Minimally invasive surgical staging is superior to endoscopic ultrasound in detecting lymph node metastases in esophageal cancer

Modified method to improve the diagnostic efficiency of 18F-FDG PET/CT in regional lymph node metastasis of esophageal squamous cell carcinoma

Background

Regional lymph node (LN) metastasis is a significant factor influencing the treatment choice of esophageal squamous cell carcinoma (ESCC). The performance PET/CT as an imaging evaluation method for regional LNs in ESCC, is unsatisfactory due to the lack of logical criterion. We explored how a modified criterion improved the diagnostic value of ¹⁸F-FDG PET/CT in regional LN metastasis.

Methods

The data from 111 patients with ESCC were analyzed retrospectively. All patients underwent preoperative PET/CT examination, resection of the cancer, and regional LN dissection. The PET/CT images were interpreted by two experienced diagnosticians. LNs were allocated to five subregions. Each LN was diagnosed by two diagnostic criteria of PET/CT (traditional criterion and the modified criterion) one by one across the same field, and the accuracy of PET/CT was determined using the histopathologic results as the reference standard.

Results

A total of 4,847 LNs were dissected, of which 147 were confirmed as metastases by postoperative pathology. A total of 656 LNs were screened by ¹⁸F-FDG PET/CT imaging. The determination of all 656 LNs by PET/CT was compared with the pathological results. The diagnostic accuracy of the modified and traditional criteria for the five subregions (paraesophageal, neck, upper mediastinal, middle-lower mediastinal and ventral subregions) was: 74.60% vs. 61.90%, 86.44% vs. 81.36%, 90.26% vs. 70.78%, 96.19% vs. 75.09%, and 87.91% vs. 85.71%, respectively.

Conclusions

The modified diagnostic criterion had better diagnostic efficiency because it combined PET and CT imaging data.

The Molecular Biologic Basis of Esophageal and Gastric Cancers

Esophageal cancer and gastric cancer are leading causes of cancer-related mortality worldwide. In this article, the authors discuss the molecular biology of esophageal and gastric cancer with a focus on esophageal adenocarcinoma. They review data from The Cancer Genome Atlas project and advances in the molecular stratification and classification of esophageal carcinoma and gastric cancer. They also summarize advances in microRNA, molecular staging, gene expression profiling, tumor microenvironment, and detection of circulating tumor DNA. Finally, the authors summarize some of the implications of understanding the molecular basis of esophageal cancer and future directions in the management of esophageal cancer.

Building CT Radiomics Based Nomogram for Preoperative Esophageal Cancer Patients Lymph Node Metastasis Prediction

PURPOSE: To build and validate a radiomics-based nomogram for the prediction of pre-operation lymph node (LN) metastasis in esophageal cancer. PATIENTS AND METHODS: A total of 197 esophageal cancer patients were enrolled in this study, and their LN metastases have been pathologically confirmed. The data were collected from January 2016 to May 2016; patients in the first three months were set in the training cohort, and patients in April 2016 were set in the validation cohort. About 788 radiomics features were extracted from computed tomography (CT) images of the patients. The elastic-net approach was exploited for dimension reduction and selection of the feature space. The multivariable logistic regression analysis was adopted to build the radiomics signature and another predictive nomogram model. The predictive nomogram model was composed of three factors with the radiomics signature, where CT reported the LN number and position risk level. The performance and usefulness of the built model were assessed by the calibration and decision curve analysis. RESULTS: Thirteen radiomics features were selected to build the radiomics signature. The radiomics signature was significantly associated with the LN metastasis (P<0.001). The area under the curve (AUC) of the radiomics signature performance in the training cohort was 0.806 (95% CI: 0.732-0.881), and in the validation cohort it was 0.771 (95% CI: 0.632-0.910). The model showed good discrimination, with a Harrell’s Concordance Index of 0.768 (0.672 to 0.864, 95% CI) in the training cohort and 0.754 (0.603 to 0.895, 95% CI) in the validation cohort. Decision curve analysis showed our model will receive benefit when the threshold probability was larger than 0.15. CONCLUSION: The present study proposed a radiomics-based nomogram involving the radiomics signature, so the CT reported the status of the suspected LN and the dummy variable of the tumor position. It can be potentially applied in the individual preoperative prediction of the LN metastasis status in esophageal cancer patients.

DVH- and NTCP-based dosimetric comparison of different longitudinal margins for VMAT-IMRT of esophageal cancer

Purpose

To cover the microscopic tumor spread in squamous cell carcinoma of the esophagus (SCC), longitudinal margins of 3–4 cm are used for radiotherapy (RT) protocols. However, smaller margins of 2–3 cm might be reasonable when advanced diagnostic imaging is integrated into target volume delineation. Purpose of this study was to compare the dose distribution and deposition to the organs at risk (OAR) for different longitudinal margins using a DVH- and NTCP-based approach.

Methods

Ten patients with SCC of the middle or lower third were retrospectively selected. Three planning target volumes (PTV) with longitudinal margins of 4 cm, 3 cm and 2 cm and an axial margin of 1.5 cm to the gross target volume (GTV) were defined for each patient. For each PTV two treatment plans with total doses of 41.4 Gy (neoadjuvant treatment) and 50.4 Gy (definite treatment) were calculated. Dose to the lungs, heart, myelon and liver were then evaluated and compared between different PTVs.

