%), and 6% (95% CI, 5%-7%) of patients after HS, SSLS, and CS anastomosis, respectively. Risk of anastomotic leakage was significantly higher with HS anastomosis (odds ratio=1.73, 95% CI: 1.47-2.03, P<0.0001) and SSLS (odds ratio=1.68, 95% CI: 1.36-2.08, P<0.0001), as compared with CS. Overall morbidity (HS: 52% vs. SLSS: 39% vs. CS: 35%) and major morbidity (HS: 33% vs. CS: 19%) rates were significantly lower with CS anastomosis. Mortality rate was 4% (95% CI, 3%-6%), 2% (95% CI, 2%-3%), and 3% (95% CI, 3%-4%) after HS, SSLS, and CS anastomosis, respectively. CONCLUSION HS and SSLS intrathoracic esophagogastric anastomoses are associated with significantly higher rates of an anastomotic leak than CS anastomosis.
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Affiliation(s)
- Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
- Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Cristian A Angeramo
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | | | - María A Casas
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | | | - Marco G Patti
- Department of Surgery, University of Virginia, Charlottesville, Virginia
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Harriott CB, Angeramo CA, Casas MA, Schlottmann F. Open vs. Hybrid vs. Totally Minimally Invasive Ivor Lewis Esophagectomy: Systematic Review and Meta-analysis. J Thorac Cardiovasc Surg 2022; 164:e233-e254. [DOI: 10.1016/j.jtcvs.2021.12.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/03/2021] [Accepted: 12/24/2021] [Indexed: 02/07/2023]
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Askari A, Munster AB, Jambulingam P, Riaz A. Critical number of lymph node involvement in esophageal and gastric cancer and its impact on long-term survival-A single-center 8-year study. J Surg Oncol 2020; 122:1364-1372. [PMID: 32803769 DOI: 10.1002/jso.26145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/22/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Nodal disease in esophageal and gastric cancer is associated with poor survival. OBJECTIVES To determine the critical level of lymph node involvement where survival becomes significantly compromised. METHODS Survival analyses using multivariable Cox regression and receiver operator characteristics (ROC) were undertaken to determine what number of positive lymph nodes were most sensitive and specific in predicting survival. RESULTS A total of 317 patients underwent esophagectomy (n = 190, 59.9%) and gastrectomy (n = 127, 40.1%) for adenocarcinoma. At multivariable analyses, four nodes positivity (irrespective of T-category) was associated with nearly a fivefold increased risk of mortality when compared to node-negative patients (hazard ratio [HR], 4.9; interquartile range 2.0-11.5; P < .001). A positive ratio of up to 50.0% was not associated with worse survival than having four nodes positive (HR, 4.6; 95% confidence interval, 2.6-8.1; P < .001). ROC analysis demonstrated four lymph nodes positive to have a sensitivity of 80.5%, a specificity of 60.1%, and an accuracy of 77.8 (P < .001). CONCLUSION The absolute number of nodes positive for cancer is more important than the proportion of positive nodes in predicting survival in esophageal/gastric cancer. Four positive lymph nodes are associated with a fivefold increase in mortality. Beyond this, increasing numbers of positive lymph nodes make no appreciable difference to survival.
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Affiliation(s)
- Alan Askari
- Department of Surgery, West Hertfordshire Hospitals NHS Trust, Watford, UK
| | - Alex B Munster
- Department of Surgery, West Hertfordshire Hospitals NHS Trust, Watford, UK
| | | | - Amjid Riaz
- Department of Surgery, West Hertfordshire Hospitals NHS Trust, Watford, UK
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Li Z, Liu C, Liu Y, Yao S, Xu B, Dong G. Comparisons between minimally invasive and open esophagectomy for esophageal cancer with cervical anastomosis: a retrospective study. J Cardiothorac Surg 2020; 15:128. [PMID: 32513211 PMCID: PMC7282040 DOI: 10.1186/s13019-020-01182-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 06/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As an extensive surgery, minimally invasive esophagectomy (MIE) has advantages in reducing morbidity and improving quality of life for patients suffering from esophageal cancer. This study aims to investigate differences between MIE and open esophagectomy (OE) for considerations of the safety of procedures, rate of tumor resection, postoperative complications, and quality of life. This paper also tends to provide some references for MIE on esophageal cancer therapy. METHODS A retrospective data analysis was undertaken on 140 patients who either underwent MIE or OE for esophageal cancer with cervical anastomosis from March 2013 to May 2014 by our surgical team. Preoperative characteristics were analyzed for both groups. Differences in perioperative and oncologic outcomes were compared in operation time, intraoperative blood loss, lymph nodes retrieved, and R0-resection rate. Accordingly, a comparative analysis was conducted on complications namely anastomotic leakage, pulmonary infection, in-hospital mortality, and short-term (3 months) postoperative EORTC C30 Global health as well. RESULTS A total of 140 patients (87 with MIE and 53 with OE) were enrolled and the two groups were homogeneous in terms of patient- and tumor-related data. There was no difference on postoperative ICU stay (21.15 ± 1.54 h vs 21.75 ± 1.68 h, p = 0.07) and R0-resection rate (100% vs 100%, p = 1.00). The operation time for MIE was significantly shorter (146.08 ± 17.35 min vs 200.34 ± 14.51 min, p < 0.0001), the intraoperative blood loss was remarkably saved (MIE vs OE, 83.91 ± 24.72 ml vs 174.53 ± 35.32 ml, P < 0.0001) and more lymph nodes were retrieved (MIE vs OE, 38.89 ± 4.31 vs 18.42 ± 3.66, P < 0.0001). There was no difference between the groups to postoperative complications and mortality. However, pulmonary infection in MIE was higher than in OE and the difference was not statistically significant (MIE vs OE, 20.75% vs 31.03%, P = 0.24). Complications such as in-hospital mortality and short-term (3 months) postoperative EORTC C30 Global health displayed no difference between both groups as well. CONCLUSIONS The number of lymph nodes and intraoperative blood loss were significantly ameliorated in MIE. A 4-5 cm longitudinal incision below the xiphoid process was made to create the gastric conduit under direct vision assisting in shortening the total operation time significantly.
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Affiliation(s)
- Zongjie Li
- Department of Thoracic and Cardiovascular Surgery, The Third Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing Municipal Hospital of Traditional Chinese Medicine, Nanjing, 210001, Jiangsu Province, China
| | - Canhui Liu
- Department of Thoracic and Cardiovascular Surgery, The Third Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing Municipal Hospital of Traditional Chinese Medicine, Nanjing, 210001, Jiangsu Province, China
| | - Yuanguo Liu
- Department of Thoracic and Cardiovascular Surgery, The Third Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing Municipal Hospital of Traditional Chinese Medicine, Nanjing, 210001, Jiangsu Province, China
| | - Sheng Yao
- Department of Thoracic and Cardiovascular Surgery, The Third Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing Municipal Hospital of Traditional Chinese Medicine, Nanjing, 210001, Jiangsu Province, China
| | - Biao Xu
- Department of Thoracic and Cardiovascular Surgery, The Third Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing Municipal Hospital of Traditional Chinese Medicine, Nanjing, 210001, Jiangsu Province, China
| | - Guohua Dong
- Department of Thoracic and Cardiovascular Surgery, The Third Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing Municipal Hospital of Traditional Chinese Medicine, Nanjing, 210001, Jiangsu Province, China.
