Indications for three-field dissection followed by esophagectomy for advanced carcinoma of the thoracic esophagus

Three-field versus two-field lymphadenectomy for esophageal squamous cell carcinoma: A long-term survival meta-analysis

BACKGROUND

In the setting of esophageal squamous cell carcinoma, controversy exists regarding the optimal extent of lymphadenectomy, while conclusive evidence regarding the advantages of 3-field versus 2-field lymphadenectomy remains controversial. The purpose of the present meta-analysis was to investigate the effect of 3-field lymphadenectomy versus 2-field lymphadenectomy on overall survival.

METHODS

Systematic review and meta-analyses were computed to compare 3-field lymphadenectomy versus 2-field lymphadenectomy in the setting of esophageal squamous cell carcinoma. Risk ratio, weighted mean difference, hazard ratio, and restricted mean survival time difference were used as pooled effect size measures.

RESULTS

Fourteen studies (3,431 patients) were included. Overall, 1,664 (48.8%) patients underwent 3-field lymphadenectomy, and 1,767 (51.5%) underwent 2-field lymphadenectomy. Three-field lymphadenectomy was associated with a significantly improved 5-year overall survival (hazard ratio: 0.80; 95% confidence interval 0.71-0.90; P < .001). The restricted mean survival time difference showed a statistically significant difference between 3-field lymphadenectomy versus 2-field lymphadenectomy up to 48 months (1.6 months; P = .04), however, no significant differences were found at 60-month follow-up (1.2 months; P = .14). No significant differences were found in term of postoperative mortality, anastomotic leak, pulmonary complications, chylothorax, and recurrent nerve palsy.

CONCLUSION

For resectable esophageal squamous cell carcinoma, 3-field lymphadenectomy seems associated with a slight trend toward improved 5-year overall survival; however, its clinical benefit remains limited.

Meta-analysis of prognostic factors of overall survival in patients undergoing oesophagectomy for oesophageal cancer

INTRODUCTION

Currently, the American Joint Commission on Cancer (AJCC) staging system is used for prognostication for oesophageal cancer. However, several prognostically important factors have been reported but not incorporated. This meta-analysis aimed to characterize the impact of preoperative, operative, and oncological factors on the prognosis of patients undergoing curative resection for oesophageal cancer.

METHODS

This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling to determine pooled univariable hazard ratios (HRs). The study was prospectively registered with the PROSPERO database (Registration: CRD42018157966).

RESULTS

One-hundred and seventy-one articles including 73,629 patients were assessed quantitatively. Of the 122 factors associated with survival, 39 were significant on pooled analysis. Of these. the strongly associated prognostic factors were 'pathological' T stage (HR: 2.07, CI95%: 1.77-2.43, P < 0.001), 'pathological' N stage (HR: 2.24, CI95%: 1.95-2.59, P < 0.001), perineural invasion (HR: 1.54, CI95%: 1.36-1.74, P < 0.001), circumferential resection margin (HR: 2.17, CI95%: 1.82-2.59, P < 0.001), poor tumor grade (HR: 1.53, CI95%: 1.34-1.74, P < 0.001), and high neutrophil:lymphocyte ratio (HR: 1.47, CI95%: 1.30-1.66, P < 0.001).

CONCLUSION

Several tumor biological variables not included in the AJCC 8th edition classification can impact on overall survival. Incorporation and validation of these factors into prognostic models and next edition of the AJCC system will enable personalized approach to prognostication and treatment.

Three-Field versus Two-Field Lymphadenectomy for Esophageal Squamous Cell Carcinoma: A Meta-analysis

BACKGROUND

Most surgeons now accept lymphadenectomy as an essential feature of the operative treatment of esophageal squamous cell carcinoma. Three-field and two-field lymphadenectomy are two of the most popular excision scopes among surgeons. Over recent years, researchers have performed a range of comparative studies regarding these techniques, although the conclusions remain inconsistent.