Results

When using a longitudinal margin of 3 cm instead of 4 cm, all dose parameters (Dmin, Dmean, Dmedian and V5-V35), except Dmax could be significantly reduced for the lungs. Regarding the heart, a significant reduction was seen for Dmean and V5, but not for Dmin, Dmax, Dmedian and V10-V35. When comparing a longitudinal margin of 4 cm to a longitudinal margin of 2 cm, a significant difference was calculated for Dmin, Dmean, Dmedian and V5-V35 of the lungs and for Dmax, Dmean and V5-V35 of the heart. Nevertheless, no difference was seen for median heart dose. An additional dose reduction for V10 of the heart was achieved for definite treatment plans when using a longitudinal margin of 3 cm. The NTCP-based risk of pneumonitis was significantly reduced by a margin reduction to 2 cm for neoadjuvant and definite treatment plans.

Conclusion

Reduction of longitudinal margins from 4 cm to 3 cm can significantly reduce the dose to lungs and Dmean of the heart. Despite clinical benefit and oncologic outcome remain unclear, reduction of the longitudinal margins might provide the opportunity to reduce side effects of chemoradiation (CRT) for SCC in upcoming studies.

Minimally invasive staging of esophageal cancer

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

The 100 most cited articles investigating the radiological staging of oesophageal and junctional cancer: a bibliometric analysis

Objectives

Accurate staging of oesophageal cancer (OC) is vital. Bibliometric analysis highlights key topics and publications that have shaped understanding of a subject. The 100 most cited articles investigating radiological staging of OC are identified.

Methods

The Thomas Reuters Web of Science database with search terms including “CT, PET, EUS, oesophageal and gastro-oesophageal junction cancer” was used to identify all English language, full-script articles. The 100 most cited articles were further analysed by topic, journal, author, year and institution.

Results

A total of 5,500 eligible papers were returned. The most cited paper was Flamen et al. (n = 306), investigating the utility of positron emission tomography (PET) for the staging of patients with potentially operable OC. The most common research topic was accuracy of staging investigations (n = 63). The article with the highest citation rate (38.00), defined as the number of citations divided by the number of complete years published, was Tixier et al. investigating PET texture analysis to predict treatment response to neo-adjuvant chemo-radiotherapy, cited 114 times since publication in 2011.

Conclusion

This bibliometric analysis has identified key publications regarded as important in radiological OC staging. Articles with the highest citation rates all investigated PET imaging, suggesting this modality could be the focus of future research.

Main Messages

• This study identifies key articles that investigate radiological staging of oesophageal cancer.

• The most common topic was accuracy of staging investigations.

• The article with the highest citation rate investigated the use of texture analysis in PET images.

Significance of tumor length as prognostic factor for esophageal cancer

Our study indicated the relationship between tumor length and clinicopathologic characteristics as well as long-term survival in esophageal cancer. A total of 116 patients who underwent curative surgery for thoracic esophageal cancer with standard lymphadenectomy in 2 fields between 2000 and 2010 were included in the study. The medical records of these patients were retrospectively reviewed. The patients with tumor length 3 cm had a highly significant difference in the involvement of adventitia and lymph node stations. The patients with tumor length 3 cm had significantly lower rates of involvement of the adventitia and lymph node stations. Tumor length could have a significant impact on both the overall survival and disease-free survival of patients with resected esophageal carcinomas and may provide additional prognostic value to the current tumor, node, and metastasis staging system before patients receive any cancer-specific treatment.

Minimally invasive surgery for esophageal cancer: review of the literature and institutional experience

BACKGROUND

Esophageal cancer represents a major public health problem in the world. Several minimally invasive esophagectomy (MIE) techniques have been described and represent a safe alternative for the surgical management of esophageal cancer in selected centers with high volume and surgeons experienced in minimally invasive procedures.

METHODS

The authors reviewed the most recent and largest studies published in the medical literature that reported the outcomes for MIE techniques.

RESULTS

In larger series, MIE has proven to be equivalent in postoperative morbidity and mortality to the open esophagectomy. However, MIE has been associated with less blood loss, reduced postoperative pain, decreased time in the intensive care unit, and shortened length of hospital stay compared with the conventional open approaches. Despite limited data, no significant difference in survival stage for stage has been observed between open esophagectomy and MIE.

CONCLUSIONS

The myriad of MIE techniques complicates the debate for defining the optimal surgical approach for the treatment of esophageal cancer. Randomized controlled trials comparing MIE with conventional open esophagectomy are needed to clarify the ideal procedure with the lowest postoperative morbidity, best quality of life after surgery, and long-term survival.

Imaging strategies in the management of oesophageal cancer: what's the role of MRI?

OBJECTIVES

To outline the current role and future potential of magnetic resonance imaging (MRI) in the management of oesophageal cancer regarding T-staging, N-staging, tumour delineation for radiotherapy (RT) and treatment response assessment.

METHODS

PubMed, Embase and the Cochrane library were searched identifying all articles related to the use of MRI in oesophageal cancer. Data regarding the value of MRI in the areas of interest were extracted in order to calculate sensitivity, specificity, predictive values and accuracy for group-related outcome measures.

RESULTS

Although historically poor, recent improvements in MRI protocols and techniques have resulted in better imaging quality and the valuable addition of functional information. In recent studies, similar or even better results have been achieved using optimised MRI compared with other imaging strategies for T- and N-staging. No studies clearly report on the role of MRI in oesophageal tumour delineation and real-time guidance for RT so far. Recent pilot studies showed that functional MRI might be capable of predicting pathological response to treatment and patient prognosis.

CONCLUSIONS

In the near future MRI has the potential to bring improvement in staging, tumour delineation and real-time guidance for RT and assessment of treatment response, thereby complementing the limitations of currently used imaging strategies.