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Jiang Y, Chen YL, Chen TW, Wu L, Ou J, Li R, Zhang XM, Yang JQ, Cao JM. Is there association of gross tumor volume of adenocarcinoma of oesophagogastric junction measured on magnetic resonance imaging with N stage? Eur J Radiol 2019; 110:181-186. [DOI: 10.1016/j.ejrad.2018.05.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/07/2018] [Accepted: 05/21/2018] [Indexed: 12/13/2022]
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Nafteux P, Depypere L, Van Veer H, Coosemans W, Lerut T. Principles of esophageal cancer surgery, including surgical approaches and optimal node dissection (2- vs. 3-field). Ann Cardiothorac Surg 2017; 6:152-158. [PMID: 28447004 DOI: 10.21037/acs.2017.03.04] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Surgery for esophageal carcinoma and carcinoma of the gastro-esophageal junction (GEJ) is considered as one of the most complex and challenging interventions on the digestive tract. This is due to the intimate relations with vital structures in the chest and the tendency of early lymphatic dissemination via a dense and complex submucosal network. This review article discusses the different aspects of surgical access routes in the light of the ever-evolving techniques, in particular the minimally invasive esophagectomy (MIE). The aspects of surgical approach are inextricably linked to the still ongoing debate on extent of lymphadenectomy, a debate that is obtaining a new dimension in view of the widely applied neoadjuvant therapy protocols as well as in view of the increasing importance of quality of life aspects after surgery. Finally, the authors provide a practical and patient tailored approach as applied in their center.
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Affiliation(s)
- Philippe Nafteux
- Department of Thoracic Surgery, University Hospital Leuven, Belgium
| | - Lieven Depypere
- Department of Thoracic Surgery, University Hospital Leuven, Belgium
| | - Hans Van Veer
- Department of Thoracic Surgery, University Hospital Leuven, Belgium
| | - Willy Coosemans
- Department of Thoracic Surgery, University Hospital Leuven, Belgium
| | - Toni Lerut
- Department of Thoracic Surgery, University Hospital Leuven, Belgium
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Shang QX, Chen LQ, Hu WP, Deng HY, Yuan Y, Cai J. Three-field lymph node dissection in treating the esophageal cancer. J Thorac Dis 2016; 8:E1136-E1149. [PMID: 27867579 DOI: 10.21037/jtd.2016.10.20] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
There are many controversies in lymphadenectomy for thoracic esophageal cancer, and whether 3-field lymphadenectomy or 2-field lymphadenectomy is better have still been in doubt. The aim of this article is to review the role of the lymph node dissection by introducing the merits and demerits in 3-field lymphadenectomy, and the development in lymphadenectomy's selection, treatment and diagnosis. All the literatures related to esophageal lymphadenectomy and minimally invasive surgery (MIE) were searched in PubMed database and the cross references were added and reviewed to complete the reference list. Several researches elucidated that better overall survival (OS) in patients with esophageal cancer after 3-field lymphadenectomy had been reported worldwide, and 3-field lymphadenectomy is more suitable for treating esophageal cancer with cervical and/or upper mediastinal lymph nodes metastasis than 2-field lymphadenectomy regardless of the tumor's histology and location. Many approaches based on the characteristics of esophageal cancer lymph node metastasis are taken to improve the accuracy of 3-field lymphadenectomy and decrease the postoperative morbidity and mortality, while every approach needs further studies to demonstrate its feasibility. The benefits of the recently rapid-developed techniques performed in treating esophageal cancer: the MIE and the robotic-assisted thoracoscopic esophagectomy are illuminated as well, and both of them are technically safe and feasible for esophageal cancer, whereas further evaluations are still necessary.
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Affiliation(s)
- Qi-Xin Shang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Long-Qi Chen
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Wei-Peng Hu
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Han-Yu Deng
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Yong Yuan
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Jie Cai
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu 610041, China
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Zheng YZ, Zhao W, Hu Y, Ding-Lin XX, Wen J, Yang H, Liu QW, Luo KJ, Huang QY, Chen JY, Fu JH. Aggressive surgical resection does not improve survival in operable esophageal squamous cell carcinoma with N2-3 status. World J Gastroenterol 2015; 21:8644-8652. [PMID: 26229406 PMCID: PMC4515845 DOI: 10.3748/wjg.v21.i28.8644] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 04/01/2015] [Accepted: 05/04/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the influence of nodal status on response and clarify the optimal treatment for operable esophageal squamous cell carcinoma (OSCC).
METHODS: We retrospectively analyzed 1490 OSCC patients who underwent transthoracic esophagectomy and lymphadenectomy between December 1996 and December 2009 at the Sun Yat-sen University Cancer Center. The surgical approach and the number of resected lymph nodes (LNs) were considered in the assessment of surgery. Patients were classified according to their nodal statuses (N0 vs N1 vs N2-3). Overall survival was defined as the time from the date of death or final follow-up. Survival analysis was performed using the Kaplan-Meier method and differences between curves were assessed by the log-rank test. Univariate and multivariate Cox regression analyses were used to identify factors associated with prognosis. Statistical significance was assumed at a P < 0.05.
RESULTS: With a median time from surgery to the last censoring date for the entire cohort of 72.2 mo, a total of 631 patients were still alive at the last follow-up and the median survival time was 35.5 mo. The surgical approach (left transthoracic vs Ivor-Lewis/tri-incisional) was verified as independent prognostic significance in patients with N0 or N1 status, but not in those with N2-3 status. Similar results were also observed with the number of resected LNs (≤ 14 vs≥ 15). Compared with surgery alone, combined therapy achieved better outcomes in patients with N1 or N2-3 status, but not in those with N0 status. For those with N2-3 status, neither the surgical approach nor the number of resected LNs reached significance by univariate analysis, with unadjusted HRs of 0.826 (95%CI: 0.644-1.058) and 0.849 (95%CI: 0.668-1.078), respectively, and aggressiveness of surgery did not influence the outcome; the longest survival was observed in those patients who received the combined therapy.
CONCLUSION: Combined therapy has a positive role in OSCC with LN metastasis, and aggressive surgical resection does not improve survival in patients with N2-3 status.