METHOD

We systematically retrieved the records of PubMed, Embase, The Cochrane Library, and ClinicalTrials.gov until October 2019 and performed preliminary and full-text screening of the articles. We used the NOS scale to evaluate the quality of the enrolled studies, with only medium- and high-quality studies included. Review Manager 5.3 and Stata15 were used for the meta-analysis.

RESULTS

A total of eight studies involving 1676 patients were included in the meta-analysis. The results showed that for esophageal squamous cell carcinoma using with two-field and three-field lymphadenectomy, although three-field lymphadenectomy led to the gaining of a higher number of lymph nodes, there were no significant differences between the two in terms of the number of positive lymph nodes and overall survival. Three-field lymphadenectomy also caused higher levels of intraoperative blood loss and higher morbidity of the anastomotic fistula. No significant differences in operation time, recurrent laryngeal nerve injury, pneumonia, chylothorax, anastomotic stenosis, ileus, cervical nodal recurrence and hospital mortality were observed.

CONCLUSIONS

According to our meta-analysis, two-field lymphadenectomy is recommended as a first-choice surgical treatment for esophageal squamous cell carcinoma. However, since the results showed a risk of bias, they should be treated with caution.

Stage-directed individualized therapy in esophageal cancer

Esophageal cancer is the eighth most common cancer worldwide, and the incidence of esophageal carcinoma is rapidly increasing. With the advent of new staging and treatment techniques, esophageal cancer can now be managed through various strategies. A good understanding of the advances and limitations of new staging techniques and how these can guide in individualizing treatment is important to improve outcomes for esophageal cancer patients. This paper outlines the recent progress in staging and treatment of esophageal cancer, with particularly attention to endoscopic techniques for early-stage esophageal cancer, multimodality treatment for locally advanced esophageal cancer, assessment of response to neoadjuvant treatment, and the role of cervical lymph node dissection. Furthermore, advances in robot-assisted surgical techniques and postoperative recovery protocols that may further improve outcomes after esophagectomy are discussed.

Therapeutic efficacy evaluation of postoperative adjuvant radiotherapy in mid-thoracic esophageal carcinoma patients underwent Ivor Lewis esophagectomy with two-field lymphadenectomy

The objective of this paper is to study the treatment outcome of postoperative adjuvant radiation therapy in Ivor Lewis esophagectomy with two-field lymphadenectomy (2FL) and evaluate whether the method can replace three-field lymphadenectomy (3FL). We collected a consecutive series of 503 patients who had undergone Ivor Lewis esophagectomy with 2FL over a seven-year period in our department and evaluated the therapeutic efficacy of postoperative adjuvant radiation therapy. Recurrence and survival rates were calculated with the Kaplan-Meier method, and the differences were compared by the log-rank test. Logistic regression analysis was used to test risk factors for postoperative lymph node metastasis. Cox regression analysis was used to identify prognostic risk factors. The overall 3- and 5-year survival rates were 62.8 and 34.4 %, respectively. There was a significant difference in 5-year survival rate between patients received adjuvant radiation therapy and did not receive radiation therapy. Postoperative adjuvant radiation therapy for patients who underwent Ivor Lewis esophagectomy with 2FL may offer the patients significant survival benefits and reduces the incidence of recurrence in cervical and superior mediastinal lymph nodes.

The impact of the number of occult metastatic lymph nodes on postoperative relapse of resectable esophageal cancer