KEY POINTS

• MRI's role in oesophageal cancer has been somewhat limited to date. • However MRI's ability to depict oesophageal cancer is continuously improving. • Optimising TN-staging, radiotherapy planning and response assessment ultimately improves individualised cancer care. • MRI potentially complements the limitations of other imaging strategies regarding these points.

Oesophageal carcinoma

Oesophageal carcinoma affects more than 450,000 people worldwide and the incidence is rapidly increasing. Squamous-cell carcinoma is the predominant form of oesophageal carcinoma worldwide, but a shift in epidemiology has been seen in Australia, the UK, the USA, and some western European countries (eg, Finland, France, and the Netherlands), where the incidence of adenocarcinoma now exceeds that of squamous-cell types. The overall 5-year survival of patients with oesophageal carcinoma ranges from 15% to 25%. Diagnoses made at earlier stages are associated with better outcomes than those made at later stages. In this Seminar we discuss the epidemiology, pathophysiology, diagnosis and staging, management, prevention, and advances in the treatment of oesophageal carcinoma.

Diagnosis and staging of cancer of the esophagus and esophagogastric junction

Esophageal/esophagogastric junction cancer staging in the 7th edition of the AJCC staging manual is data driven and harmonized with gastric staging. New definitions are Tis, T4, regional lymph node, N, and M. Nonanatomic characteristics (histopathologic cell type, histologic grade, cancer location) and TNM classifications determine stage groupings. Classifications before treatment define clinical stage (cTNM or ycTNM). Current best clinical staging modalities include endoscopic ultrasonography for T and N and CT/PET for M. Classifications at resection define pathologic stage (pTNM or ypTNM). Accurate pathologic stage requires communication/cooperation between surgeon and pathologist. Classifications are defined at retreatment (rTNM) and autopsy (aTNM).

Endoscopic tumor length is an independent prognostic factor in esophageal squamous cell carcinoma

PURPOSE

To investigate the impact of endoscopic esophageal tumor length on survival for patients with resected esophageal squamous cell carcinoma (ESCC).

METHODS

We retrospectively reviewed the clinicopathologic characteristics of 244 ESCC patients who underwent curative resection as the primary treatment at Taipei Veterans General Hospital between January 2000 and November 2010. The endoscopic tumor length was defined as a uniform measurement before completion of the esophagectomy. The impact of endoscopic tumor length on a patient's overall survival (OS) and disease-free survival (DFS) were assessed. A Cox regression model was used to identify prognostic factors.

RESULTS

The 1-, 3-, and 5-year OS rates were 81.2, 48.2, and 39.6%, respectively, with a median survival time of 18.0 months. The 1-, 3-, and 5-year DFS rates were 66.2, 34.7, and 32.4%, respectively, with a median DFS of 15.0 months. Endoscopic tumor length correlated with pathologic tumor length [Pearson correction (r)=0.621; P<0.001] Regression trees analyses suggested an optimum cutoff point of >4 cm to identify patients with decreased long-term survival. In multivariate survival analysis, endoscopic tumor length (more or less than 4 cm) remained an independent prognostic factor for both OS (P=0.006) and DFS (P=0.002).

CONCLUSIONS

Endoscopic tumor length could have a significant impact on both the OS and DFS of patients with resected ESCC and may provide additional prognostic value to the current tumor, node, and metastasis staging system before patients receive any cancer-specific treatment.

The role of FDG-PET and staging laparoscopy in the management of patients with cancer of the esophagus or gastroesophageal junction

The effort to improve outcomes in esophageal cancer has included attempts at improving staging and patient selection. 2-Deoxy-2-[(18)F]fluoro-Dglucose positron emission tomography (FDG-PET) has been extensively studied in this context and has been widely accepted as a staging tool. Its role in restaging or assessing therapeutic response is investigational and promising. Laparoscopy has also been studied as a means for improving staging, but its role may be limited in the era of PET. This article discusses the literature assessing these modalities, particularly with regard to the practical management of the patient in the clinic.

Long-term results of a phase II trial of neoadjuvant chemotherapy followed by esophagectomy for locally advanced esophageal neoplasm

BACKGROUND

Effective systemic therapy is considered essential to improve the outcome for patients with surgically resectable locally advanced esophageal carcinoma. We report the long-term results of our phase II study of neoadjuvant chemotherapy, followed by esophagectomy and adjuvant chemotherapy for potentially resectable esophageal carcinoma.

METHODS

Patients were staged with computed tomography scan (n = 70), endoscopic ultrasonography (n = 63), and laparoscopy with or without thoracoscopy (n = 70). The pretreatment stages were T2N0 (n = 1), T2N1 (n = 15), T3N0 (n = 13), and T3N1 (n = 41). Chemotherapy consisted of 2 or 3 cycles of cisplatin, 5-fluorouracil, and paclitaxel followed by esophagectomy and adjuvant chemotherapy. Patients were monitored for recurrence and survival.

RESULTS

A total of 70 patients were enrolled (66 adenocarcinoma, 4 squamous cell carcinoma; 64 men and 6 women; median age, 60 years). Esophagectomy was performed in 63 patients. Operative mortality was 0%. The median overall survival of the entire group was 27.4 months. Seventeen patients were alive at a median follow-up of 62.8 months (range, 39.1 to 142). Fourteen patients were alive without recurrence at a median follow-up of 79 months (range, 39 to 138). Nodal status was an important predictor of overall survival. Patients who were downstaged experienced a significantly improved median survival of 63.4 months versus 21.5 months and overall survival (p = 0.005).