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van der Schaaf M, Johar A, Wijnhoven B, Lagergren P, Lagergren J. Extent of lymph node removal during esophageal cancer surgery and survival. J Natl Cancer Inst 2015; 107:djv043. [PMID: 25748792 DOI: 10.1093/jnci/djv043] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND It is unclear how the extent of surgical lymph node clearance influences prognosis after surgery for esophageal cancer. METHODS This nationwide, population-based cohort study included 1044 esophageal cancer patients who had undergone esophagectomy between 1987 and 2010 in Sweden, with follow-up until 2012. The independent role of lymph node removal in relation to survival was analyzed using Cox proportional hazards regression, providing hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for age, sex, comorbidity, tumor (T) stage, neo-adjuvant treatment, surgeon volume, and calendar period. Statistical tests were two-sided, except tests for trend. RESULTS Analyzed as a linear variable, a higher number of lymph nodes removed did not influence the overall five-year mortality (adjusted HR = 1.00, 95% CI = 0.99 to 1.01). Patients in the third (7-15 nodes) and fourth (16-114 nodes) quartiles of removed nodes did not demonstrate any decreased overall five-year mortality compared with those in the lowest two quartiles (<7 nodes) (HR = 1.13, 95% CI = 0.95 to 1.35 and HR = 1.17, 95% CI = 0.94 to 1.46, respectively). In early T stages (Tis-T1) the hazard ratios indicated a worse survival with more lymphadenectomy using the median as cutoff (HR = 1.53, 95% CI = 1.13 to 2.06). Increased lymph node removal did not decrease mortality in any specific T stage. A greater number of metastatic nodes and a higher positive-to-negative node ratio were associated with strongly increased mortality. All results were similar when disease-specific mortality was analyzed. CONCLUSION This population-based study indicates that more extensive lymph node clearance during surgery for esophageal cancer may not improve survival. These results challenge current clinical guidelines, and further research is needed to change clinical practice.
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Affiliation(s)
- Maartje van der Schaaf
- Department of Molecular medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (MvdS, AJ, PL, JL); Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands (BW); Division of Cancer Studies, King's College London, London, UK (JL)
| | - Asif Johar
- Department of Molecular medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (MvdS, AJ, PL, JL); Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands (BW); Division of Cancer Studies, King's College London, London, UK (JL)
| | - Bas Wijnhoven
- Department of Molecular medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (MvdS, AJ, PL, JL); Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands (BW); Division of Cancer Studies, King's College London, London, UK (JL)
| | - Pernilla Lagergren
- Department of Molecular medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (MvdS, AJ, PL, JL); Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands (BW); Division of Cancer Studies, King's College London, London, UK (JL)
| | - Jesper Lagergren
- Department of Molecular medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (MvdS, AJ, PL, JL); Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands (BW); Division of Cancer Studies, King's College London, London, UK (JL).
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Abstract
Lymphadenectomy as an essential part of the surgical treatment has been one of the most controversial aspects in the management of esophageal cancers. The purpose of this article was to review the evolution, the current role, and the optimal extent of lymphadenectomy for the treatment of esophageal cancers. Studies discussing the outcome of esophagectomy with lymph nodes dissection and comparing among different extent of lymphadenectomy were used in the analysis. Several studies including recently published articles reveal that additional radical lymphadenectomy may be beneficial in some patients with non-extreme esophageal cancer undergoing esophagectomy, whereas two-field lymph node dissection is suitable for distal esophageal cancers regardless of the histology of the tumor. Minimally invasive surgery and neoadjuvant therapy combined with radical surgery seem to show more benefit in selected cases, but further studies should be required to clearly demonstrate their efficacy and safety. The expertise and experience of the surgeons should also be taken into account in determining the success of these radical procedures.
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Affiliation(s)
- P Hiranyatheb
- Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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Wang N, Jia Y, Wang J, Wang X, Bao C, Song Q, Tan B, Cheng Y. Prognostic significance of lymph node ratio in esophageal cancer. Tumour Biol 2014; 36:2335-41. [PMID: 25412956 DOI: 10.1007/s13277-014-2840-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 11/11/2014] [Indexed: 12/12/2022] Open
Abstract
N staging predicting esophageal cancer patient prognosis has been studied. Lymph node ratio, which is considered to show metastatic lymph node status more accurately, is found to have prognostic significance in several tumors. We investigated whether lymph node ratio (LNR) was associated with the prognosis of esophageal cancer in this study. Esophageal cancer patients who underwent esophagectomy at Qilu Hospital of Shandong University from January 2007 to December 2008 were studied. A total of 209 cases were evaluated in this study. The median disease-free survival (DFS) of this cohort was 35.2 months, and 5-year DFS rate was 32.1%. The median overall survival (OS) was 46.4 months, and 5-year OS rate was 40.0%. Kaplan-Meier survival analysis revealed that patients with LNR higher than 0.2 had significantly poorer DFS (p < 0.001) and OS (p < 0.001) than those with LNR less than 0.2. In a multivariate analysis, LNR was found to be an independent prognostic factor for DFS (p = 0.008, HR 1.863, 95% CI 1.180-2.942) and OS (p = 0.025, HR 1.708, 95% CI 1.068-2.731). N stage (p = 0.028, HR 1.626, 95% CI 1.055-2.506) was also found to be an independent prognostic factors for OS. Subgroups analysis revealed significant difference in OS and DFS rates between different LNR categories within the same N stages (p < 0.05) but not between different N stages within the same LNR category (p > 0.05). LNR was recognized as an independent factor in both OS and DFS in esophageal cancer. Besides, LNR showed a better prognostic value than N stage for esophageal cancer.