CONCLUSIONS

This prospective study for esophageal carcinoma demonstrates encouraging long-term results. In particular, downstaging of the tumor with preoperative chemotherapy is predictive of better long-term outcome. Our results support the role for perioperative chemotherapy for locally advanced resectable esophageal cancer.

Resection for esophageal cancer: strategies for optimal management

There are several controversies in the optimal management of esophageal cancer, including the surgical approach, extent of resection, and the role of multimodality treatment. Optimal surgical treatment strategies include patient selection, accurate staging and risk assessment, selection of an appropriate surgical approach, and the use of multimodality treatment in the management of these patients. In addition, other factors such as hospital and surgeon volume are important in reducing the risks of esophagectomy. In this article we discuss our approach and review the literature on these aspects that have an impact on outcomes after esophagectomy.

Endoscopic ultrasound as a first test for diagnosis and staging of lung cancer: a prospective study

RATIONALE

Multiple tests are required for the management of lung cancer.

OBJECTIVES

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) was evaluated as a single test for the diagnosis and staging (thoracic and extrathoracic) of lung cancer.

METHODS

Consecutive subjects with computed tomography (CT) findings of a lung mass were enrolled for EUS and results were compared with those from CT and positron emission tomography scans.

RESULTS

Of 113 subjects with lung cancer, EUS was performed as a first test (after CT scan) for diagnosis in 93 (82%) of them. EUS-FNA established tissue diagnosis in 70% of cases. EUS-FNA, CT, and positron emission tomography detected metastases to the mediastinal lymph nodes with accuracies of 93, 81, and 83%, respectively. EUS-FNA was significantly better than CT at detecting distant metastases (accuracies of 97 and 89%, respectively; p = 0.02). Metastases to lymph nodes at the celiac axis (CLNs) were observed in 11% of cases. The diagnostic yields of EUS-FNA and CT for detection of metastases to the CLNs were 100 and 50%, respectively (p < 0.05). EUS was able to detect small metastases (less than 1 cm) often missed by CT. Metastasis to the CLNs was a predictor of poor survival of subjects with non-small cell lung cancer, irrespective of the size of the CLNs. Of 44 cases with resectable tumor on CT scan, EUS-FNA avoided thoracotomy in 14% of cases.

CONCLUSIONS

EUS-FNA as a first test (after CT) has high diagnostic yield and accuracy for detecting lung cancer metastases to the mediastinum and distant sites. Metastasis to the CLNs is associated with poor prognosis. EUS-FNA is able to detect occult metastasis to the CLNs and thus avoids thoracotomy.

The impact of endoscopic ultrasound and computed tomography on the TNM staging of early cancer in Barrett's esophagus

INTRODUCTION

Computed tomography (CT) and endoscopic ultrasound (EUS) are part of the regular staging protocol in esophageal cancer. The value of the two methods was assessed in patients with early cancer in Barrett's esophagus.

METHODS

One hundred consecutive patients (median age 64 yr, interquartile range [IQR] 58-72) with suspected early cancer in Barrett's esophagus who were referred to our hospital for endoscopic therapy were prospectively included in a standardized staging program with upper gastrointestinal endoscopy, EUS (7.5 MHz in all cases plus 12.5 or 20 MHz for elevated and/or depressed lesions), CT of the chest and upper abdomen, and abdominal ultrasonography. The results were summarized in accordance with the TNM classification. On the basis of the lymph node findings on CT and/or EUS, the patients were assigned to three categories: C1, no suspicious lymph nodes; C2, paraesophageal lymph nodes < or =1 cm in size at the tumor level, lymph nodes > or =1 cm in size not at the tumor level in the mediastinum or celiac trunk; and C3, paraesophageal lymph nodes > 1 cm in size at the tumor level. The EUS and CT findings were checked every 6 months in patients who underwent endoscopic treatment. Surgical resection was scheduled in operable patients if staging showed a T category higher than T1 and/or the lymph node staging was assessed as C3. Patients with suspected submucosal infiltration underwent diagnostic endoscopic resection, and if submucosal involvement was confirmed were referred for surgery.

RESULTS

The median follow-up period was 25 months (IQR 19.5-30.0). The T category diagnosed with CT was < or = T1 in all patients. On EUS, the T category was classified as T1 in 92% of cases (N = 92) and as > T1 in 8% (N = 8, p < 0.05). Enlarged lymph nodes (C2 and C3) were detected in 45% of the patients. Significantly more C2 lymph nodes were diagnosed with EUS than CT (28 vs 19, p < 0.05). Lymph nodes at the level with the highest suspicion, C3, were detected using CT in only three of nine cases. Sensitivity of CT for N staging was not acceptable compared with EUS (38%vs 75%). No extranodal metastases were found on CT.

CONCLUSIONS

In suspected early cancer in Barrett's esophagus, EUS is superior to CT for T staging and N staging. As CT had no influence on the TNM classification in any of these patients, it may be possible to dispense with this method as a staging procedure in patients with cancer in Barrett's esophagus. By contrast, EUS is required in order to differentiate between patients with cancer in Barrett's esophagus in whom endoscopic therapy is suitable and those in whom surgical treatment is required.

EUS staging of upper GI malignancies: results of a prospective randomized trial

BACKGROUND

Electronic 270 degrees transverse-array EUS (TA-EUS) provides high-quality cross-sectional images but cannot guide FNA. Linear EUS (L-EUS) provides longitudinal images of malignancies and the ability to guide FNA.

OBJECTIVE

We conducted a prospective randomized comparison of TA-EUS and L-EUS for the staging of upper-GI (UGI) malignancies.

DESIGN

Forty-three patients underwent L-EUS immediately followed by TA-EUS (N = 27, 63%) or TA-EUS immediately followed by L-EUS (N = 16, 37%).

PATIENTS

Forty-three subjects (mean age, 64 years; 37 men) with an UGI malignancy (4 stomach and 38 esophageal) were evaluated with both TA-EUS and L-EUS.

INTERVENTIONS

Abnormal lymph nodes were sampled by FNA for cytology.

RESULTS

There was agreement on the T stage by linear and radial techniques in 38 of 43 subjects (88%). Twenty-seven of 43 patients (63%) had abnormal lymph nodes by linear or transverse-array imaging. L-EUS demonstrated 66 abnormal lymph nodes in 27 subjects (average of 2.4 nodes/subject). TA-EUS demonstrated 90 abnormal lymph nodes in 27 subjects (average of 3.3 nodes/subject, P = .009, compared with L-EUS). In 16 of the 27 subjects, an FNA was performed, which was positive in 13 cases (81%) and negative in 3 cases (10%) for malignancy.

CONCLUSIONS

TA-EUS and L-EUS provide similar results of T staging of UGI malignancies. However, the number of abnormal lymph nodes detected by TA-EUS was more than by L-EUS. These findings suggest that radial or transverse-array EUS imaging should be the primary method for staging of UGI malignancies.

Surgical treatment of superficial esophageal cancer

OBJECTIVE

The worldwide incidence of superficial esophageal cancer (SEC) is increasing. The aim of this study is to review the systematic surgical outcomes of esophagectomy for SEC.

DATA SOURCES

Only manuscripts written in English and written between 1980 and 2003 were selected from MEDLINE. The keywords consisting of superficial esophageal cancer, early esophageal cancer, and early stage or superficial stage or stage I in esophageal cancer were searched.

STUDY SELECTION

There were no exclusion criteria for published information relevant to the topics. The most representative articles were selected when there were several articles from the same institution. Case reports were excluded. DATA EXTRACTIONS: Thirty-two manuscripts were finally collected from MEDLINE and eight articles were also added from reference lists of the pertinent literatures. In evaluating the statistical analysis of the complications of the reported literature, collective method was used.

DATA SYNTHESIS

The collected information was organized.

CONCLUSIONS

The conclusions drawn from those articles showed that the overall prevalence of SEC accounted around 10% and increased to 25% in the 2000s. The overall incidence of lymph node metastasis of SEC was about 25% and its incidences in mucosal and submucosal cancer were 5 and 35%, respectively. The percentage of the cases of squamous cell carcinoma (SCC) vs adenocarcinoma (AC) widely varied depending on the geographic locations reported; most SCC cases were from the Asian countries and most AC cases were from the European countries. Clinical significance of multimodal treatment for SEC has dramatically developed in the recent era and could provide various potential therapeutic options for SEC. These concepts make it possible to individualize surgical management of SEC as part of various multimodal treatments. The operative approaches for SEC varied from minimally invasive thoracoscopic esophagectomy, limited transabdominal distal esophagectomy, conventional transthoracic esophagectomy, transhiatal esophagectomy without thoracotomy, en bloc esophagectomy, and to extended esophagectomy with a complete three-field lymph node dissection. A 5-year overall survival rate of SEC after esophagectomy was good (46 to 83%) to excellent (71 and 100%) for mucosal SEC, but far from satisfactory (33 and 78%) for submucosal SEC. Early diagnosis, development of multimodal treatment, standardization of the surgical procedure including routine lymph node dissection, and improved perioperative management of patients have led to a better survival for patients with SEC.

Present state of the Mini-Invasive Surgery (MIS) in esophageal and gastric cancer

The purpose of this review is to stress the role of the Mini-Invasive Surgery (MIS) in the treatment of the esophagogastric malignant illnesses, supporting ourselves on the most relevant publications of the literature as well as on our own experience in this subject. In short, although no randomised prospective study has proven the MIS advantages in relation to the traditional surgery in the esophagectomy due to cancer, some authors preferently indicate this approach to selected and informed enough patients, who present the following: - High grade dysplasia, preferently choosing from laparoscopic transhiatal esophagectomy (LTE). - Carcinoma in situ, preferently choosing the LTE vs thoracoscopy. - Esophageal tumour locally advanced, in resectable patients with contraindication for a thoracotomy or, in initially non-resectable patients with tumoral reduction after neo-adjuvant chemo-radiotherapy. The arguments given by the authors are the postoperative spectacular improvement in relation to the comfort and quality of life and, the absence of oncological negative effects in the long-term followup. Concerning gastric cancer, the MIS, as exeresis surgical tool in the so-called <<advanced>> gastric forms, is such a definite and oncological approach as the traditional approach, and superior to this as far as quality of life is concerned. When the MIS is used for treating locally advanced forms of gastric cancer, it is as safe as the laparotomic way and it seems to obtain the same oncological outcomes in the long-term.

Staging in oesophageal cancer

Accurate staging defines groups for stage-specific treatment, minimising inappropriate treatment. Application of dedicated staging methods - including 16-64 multidetector computed tomography (CT), endoscopic ultrasonography with fine-needle aspiration (EUS-FNA) and positron emission tomography (PET) - results in better staging of oesophageal cancer. PET as a metabolic imaging technique that is usually applied after (or recently in combination with) CT (PET/CT) improves the accuracy of non-invasive staging, especially in locally advanced oesophageal cancer patients. Whether EUS-FNA or PET/CT should be performed as a first diagnostic step is still a matter of debate. Fluoro-2-deoxyglucose (FDG) PET is also promising tool in assessing neoadjuvant treatment response. Application of these dedicated staging methods has a learning curve, suggesting a prominent role for centralisation.