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Affiliation(s)
- Nana Wang
- Department of Radiation Oncology, Qilu Hospital of Shandong University, 107 West Wenhua Road, Jinan, 250012, People's Republic of China
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Karakas E, Oetzmann von Sochaczewski C, Haist T, Pauthner M, Lorenz D. Grenzen der Chirurgie bei Karzinomen des oberen Intestinaltraktes. Chirurg 2014; 85:186-91. [DOI: 10.1007/s00104-013-2598-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Nafteux P, Lerut T, De Hertogh G, Moons J, Coosemans W, Decker G, Van Veer H, De Leyn P. Can extracapsular lymph node involvement be a tool to fine-tune pN1 for adenocarcinoma of the oesophagus and gastro-oesophageal junction in the Union Internationale contre le Cancer (UICC) TNM 7th edition? Eur J Cardiothorac Surg 2014; 45:1001-10. [DOI: 10.1093/ejcts/ezt546] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Kim DJ, Park SY, Lee S, Kim HI, Hyung WJ. Feasibility of a robot-assisted thoracoscopic lymphadenectomy along the recurrent laryngeal nerves in radical esophagectomy for esophageal squamous carcinoma. Surg Endosc 2014; 28:1866-73. [PMID: 24464384 DOI: 10.1007/s00464-013-3406-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 12/24/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND Lymph node dissection along bilateral recurrent laryngeal nerves (RLNs) is an essential component of radical esophagectomy for esophageal squamous carcinoma. However, it is associated with significant morbidity and requires a great deal of skill when performed with minimally invasive surgery. METHODS Between October 2010 and July 2012, 40 consecutive patients underwent a robot-assisted thoracoscopic esophagectomy and total mediastinal lymphadenectomy. The lymph nodes along the dorsal side of the RLNs were removed in the initial 18 patients (group 1), and the RLNs were skeletonized by dissection of all the lymph nodes and surrounding fatty tissues in the following 22 patients (group 2). RESULTS All but one patient underwent a successful robot-assisted, thoracoscopic esophagectomy. The mean operation time was 428.6 ± 75.0 min, and the mean robot console time was 186.7 ± 52.1 min. An average of 42.6 ± 14.1 nodes was retrieved, and the mean number of dissected nodes from the mediastinum and the RLN chains were 25.5 ± 9.6 and 9.6 ± 6.5, respectively. One mortality occurred (2.5%), and the incidences of pneumonia and RLN palsy were 12.5 and 20%, respectively. The mean robot console time was longer in group 2 (211.4 ± 49.5 min) than in group 1 (156.6 ± 38.2 min) (p < 0.001), and group 2 had higher mean numbers of dissected nodes from the mediastinum (30.3 ± 7.9 vs 19.6 ± 8.2; p < 0.001) and the RLN chains (13.5 ± 5.7 vs 4.8 ± 3.6; p < 0.001). Although RLN palsy was more common in group 2 (31.8 vs 5.6%; p = 0.054), all palsies resolved within 1 year. CONCLUSIONS Robot-assisted thoracoscopic lymphadenectomy along bilateral RLNs was technically feasible and safe. Skeletonization of the RLNs yields more lymph nodes, but efforts should be made to decrease the incidence of RLN palsy.
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Affiliation(s)
- Dae Joon Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea,
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Sisic L, Blank S, Weichert W, Jäger D, Springfeld C, Hochreiter M, Büchler M, Ott K. Prognostic impact of lymph node involvement and the extent of lymphadenectomy (LAD) in adenocarcinoma of the esophagogastric junction (AEG). Langenbecks Arch Surg 2013; 398:973-81. [PMID: 23887283 DOI: 10.1007/s00423-013-1101-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 07/11/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND The prognostic importance of lymph node (LN) involvement for patients with adenocarcinoma of the esophagogastric junction (AEG) is well-known. In the latest edition of the UICC staging system, the number of metastatic LNs was taken into account, while the extent of lymphadenectomy (LAD) remains unaddressed. Removal of at least six LNs is recommended, but there is no defined minimum number as to classify as (y)pN0. We examined the prognostic value of the number of positive LNs, number of LNs removed, and LN ratio (LNR) in order to determine the influence of an adequate LAD on overall survival (OS). METHODS We analyzed data of 316 patients with AEG treated in our institution (2001-2011) regarding clinicopathological data, treatment, morbidity, mortality, and long-term prognosis. Univariate and multivariate analysis was performed using Cox regression to evaluate the prognostic impact of(y)pN category, number of LNs removed and LNR. RESULTS OS decreased with higher count of positive LNs (p < 0.001) and higher LNR (p < 0.001). Whether >6, >15, or >30 LNs were removed did not influence OS, neither in the entire study population nor within individual (y)pT or (y)pN categories. Multivariate analysis revealed LNR (p < 0.001) besides M category (p = 0.015) and tracheotomy during the postoperative course (p = 0.005) as independent predictors of OS. CONCLUSION The classification according to the number of involved LNs in the latest edition of the UICC staging system improves prognostication in patients with AEG. The importance of an adequate LAD is shown by the high prognostic relevance of the LNR rather than the absolute number of LNs removed.
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Affiliation(s)
- Leila Sisic
- Department of Surgery, University Hospital Heidelberg, INF 110, 69120, Heidelberg, Germany,
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Ouattara M, D'Journo XB, Loundou A, Trousse D, Dahan L, Doddoli C, Seitz JF, Thomas PA. Body mass index kinetics and risk factors of malnutrition one year after radical oesophagectomy for cancer. Eur J Cardiothorac Surg 2012; 41:1088-93. [DOI: 10.1093/ejcts/ezr182] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Schuhmacher C, Novotny A, Reim D, Ulm K, Friess H. Lymphadenektomie bei Malignomen des oberen Gastrointestinaltraktes. Chirurg 2011; 82:1091-5. [DOI: 10.1007/s00104-011-2116-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Kayani B, Zacharakis E, Ahmed K, Hanna GB. Lymph node metastases and prognosis in oesophageal carcinoma--a systematic review. Eur J Surg Oncol 2011; 37:747-53. [PMID: 21839394 DOI: 10.1016/j.ejso.2011.06.018] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2010] [Revised: 02/09/2011] [Accepted: 06/28/2011] [Indexed: 12/27/2022] Open
Abstract
Oesophageal cancer is the 7th most common cause of cancer-related death in the developed world and the incidence of oesophageal adenocarcinoma is now the fastest growing of any gastrointestinal cancer. Lymph node involvement is the single most important prognostic factor in oesophageal cancer. Imaging to determine the extent of lymph node involvement and plan treatment often requires a combination of modalities to avoid under-staging. The 7th edition of the staging system released by the International Union Against Cancer (IUCC) has stratified lymph node involvement according to the number of lymph nodes involved and redefined its groupings for location of metastatic lymph node involvement. This review discusses the prognostic and treatment implications of these modifications and explores micrometastatic lymph node involvement, capsular infiltration and lymph node ratio as possible additions to the staging system.
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Affiliation(s)
- B Kayani
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, Praed Street, London W2 1NY, UK
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Yakoub D, Keun HC, Goldin R, Hanna GB. Metabolic profiling detects field effects in nondysplastic tissue from esophageal cancer patients. Cancer Res 2010; 70:9129-36. [PMID: 20884633 DOI: 10.1158/0008-5472.can-10-1566] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The variable rate of missed cancer in endoscopic biopsies and lack of other biomarkers reduce the effectiveness of surveillance programs in esophageal cancer. Based on the "field cancerization" hypothesis that tumors arise within a transformed field with an altered biochemical phenotype, we sought to test if metabolic profiling could differentiate between histologically normal tissue from individuals with and without esophageal cancer. Thirty-five patients with esophageal adenocarcinoma and 52 age-matched controls participated in the study. Using 1H magic angle spinning-nuclear magnetic resonance spectroscopy of intact tissue, we generated metabolic profiles of tumor tissue, proximal histologically normal mucosa from cancer patients (PHINOM), and proximal histologically normal mucosa from a control group. Using multivariate regression and receiver-operator characteristic analysis, we identified a panel of metabolites discriminating malignant and histologically normal tissues from cancer patients and from that of controls. Whereas 26% and 12% of the spectral profile regions were uniquely discriminating tumor or control tissue, respectively, 5% of the profile exhibited a significant progressive change in signal intensity from controls to PHINOM to tumor. Regions identified were assigned to phosphocholine (PC), glutamate (Glu), myo-inositol, adenosine-containing compounds, uridine-containing compounds, and inosine. In particular, the PC/Glu ratio in histologically normal tissue signified the presence of esophageal cancer (n=123; area under the curve, 0.84; P<0.001). In conclusion, our findings support the hypothesis of the presence of metabonomic field effects in esophageal cancer, even in non-Barrett's segments. This indicates that metabolic profiling of tissue can potentially play a role in the surveillance of cancer by reporting on the phenotypic consequences of field cancerization.