Immediate preoperative laparoscopic staging for squamous cell carcinoma of the esophagus

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Preoperative evaluation of prognostic factors in esophageal squamous cell cancer]

Despite substantial improvements in the surgical therapy of esophageal squamous cell cancer, the prognosis still remains poor. This is mainly due to locally advanced tumors (T3-4, N+) or systemic metastases (M1) in the majority of patients at initial presentation. It is of the utmost importance to reliably detect relevant pretherapeutic prognostic indicators for optimal individual therapeutic strategies. Pretherapeutic prognostic indicators should therefore discriminate precisely between incurable and potentially curative disease. Preoperative or definitive multimodal treatment is increasingly being offered to patients with locally advanced tumors and opens a broad field for innovative techniques such as pretherapeutic molecular response prediction or early response detection by PET scan to further individualize and optimize treatment strategies.

Plasma D-dimer levels show correlation with number of lymph node metastases in patients with esophageal cancer

BACKGROUND

Systemic activation of hemostasis and fibrolysis has been shown to be related to tumor progression in patients with malignancies such as lung cancer and colorectal cancer, but there has been no report of these clotting abnormalities in esophageal cancer. We investigated the clinical importance of measuring plasma levels of D-dimer (DD), which is a marker of the hypercoagulable stage, in preoperative patients with esophageal cancer.

STUDY DESIGN

Preoperative plasma DD levels were measured in 96 patients with primary esophageal cancer who were scheduled for esophagectomy with lymphadenectomy without preoperative treatment at our hospital. Results were correlated with the clinicopathological findings.

RESULTS

Significantly different plasma DD levels were found with respect to histologic T (p = 0.0015), histologic N (p < 0.0001), number of metastatic nodes (p < 0.0001), and histologic stages (p < 0.0001). The number of lymph node metastases (0/1 to 3/4 to 7/8-) was found to have the strongest association with DD level among the significant clinicopathologic factors (Spearman rank correlation 0.591, p < 0.0001). The most useful cut-off level of the plasma DD levels for diagnosis of lymph node metastasis was determined to be 0.4 microg/mL, with specificity and sensitivity for lymph node metastasis being 62.9% and 88.2%, respectively.

CONCLUSIONS

Plasma DD levels are useful for assessing lymph node metastasis in patients with esophageal cancer and should be measured preoperatively.

Current staging of esophageal carcinoma

The rational treatment of esophageal cancer requires the complete evaluation and preoperative staging of this disease. As the incidence of esophageal cancer increases, more clinicians will face the difficult task of allocating the appropriate treatment course for these patients. Accurate esophageal cancer staging is critical if stage-dependent algorithms are used to direct appropriate therapies. Although all of the staging techniques discussed may potentially provide useful information, it is not possible to use all techniques in all patients, especially given the limited availability of resources. The optimal staging strategy has not yet been determined; the authors provide the general algorithm used in our institution. Ultimately,minimally invasive surgical approaches will allow surgeons to evaluate locoregional disease with little or no procedure-associated morbidity, much as mediastinoscopy is used in lung cancer staging. Although currently the use of molecular biologic techniques may only be investigational, it holds great promise in the future.

Minimally invasive esophagectomy

Minimally invasive esophagectomy can be safely performed in selected cases in centers specializing in minimally invasive esophageal surgery.Potential benefits include lessened physiologic insult, with decreased hospital stay and a more rapid recovery to full activity. Drawbacks include the cost of the disposable instrumentation and the steep learning curve. As thoracic surgeons continue to acquire expertise with this procedure, improved results may be expected. Prospective trials with longer follow-up will be required to confirm any advantages of MIE over conventional approaches. Open surgical approaches should remain the standard operation for esophagectomy in most institutions.

Advanced esophageal cancer

Although the prognosis for patients with early cancer is good, throughout the world the majority of patients present with advanced disease, and in them, survival is poor. Accurate staging is essential to inform prognosis; to select candidates who may be cured by surgery alone; to select patients requiring neoadjuvant therapy, especially when new protocols are being studied; and to detect patients with advanced disease who would be best served by palliative therapy.

Minimally invasive esophagectomy: outcomes in 222 patients

OBJECTIVE

To assess our outcomes after minimally invasive esophagectomy (MIE).

SUMMARY BACKGROUND DATA

Esophagectomy has traditionally been performed by open methods. Results from most series include mortality rates in excess of 5% and hospital stays frequently greater than 10 days. MIE has the potential to improve these results, but only a few small series have been reported. This report summarizes our experience of 222 cases.

METHODS

From 1996 to 2002, MIE was performed in 222 patients. Indications for operation included high-grade dysplasia (n = 47) and cancer (n = 175). Neoadjuvant chemotherapy was used in 78 (35.1%) and radiation in 36 (16.2%). Initially, a laparoscopic transhiatal approach was used (n = 8), but subsequently our approach evolved to include thoracoscopic mobilization (n = 214).

RESULTS

There were 186 men and 36 women. Median age was 66.5 years (range, 39-89). Nonemergent conversion to open procedure was required in 16 patients (7.2%). MIE was successfully completed in 206 (92.8%) patients. The median intensive care unit stay was 1 day (range, 1-30); hospital stay was 7 days (range, 3-75). Operative mortality was 1.4% (n = 3). Anastomotic leak rate was 11.7% (n = 26). At a mean follow-up of 19 months (range, 1-68), quality of life scores were similar to preoperative values and population norms. Stage specific survival was similar to open series.

CONCLUSIONS

MIE offers results as good as or better than open operation in our center with extensive minimally invasive and open experience. In this single institution experience, we observed a lower mortality rate (1.4%) and shorter hospital stay (7 days) than most open series. Given these results, we are now developing an intergroup trial (ECOG 2202) to assess MIE in a multicenter setting.

Prospective Analysis of Accuracy of Positron Emission Tomography, Computed Tomography, and Endoscopic Ultrasonography in Staging of Adenocarcinoma of the Esophagus and the Esophagogastric Junction

BACKGROUND

Exact preoperative staging of esophageal cancer is essential for accurate prognosis and selection of appropriate treatment modalities.

METHODS

Forty-two patients with adenocarcinoma of the esophagus or the esophagogastric junction suitable for radical esophageal resection were staged with positron emission tomography (PET), spiral computed tomography (CT), and endoscopic ultrasonography (EUS).

RESULTS

Diagnostic sensitivity for the primary tumor was 83% for PET and 67% for CT; for local peritumoral lymph node metastasis, it was 37% for PET and 89% for EUS; and for distant metastasis, it was 47% for PET and 33% for CT. Diagnostic specificity for local lymph node metastasis was 100% with PET and 54% with EUS, and for distant metastasis, it was 89% for PET and 96% for CT. Accuracy for locoregional lymph node metastasis was 63% for PET, 66% for CT, and 75% for EUS, and for distant metastasis, it was 74% with PET and 74% with CT. Of the 10 patients who were considered inoperable during surgery, PET identified 7 and CT 4. The false-negative diagnoses of stage IV disease in PET were peritoneal carcinomatosis in two patients, abdominal para-aortic cancer growth in one, metastatic lymph nodes by the celiac artery in four, and metastases in the pancreas in one. PET showed false-positive lymph nodes at the jugulum in three patients.

CONCLUSIONS

The diagnostic value of PET in the staging of adenocarcinoma of the esophagus and the esophagogastric junction is limited because of low accuracy in staging of paratumoral and distant lymph nodes. PET does, however, seem to detect organ metastases better than CT.

Gamma camera coincidence imaging with [18F]fluorodeoxyglucose in the pretreatment evaluation of patients with oesophageal cancer

This study investigated the role of [18F]fluorodeoxyglucose (FDG) dual-head gamma camera coincidence imaging (GCI) in the pretreatment evaluation of patients with oesophageal cancer. Twenty-two patients (20 men; mean age, 64 years) with untreated, biopsy proven squamous cell carcinoma of the oesophagus underwent positron emission tomography (PET) and GCI 1 and 3 h after a single injection of FDG, respectively. Computed tomography (CT) was performed within 2 weeks of the FDG imaging. The sensitivity of lesion detection was compared between GCI and PET. Regional (N) and distant (M) metastases detected by GCI were evaluated with reference to PET and CT. The staging obtained by each modality was also compared with pathological staging in nine patients who underwent surgery. FDG PET detected 22 primary tumours, 34 metastatic lymph nodes and four organ metastases. Of them, GCI detected all primary tumours, 24 (71%) metastatic lymph nodes, and none of the organ metastases. Lymph nodes missed by GCI were smaller in size and the majority of them were located in the thoracic region. GCI provided N and M staging identical to CT and PET in eight patients and improved staging over CT in four patients. On the other hand, GCI missed metastases detected by both PET and CT in five patients. The addition of GCI to CT could improve detection of patients with metastasis to 82% (18/22) compared with 64% (14/22) detected by CT alone. In patients with pathological staging (n = 9), GCI could influence management changes in two patients (22%). In conclusion, FDG GCI has a role that is complementary to CT in the initial staging of patients with oesophageal cancer, and due to the additional detection of nodal metastasis, GCI can provide staging information, which may influence changes in management.

[Surgery for oesophageal cancer: current controversies]

Any attempt to define the present role of surgery in the treatment of oesophageal cancer should integrate the dramatic changes that occurred within this disease over the last 2 decades: major shift in the histologic type of tumours, improved staging methods, spectacular reduction of operative risks, standardization of oncologic principles focusing on the completeness of resection, and development of multimodality therapeutic strategies. Surgery has still a pivotal role. Esophagectomy should be performed by trained surgeons in high-volume institutions. Radical surgery with en-bloc resection and 2 fields lymphadenectomy, should be encouraged in low-risk patients with subcarinal tumors. Although multimodality treatment strategy is commonly applied for locally advanced disease, few data support its superiority over surgical resection alone, followed by adjuvant therapy when appropriate. One may thus hypothesize that the risk/benefit ratio of such strategies is probably optimal in case of early stage tumors, and future studies may further clarify this issue. Conversely, locally advanced tumors, particularly those located in the upper mediastinum and the neck, may be managed alternatively without surgery. However, surgery remains an important tool to ensure optimal palliation of dysphagia, to achieve local control, and finally to improve quality of life. In that way, video-assisted techniques and/or trans hiatal approaches aiming to minimize the surgical insult may have a place in the treatment of patients who have substantially responded to induction therapy. Tumors located close to the pharyngo-oesophageal junction are best managed with chemotherapy and radiotherapy. Finally, salvage surgery may be considered in highly selected patients in case of non-response or local relapse without distant metastases.