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Affiliation(s)
- Danny Yakoub
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, United Kingdom
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Metzger R, Bollschweiler E, Drebber U, Mönig SP, Schröder W, Alakus H, Kocher M, Baldus SE, Hölscher AH. Neoadjuvant chemoradiotherapy for esophageal cancer: Impact on extracapsular lymph node involvement. World J Gastroenterol 2010; 16:1986-92. [PMID: 20419835 PMCID: PMC2860075 DOI: 10.3748/wjg.v16.i16.1986] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the effects of neoadjuvant chemoradiotherapy (CRT) on the presence of extracapsular lymph node involvement (LNI) and its prognostic value in patients with resected esophageal cancer.
METHODS: Two hundred and ninety-eight patients with advanced esophageal cancer underwent esophagectomy between 1997 and 2006. One hundred and ninety patients (63.8%) were treated with neoadjuvant CRT prior to resection. A total of 986 metastatic LNs were examined. Survival of the patients was analyzed according to intra- and extra-capsular LNI.
RESULTS: Five-year survival rate was 22.5% for the entire patient population. Patients with extracapsular LNI had a 5-year survival rate of 16.7%, which was comparable to the 15.8% in patients with infiltrated nodes of the celiac trunk (pM1lymph). In contrast to patients treated with surgery alone, neoadjuvant therapy resulted in significantly (P = 0.001) more patients with pN0/M0 (51.6% vs 25.0%). In 17.6% of the patients with surgery alone vs 16.8% with neoadjuvant CRT, extracapsular LNI was detected. Neoadjuvant therapy does not reduce the occurrence of extracapsular LNI.
CONCLUSION: Extracapsular LNI is an independent negative prognostic factor not influenced by neoadjuvant CRT. In a revised staging system for esophageal cancer, extracapsular LNI should be considered.
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Schiesser M, Schneider PM. Surgical strategies for adenocarcinoma of the esophagogastric junction. Recent Results Cancer Res 2010; 182:93-106. [PMID: 20676874 DOI: 10.1007/978-3-540-70579-6_8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
This chapter summarizes the surgical strategies for adenocarcinomas of the distal esophagus, gastric cardia, and subcardial gastric cancer invading the cardia+/-distal esophagus known as adenocarcinomas of the esophagogastric junction (AEG). The different surgical approaches according to the tumor origin, localization, and tumor stage are addressed with particular attention to the extent and type of resection and appropriate lymphadenectomy (LAD). The classification of AEG according to Siewert is helpful for the selection of the surgical strategy. While type I tumors benefit from a transthoracic en bloc esophagectomy including a two-field LAD, type II and III tumors can be treated by an extended total gastrectomy with a transhiatal resection of the distal esophagus and LAD of the lower mediastinum and the abdominal D2 compartment. Limited resections appear to be -possible for early tumor stages in selected cases of type I-III tumors.
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Boone J, Schipper MEI, Moojen WA, Borel Rinkes IHM, Cromheecke GJE, van Hillegersberg R. Robot-assisted thoracoscopic oesophagectomy for cancer. Br J Surg 2009; 96:878-86. [PMID: 19591168 DOI: 10.1002/bjs.6647] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Thoracoscopic oesophagectomy was introduced to reduce the morbidity of transthoracic oesophagectomy. The aim was to assess the short- and mid-term results of robot-assisted thoracoscopic oesophagectomy for oesophageal cancer. METHODS Between October 2003 and May 2007, 47 patients with resectable oesophageal cancer underwent robot-assisted thoracoscopic oesophagectomy. Clinical data were collected prospectively. RESULTS Conversion to thoracotomy was necessary in seven patients. Median operating time was 450 min and median blood loss 625 ml. Median postoperative ventilation time was 1 day, intensive care stay 3 days and hospital stay 18 days. Twenty-one of 47 patients had pulmonary complications. Three patients died in hospital. A median of 29 (range 8-68) lymph nodes was dissected and R0 resection was achieved in 36 patients. Twenty-three patients had stage IVa disease. After a median follow-up of 35 months, median disease-free survival was 15 (95 per cent confidence interval 12 to 18) months. CONCLUSION Robot-assisted thoracoscopic oesophagectomy was oncologically acceptable. Operating time, blood loss and pulmonary complications might decrease with further experience.
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Affiliation(s)
- J Boone
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Slim K, Blay JY, Brouquet A, Chatelain D, Comy M, Delpero JR, Denet C, Elias D, Fléjou JF, Fourquier P, Fuks D, Glehen O, Karoui M, Kohneh-Shahri N, Lesurtel M, Mariette C, Mauvais F, Nicolet J, Perniceni T, Piessen G, Regimbeau JM, Rouanet P, sauvanet A, Schmitt G, Vons C, Lasser P, Belghiti J, Berdah S, Champault G, Chiche L, Chipponi J, Chollet P, De Baère T, Déchelotte P, Garcier JM, Gayet B, Gouillat C, Kianmanesh R, Laurent C, Meyer C, Millat B, Msika S, Nordlinger B, Paraf F, Partensky C, Peschaud F, Pocard M, Sastre B, Scoazec JY, Scotté M, Triboulet JP, Trillaud H, Valleur P. [Digestive oncology: surgical practices]. ACTA ACUST UNITED AC 2009; 146 Suppl 2:S11-80. [PMID: 19435621 DOI: 10.1016/s0021-7697(09)72398-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- K Slim
- Chirurgien Clermont-Ferrand.
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Extracapsular Lymph Node Involvement Is a Negative Prognostic Factor After Neoadjuvant Chemoradiotherapy in Locally Advanced Esophageal Cancer. J Thorac Oncol 2009; 4:534-9. [DOI: 10.1097/jto.0b013e31819c862d] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Epari K, Cade R. Oesophagectomy for tumours and dysplasia of the oesophagus and gastro-oesophageal junction. ANZ J Surg 2009; 79:251-7. [DOI: 10.1111/j.1445-2197.2009.04855.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Udagawa H, Ueno M, Kinoshita Y. Rationale for video-assisted radical esophagectomy. Gen Thorac Cardiovasc Surg 2009; 57:127-31. [PMID: 19280307 DOI: 10.1007/s11748-008-0362-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Indexed: 10/21/2022]
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Grotenhuis BA, Wijnhoven BPL, van Marion R, van Dekken H, Hop WC, Tilanus HW, van Lanschot JJB, van Eijck CHJ. The sentinel node concept in adenocarcinomas of the distal esophagus and gastroesophageal junction. J Thorac Cardiovasc Surg 2009; 138:608-12. [PMID: 19698844 DOI: 10.1016/j.jtcvs.2008.11.061] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Revised: 10/17/2008] [Accepted: 11/27/2008] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The sentinel node concept is of great value in the treatment of various malignancies. In this study we investigated whether the application of the sentinel node procedure is feasible in esophageal adenocarcinoma and whether it can tailor surgical treatment of the individual patient. METHODS In 40 patients with an adenocarcinoma of the distal esophagus or gastroesophageal junction, blue dye was injected around the tumor intraoperatively. Sentinel nodes (blue-stained) and nonsentinel nodes were identified and dissected during transhiatal esophagectomy. In sentinel nodes negative for tumor cells on routine hematoxylin-eosin examination, multilevel sectioning and immunohistochemical staining were performed to search for micrometastases. RESULTS The sentinel node procedure was technically successful in 39 of 40 patients (98%). The median number of sentinel nodes identified was 4. Sentinel nodes were present in more than 1 nodal station in 8 patients (21%). In 6 patients in whom the sentinel node was negative for metastasis, nonsentinel nodes were positive for tumor cells (false-negative rate 6/39 = 15%). Micrometastases and isolated tumor cells were detected in 7 of 19 patients (37%) with sentinel nodes, but this finding did not affect the false-negative rate. CONCLUSION Detection of sentinel nodes is technically feasible during esophagectomy for cancer. However, given the relatively high false-negative rate of 15% and the high frequency of sentinel nodes in more than 1 nodal station, the clinical relevance of the sentinel node concept (through application of the blue dye technique) in the current treatment of patients with an adenocarcinoma of the distal esophagus or gastroesophageal junction seems limited.
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Thompson SK, Ruszkiewicz AR, Jamieson GG, Esterman A, Watson DI, Wijnhoven BPL, Lamb PJ, Devitt PG. Improving the Accuracy of TNM Staging in Esophageal Cancer: A Pathological Review of Resected Specimens. Ann Surg Oncol 2008; 15:3447-58. [DOI: 10.1245/s10434-008-0155-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2008] [Revised: 08/14/2008] [Accepted: 08/14/2008] [Indexed: 12/20/2022]
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Wu J, Chai Y, Zhou XM, Chen QX, Yan FL. Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for squamous cell carcinoma of the lower thoracic esophagus. World J Gastroenterol 2008; 14:5084-9. [PMID: 18763294 PMCID: PMC2742939 DOI: 10.3748/wjg.14.5084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the clinical outcome of Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for patients with squamous cell carcinoma of the lower thoracic esophagus.
METHODS: From January 1998 to December 2001, 73 patients with lower thoracic esophageal carcinoma underwent Ivor-Lewis subtotal esophagectomy with two-field lymphadenectomy. Clinicopathological information, postoperative complications, mortality and long term survival of all these patients were analyzed retrospectively.
RESULTS: The operative morbidity and mortality was 15.1% and the mortality was 2.7%. Lymph node metastases were found in 52 patients (71.2%). Nodal metastases to the upper, middle, lower mediastini and upper abdomen were found in 13 (17.8%), 15 (20.5%), 30 (41.1%), and 25 (34.2%) patients, respectively. Postoperative staging was as follows: stageI in 5 patients, stage II in 34 patients, stage III in 32 patients, and stage IV in 2 patients, respectively. The overall 5-year survival rate was 23.3%. For N0 and N1 patients, the 5-year survival rate was 38.1% and 17.3%, respectively (χ2 = 22.65, P < 0.01). The 5-year survival rate for patients in stages IIa, IIb and III was 31.2%, 27.8% and 12.5%, respectively (χ2 = 29.18, P < 0.01).
CONCLUSION: Ivor Lewis subtotal esophagectomy with two-field (total mediastinum) lymphadenectomy is a safe and appropriate operation for squamous cell carcinoma of the lower thoracic esophagus.
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D’Journo XB, Michelet P, Avaro JP, Trousse D, Giudicelli R, Fuentes P, Doddoli C, Thomas P. Complications respiratoires de l’œsophagectomie pour cancer. Rev Mal Respir 2008; 25:683-94. [DOI: 10.1016/s0761-8425(08)73798-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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The number of metastatic lymph nodes and the ratio between metastatic and examined lymph nodes are independent prognostic factors in esophageal cancer regardless of neoadjuvant chemoradiation or lymphadenectomy extent. Ann Surg 2008; 247:365-71. [PMID: 18216546 DOI: 10.1097/sla.0b013e31815aaadf] [Citation(s) in RCA: 315] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate whether the number of lymph nodes metastasis (LNMs) and the ratio between metastatic and examined lymph nodes (LNs) are better prognostic factors when compared with traditional staging systems in patients with esophageal carcinoma. SUMMARY BACKGROUND DATA The accuracy of the 6th UICC/TNM classification is suboptimal, especially when not taking into account neoadjuvant therapy and lymphadenectomy extent. METHODS For 536 patients who underwent curative en bloc esophagectomy, in whom 51.5% (n = 276) received neoadjuvant chemoradiation, LNMs were classified according to the 6th UICC/TNM classification and systems based on the number (< or =4 and >4) or the ratio (< or =0.2 and >0.2) of LNMs. Survival of the respective stages, predictors of survival, and influence of both chemoradiation and number of examined LNs were studied. RESULTS After a median follow-up of 50 months, the 5-year survival rates were 47% for the entire population, significantly poorer for patients with >4 LNMs (8% vs. 53%, P < 0.001) or a ratio of LNMs >0.2 (22% vs. 54%, P < 0.001). After adjustment for confounding variables, a number of LNMs >4 and a ratio of LNMs >0.2 were the only predictors of poor prognosis. The prognostic role of both the number and the ratio of LNMs was maintained whether patients received neoadjuvant chemoradiation or not. Moreover, LN ratio is shown to be more accurate for inadequately staged patients (<15 examined LNs), whereas the number of LNMs is pertinent for adequately staged patients (> or =15 examined LNs). CONCLUSION Staging systems for esophageal cancer that use the number (< or =4 or >4) and the ratio (< or =0.2 or >0.2) of LNMs have greater prognostic importance than the current staging systems because of the good stratification of the groups and their clinical utility, taking into account neoadjuvant therapy and lymphadenectomy extent.