Surgical management of esophageal malignancy

Esophageal carcinoma is a highly lethal disease with increasing prevalence and an equally dramatic epidemiologic shift. Its causal association with gastroesophageal reflux disease and adenocarcinoma of the esophagus is well established, and the molecular events underlying this progression from mucosal injury to metaplasia to dysplasia to carcinoma are now becoming clear. Current diagnostic modalities and preoperative staging systems have significant limitations. The extent of surgical resection for esophageal carcinoma remains controversial. Disease confined to the mucosa and submucosa is more common, and endoscopic ablative techniques have been proposed. However, preoperative evaluation of tumor depth and regional nodal metastases remains inadequate in these very early lesions and urges caution before adoption of therapies that may compromise cure. Patients with disease confined to the mucosa or submucosa should undergo resectional therapy aimed at removing the entire esophageal wall, including the periesophageal and perihiatal lymph nodes. For disease penetrating the submucosa, the extent of surgical therapy must be tailored to the objectives of treatment (cure vs palliation) and preoperative stage. Although data from seven prospective, randomized trials are encouraging, no clear survival benefit has been documented for neoadjuvant combined-modality therapy. Surgical resection remains the standard of care and best chance for cure in the treatment of esophageal malignancy, with combined-modality therapy reserved for prohibitive surgery candidates.

New techniques for staging esophageal cancer

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

Multimodality therapy for esophageal cancer

Esophageal cancer is undergoing a major shift in its epidemiology. Its incidence is dramatically growing and it more commonly affects younger and healthier patients. Based on the published data, there is no strong evidence to recommend routine preoperative chemotherapy for the treatment of surgically resectable esophageal carcinoma. It might be that a large-scale randomized study-which will be published in the near future-will shed some different light on this subject. The role of preoperative CRT remains undetermined. To settle this issue, larger, clinical, controlled trials are needed. Improvement in the preoperative regimen and use of new drugs should be evaluated. Concomitant CRT should be considered for potential benefit in survival and local control in patients who have localized disease and are candidates for radical non-surgical treatment. Patients with pCR following neoadjuvant therapy have a consistent, substantial survival benefit. Biologic markers can be used to predict response to therapy and might allow designation of treatment based on the individual tumor. Pretreatment staging is necessary for standardization of patients undergoing treatment protocols and for outcome evaluation. Pretreatment staging will be even more important in the future for adjusting treatment to individual patient. Video-assisted thoracoscopy and laparoscopy have been found to be the most accurate lymph node staging techniques.

State of the art in thoracospic surgery: a personal experience of 2000 videothoracoscopic procedures and an overview of the literature

BACKGROUND

Herein we compare our personal experience with a series of > 2000 videothoracoscopic procedures with those reported in the literature to identify the procedures now accepted as the gold standard, those still regarded as investigational, and those considered unacceptable.

METHODS

Between June 1991 and December 2000, we performed 2068 videothoracoscopic procedures, including lung cancer staging (n = 910), wedge resections (n = 261), lobectomies (n = 221), pneumonectomies (n = 6), the diagnosis and treatment of pleural diseases (n = 200), the treatment of pneumothorax (n = 170), giant bullae (n = 57), lung volume reduction surgery (LVRS) for emphysema (n = 41), the diagnosis and treatment of mediastinal diseases (n = 133), the treatment of esophageal diseases (n = 39), and 30 other miscellaneous procedures.

RESULTS

A review of the literature indicates that videothoracoscopy is usually considered the preferred approach for the treatment of spontaneous pneumothorax, the diagnosis of indeterminate pleural effusions, the treatment of malignant pleural effusions, sympathectomy, and the diagnosis and treatment of benign esophageal or mediastinal diseases. The videoendoscopic approach to LVRS for emphysema is still under evaluation. Videothoracoscopic wedge resections for the diagnosis of indeterminate nodules and the treatment of primary lung cancer, metastases, and other malignancies are still controversial due to oncologic concerns. Videoendoscopic major pulmonary resections are usually considered investigational or even unacceptable due to oncologic concerns, technical difficulties, and the risk of complications.

CONCLUSIONS

Although we generally agree with the foregoing recommendations, we consider videoendoscopy the best approach for LVRS and particularly useful for the staging of lung cancer, where we always perform it as the first step of the operation. We widely perform videoendoscopic major pulmonary resections, but we believe that these procedures should only be used in strictly selected cases and at specialized centers.

Multimodality therapy for resectable cancer of the thoracic esophagus

The frequency of esophageal carcinoma continues to increase in North America primarily because of the increased incidence of Barrett's epithelium in the distal esophagus and its malignant potential. Aggressive treatments involving multimodality therapies have been offered to improve overall poor survival rates. A review of this experience follows, to explain the rationale and to compare results of therapies. Although preoperative chemoradiation therapy is commonly used for locally advanced disease, few data support its superiority over surgical resection alone, followed by adjuvant therapy when appropriate. Hence this regimen should be limited to patients enrolled in controlled, randomized studies until the data support its widespread use.

Cancer of the esophagus and gastro-esophageal junction: potentially curative therapies

The definition of potential curative tumors of the esophagus and gastro-esophageal junction remains problematic. This is due to a lack of accuracy in clinical staging despite recent advances in CT, endoscopic ultrasonography (EUS), positron emission tomography scan and minimally invasive staging modalities. As a result much controversy persists regarding indications for surgery and extent of resection and lymphadenectomy. Today surgery with curative option results in five-year survival of over 30%. Multimodality regimens, especially neoadjuvant chemoradiotherapy, seem to be beneficial in patients with a complete response on pathologic staging. Other indications are investigational and should be studied within carefully monitored study protocols. In early carcinoma T(is)-T(1a) endoluminal ablation technique seem to open promising perspectives provided of discrimination between T(is)-T(1a) and T(1b) can be made by the use of 20mhz EUS probes.