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Schwarz RE, Smith DD. Clinical impact of lymphadenectomy extent in resectable esophageal cancer. J Gastrointest Surg 2007; 11:1384-93; discussion 1393-4. [PMID: 17764019 DOI: 10.1007/s11605-007-0264-2] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Accepted: 07/19/2007] [Indexed: 01/31/2023]
Abstract
Esophageal cancer (EC) frequently presents with advanced stages and is associated with high recurrence rates after esophagectomy. The value of an extended lymph node dissection (ELND) remains unclear in this setting. An EC data set was created from the Surveillance, Epidemiology, and End-Results 1973-2003 database. Relationships between the number of lymph nodes (LNs) examined and overall survival (OS) were analyzed. From a cohort of 40,129 EC patients, 5,620 individuals were selected. The median age was 65 (range: 11-102), and 75% were men. The median tumor size was 5.0 cm (0.1-30). On multivariate analysis, total LN count (or negative LN count, respectively) was an independent prognostic variable, aside from age, race, resection status, radiation, T category, N category (all at p < 0.0001), and M category (p = 0.0003). Higher total LN count (>30) and negative LN count (>15) categories were associated with best OS and lowest 90-day mortality (p < 0.0001). The numeric LN effect on OS was independent from nodal status or histology. Greater total and negative LN counts are associated with longer EC survival. Although the mechanism remains uncertain, it does not appear to be limited to stage migration. ELND during potentially curative esophagectomy for EC can be supported by the data.
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Affiliation(s)
- Roderich E Schwarz
- Division of Surgical Oncology, UT Southwestern Cancer Center, Dallas, TX 75390, USA.
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Pedrazzani C, de Manzoni G, Marrelli D, Giacopuzzi S, Corso G, Minicozzi AM, Rampone B, Roviello F. Lymph node involvement in advanced gastroesophageal junction adenocarcinoma. J Thorac Cardiovasc Surg 2007; 134:378-85. [PMID: 17662776 DOI: 10.1016/j.jtcvs.2007.03.034] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2006] [Revised: 01/24/2007] [Accepted: 03/08/2007] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The prognosis of gastroesophageal junction adenocarcinoma is unquestionably related to the extent of nodal involvement; nonetheless, few studies deal with the pattern of lymph node spread and specifically analyze the prognostic value of the site of metastasis. The present study was aimed at evaluating these key aspects in advanced gastroesophageal junction adenocarcinoma. METHODS Of 219 patients consecutively operated on for gastroesophageal junction adenocarcinoma at the Department of General Surgery and Surgical Oncology, University of Siena, and at the Department of General Surgery, University of Verona, 143 pT2-4 tumors not submitted to prior chemoradiation were analyzed according to the Japanese Gastric Cancer Association pN staging system. RESULTS The majority of patients were given diagnoses of nodal metastases (77.6%). The mean number (P = .076) and the percentage of patients with pN+ disease (P = .022) progressively increased from Siewert type I to type III tumors. Abdominal nodes were involved in all but 1 of the patients with pN+ disease; conversely, nodal metastases into the chest were 46.2% for type I, 29.5% for type II, and 9.3% for type III tumors. Survival analysis showed virtually no chance of recovery for patients with more than 6 metastatic nodes or lymph nodes located beyond the first tier. CONCLUSIONS In advanced gastroesophageal junction adenocarcinoma, the high frequency of nodal metastases and the related unfavorable long-term outcome achieved by means of surgical intervention alone are indicative of the need for aggressive multimodal treatment along with surgical intervention to improve long-term results.
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Affiliation(s)
- Corrado Pedrazzani
- Department of Human Pathology and Oncology, Unit of Surgical Oncology, University of Siena, Siena, Italy
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Upponi S, Ganeshan A, Slater A, D'Costa H, Low L, Maynard N, Bungay H. Imaging following surgery for oesophageal cancer. Clin Radiol 2007; 62:724-31. [PMID: 17604759 DOI: 10.1016/j.crad.2007.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2006] [Revised: 01/23/2007] [Accepted: 01/29/2007] [Indexed: 11/16/2022]
Abstract
The incidence of oesophageal malignancy is increasing in the UK. Surgical management with oesophagectomy is determined by tumour location, stage and extent of lymphadenectomy,and is also dependent on patient age and co-morbidity. Surgery is associated with considerable postoperative morbidity and mortalities of up to 7%. The indications for imaging and findings in both the immediate and delayed postoperative periods are discussed.
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Affiliation(s)
- S Upponi
- Department of Radiology, John Radcliffe Hospital, Oxford, UK
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Gervasoni JE, Sbayi S, Cady B. Role of lymphadenectomy in surgical treatment of solid tumors: an update on the clinical data. Ann Surg Oncol 2007; 14:2443-62. [PMID: 17597349 DOI: 10.1245/s10434-007-9360-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2006] [Accepted: 01/09/2007] [Indexed: 12/31/2022]
Abstract
BACKGROUND The role of lymphadenectomy as an adjunct of standard excision for treatment of cancer is highly debated and controversial. Standard practice for treatment of solid tumors is resection with regional lymphadenectomy. This surgical concept assumes that cancers grow and spread in an orderly manner, from primary cancer to regional lymph nodes and finally to vital organs. We reviewed randomized trials, published a description of lymphatic anatomy and physiology, and presented data that disputed the role of lymphadenectomy as standard practice. The present review updates the literature and reiterates the concept that lymphadenectomy does not increase survival in the surgical treatment of solid tumors. METHODS We reviewed the English-language literature (Medline) for prospective randomized trials and nonrandomized reports, as well as retrospective studies addressing the role of lymphadenectomy in cancers of the esophagus, lung, stomach, pancreas, breast, and skin (melanoma) reported between 2000 and 2006. RESULTS This extensive review demonstrates that there are few prospective randomized trials assessing patient survival with solid tumors that contrast resection with or without lymphadenectomy. However, there was at least one, and for some cancers more than one, prospective randomized trial for each organ site studied, and the data demonstrate no statistically significant difference in overall survival of patients treated with or without lymphadenectomy. Most nonrandomized and retrospective studies, with a few exceptions, support the conclusions of randomized trials; lymphadenectomy does not improve overall survival in solid tumors. Overall survival is primarily a function of the biological nature of the primary tumor, as evidenced by lymphovascular invasion, lymph node involvement, and other prognostic features. CONCLUSIONS This extensive literature review of recent reports indicates that lymphadenectomy does not improve overall survival. Lymph node resection should be conceived in terms of staging, prognosis, and regional control only.
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Affiliation(s)
- James E Gervasoni
- Department of Surgery, Saint Peter's University Hospital, 254 Easton Ave, New Brunswick, New Jersey 08901, USA.
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Michelet P, Jaber S, Eledjam JJ, Auffray JP. Prise en charge anesthésique de l'œsophagectomie: avancées et perspectives. ACTA ACUST UNITED AC 2007; 26:229-41. [PMID: 17270381 DOI: 10.1016/j.annfar.2006.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Accepted: 11/21/2006] [Indexed: 01/06/2023]
Abstract
Oesophagectomy is still characterized by a high postoperative mortality and respiratory morbidity. Nevertheless, epidemiological, medical and surgical advances have improved the management of this surgical procedure. The anaesthesiologist influence is present at each level, from the preoperative evaluation to the management of postoperative complications. The preoperative period is improved by the use of assessment scores, the better knowing of respiratory risk factors and of the neoadjuvant therapy adverse effects. The main objective of the operative period is to ensure a rapid weaning procedure and stability of the respiratory and haemodynamic functions, warranting the anastomotic healing. The interest of the association between respiratory rehabilitation and thoracic epidural analgesia is highlighted in the postoperative period. The management of postoperative complications, mainly represented by respiratory failure and anastomotic leakages, requires a multidisciplinary analysis. The potential interest of non-invasive ventilation and of the modulation of postoperative inflammatory response needs further investigation.
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Affiliation(s)
- P Michelet
- Département d'anesthésie-réanimation, hôpital Sainte-Marguerite, 270, boulevard Sainte-Marguerite, 13009 Marseille, France.
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Wind J, Lagarde SM, Ten Kate FJW, Ubbink DT, Bemelman WA, van Lanschot JJB. A systematic review on the significance of extracapsular lymph node involvement in gastrointestinal malignancies. Eur J Surg Oncol 2006; 33:401-8. [PMID: 17175130 DOI: 10.1016/j.ejso.2006.11.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2006] [Accepted: 11/01/2006] [Indexed: 12/13/2022] Open
Abstract
AIMS The impact of extracapsular lymph node involvement (LNI) has been studied for several malignancies, including gastrointestinal malignancies. Aim of this study was to assess the current evidence on extracapsular LNI as a prognostic factor for recurrence in gastrointestinal malignancies. METHODS The Cochrane Database of systematic reviews, the Cochrane central register of controlled trials, and MEDLINE databases were searched using a combination of keywords relating to extracapsular LNI in gastrointestinal malignancies. Primary outcome parameters were incidence of extracapsular LNI and overall five-year survival rates. FINDINGS Fourteen manuscripts were included, concerning seven oesophageal, three gastric, one colorectal, and three rectal cancer series with a total of 1528 node positive patients. The pooled incidence of extracapsular LNI was 57% (95% CI: 53-61%) for oesophageal cancer, 41% (95% CI: 36-47%) for gastric cancer, and 35% (95% CI: 31-40%) for rectal cancer. In nine of the 14 studies a multivariate analysis was performed. In eight of these nine studies extracapsular LNI was identified as an independent risk factor for recurrence. CONCLUSION Extracapsular LNI is a common phenomenon in patients with gastrointestinal malignancies. It identifies a subgroup of patients with a significantly worse long-term survival. This systematic review highlights the importance of assessing extracapsular LNI as a valuable prognostic factor. Pathologists and clinicians should be aware of this important feature.
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Affiliation(s)
- J Wind
- Department of Surgery, Academic Medical Centre, Post-box 22660, Meibergdreef 9, 1100 DD Amsterdam, The Netherlands.
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Barbour AP, Rizk NP, Gonen M, Tang L, Bains MS, Rusch VW, Coit DG, Brennan MF. Lymphadenectomy for Adenocarcinoma of the Gastroesophageal Junction (GEJ): Impact of Adequate Staging on Outcome. Ann Surg Oncol 2006; 14:306-16. [PMID: 17091329 DOI: 10.1245/s10434-006-9166-x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2006] [Revised: 07/02/2006] [Accepted: 07/03/2006] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Adequate staging of gastric cancer requires examination of at least 15 lymph nodes. Most resected patients are inadequately staged potentially confounding the interpretation of clinical data. The aim of this study was to determine whether adequate staging revealed different prognostic factors or improved survival compared with patients with <15 nodes examined after R0 resection for GEJ cancer. METHODS A prospectively maintained database identified 366 patients with Siewert types II and III adenocarcinoma of the GEJ who underwent R0 resection without neoadjuvant therapy at a single institution. Patients were grouped into adequately (>or=15 nodes examined) or inadequately staged (<15 nodes examined). Median follow up was 51 months. RESULTS From 1985 through 2003, 250/366 (68%) patients were adequately staged and 116/366 (32%) were inadequately staged. There was no difference in operative mortality between adequately staged (5.2%) and inadequately staged patients (4.3%, P = NS). Adequately staged patients had more positive lymph nodes (median 2) compared with inadequately staged patients (median 1, P < 0.01). Multivariable analysis of adequately staged patients found the number of positive lymph nodes, T stage, and lymphovascular invasion to be independent prognostic factors for overall survival (OS). For inadequately staged patients only the number of positive lymph nodes and T stage were independent prognostic factors. Adequate staging was an independent prognostic factor for patients with advanced (T >or= 2 Nany) tumors. For T1 tumors adequate staging was not associated with improved survival. CONCLUSIONS Patients with GEJ cancer should undergo adequate lymphadenectomy to permit examination of >or=15 lymph nodes allowing the accurate identification of prognostic variables. Removal of >or=15 lymph nodes is associated with more accurate survival estimates for patients with advanced disease.
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Affiliation(s)
- Andrew P Barbour
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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Lagarde SM, ten Kate FJW, Reitsma JB, Busch ORC, van Lanschot JJB. Prognostic factors in adenocarcinoma of the esophagus or gastroesophageal junction. J Clin Oncol 2006; 24:4347-55. [PMID: 16963732 DOI: 10.1200/jco.2005.04.9445] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The incidence of adenocarcinoma of the esophagus is rising rapidly in Western Europe and North America. It is an aggressive disease with early lymphatic and hematogenous dissemination. TNM cancer staging systems predict survival on the basis of the anatomic extent of the tumor. However, the adequacy of the current TNM staging system for adenocarcinoma of the esophagus or gastroesophageal junction (GEJ) is questioned repeatedly. Numerous prognostic factors have been described, but are not included in the TNM system. This review describes clinical parameters, aspects of operative technique, response to preoperative chemoradiotherapy therapy, complications and established pathologic determinants found in the resection specimen that have a prognostic impact. Furthermore, their potential application in the clinical setting in patients with adenocarcinoma of the esophagus or GEJ is discussed. Future directions to improve staging systems are given.
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Affiliation(s)
- Sjoerd M Lagarde
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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