Clinical stage II/III esophageal cancer (EC), as defined by the Japanese Classification, relapses at a moderately high rate even after curative resection. The number of lymph node metastases is known to be associated with tumor relapse. Recently, the prognostic significance of occult metastatic lymph nodes (MLNs), as well as that of overt MLNs, has been reported. The aim of this study was to investigate the impact of the total number of MLNs including occult MLNs on postoperative relapse in clinical stage II/III EC. One hundred and five patients with clinical stage II/III EC who underwent esophagectomy accompanied by radical lymphadenectomy at the Department of Surgical Oncology in Osaka City University Hospital between January 2000 and October 2008 were included in this study. Occult MLNs, metastases not detected by hematoxylin-eosin staining, were identified by immunohistochemistry (IHC) using antipancytokeratin antibody AE1/AE3. The clinicopathological features of occult MLNs were compared between the relapse and no relapse groups. A total of 6558 lymph nodes (1357 from two-field dissection and 5201 from three-field dissection) were examined by IHC staining; 362 overt MLNs and 143 occult MLNs were detected. The number of occult MLNs increased in proportion to the International Union Against Cancer pathological (p)N-status and pStage. When the number of occult MLNs was added to the number of pNs, the number of total MLNs was associated with postoperative relapse. With respect to tumor, node, metastasis stage, 6 of 22 patients (27%) who were pathological node-negative converted to node-positive by considering total MLNs. The number of N3 patients with relapse increased markedly with restaging by total MLNs. The number of total MLNs, but not overt MLNs, was an independent prognostic factor on multivariate analysis. These results suggest that occult MLNs were often found, and they were associated with postoperative relapse of resectable esophageal cancer. The total number of MLNs including occult MLNs could contribute to evaluating the precise stage of patients with esophageal cancer.

Thoracic recurrent laryngeal lymph node metastases predict cervical node metastases and benefit from three-field dissection in selected patients with thoracic esophageal squamous cell carcinoma

BACKGROUND AND OBJECTIVES

Recurrent laryngeal nerve lymph nodes (RLN LNs) are considered sentinel nodes for cervical LN metastases of esophageal cancer. Surgery is the treatment of choice, but whether three-field lymph node dissection (3FL), which includes cervical LN dissection, or 2FL, which does not, should be performed is controversial.

METHODS

We retrospectively analyzed medical records of 200 patients with esophageal cancer who underwent 3FL from January 2000 to August 2010, focusing on LN status. We also compared survival rates between these patients and those who underwent 2FL.

RESULTS

The rate of cervical LN metastases did not differ significantly between RLN LN+ (for metastasis) and RLN LN- 3FL groups. However, in a subgroup of patients with middle/lower thoracic esophageal tumors, cervical LN metastases were significantly more common in patients with positive rather than negative RLN LNs. Survival did not differ after 3FL versus 2FL in general. However, 3FL was associated with longer survival than 2FL in patients with RLN LN positivity and either lower thoracic esophageal tumors or more than four abdominal/thoracic LN metastases.

CONCLUSIONS

Metastasis to RLN LNs is a reliable indicator of cervical LN metastasis in middle/lower thoracic esophageal cancer, while 3FL offers survival benefit over 2FL in certain patient subgroups.

Comparison of survival and recurrence pattern between two-field and three-field lymph node dissections for upper thoracic esophageal squamous cell carcinoma

INTRODUCTION

It is controversial to routinely perform three-field lymph node dissection in patients with upper thoracic esophageal carcinoma. The objective of this study was to compare survival and recurrence according to the extent of lymph node dissection in patients with upper thoracic esophageal squamous cell cancer.

METHODS

Between 1995 and 2007, 91 patients underwent R0 esophagectomy (with no residual tumor) for squamous cell carcinoma of the upper thoracic esophagus at our institution. Of these, 57 patients received three-field (cervical, mediastinal, and abdominal stations) lymph node dissection (3 FL group), whereas 34 received two-field (mediastinal and abdominal stations) lymph node dissection (2 FL group). We retrospectively compared the early and late postoperative outcomes between the two groups.

RESULTS

No differences were observed between the two groups with regard to age, gender, and pathologic stage. There was no in-hospital mortality in either group. The 5-year survival rate was 52% for the 2 FL group and 44% for the 3 FL group (p = 0.65). The disease-free 5-year survival rate was 39% for the 2 FL group and 38% for the 3 FL group (p = 0.97). The overall recurrence rate and the incidence of cervical nodal recurrence were not significantly different between the two groups.

CONCLUSIONS

Our findings suggest that there was no survival benefit from the addition of cervical nodal dissection in patients with upper thoracic esophageal squamous cell carcinoma who had no evidence of cervical lymph node metastasis.

Clinical course and outcome after esophagectomy with three-field lymphadenectomy in esophageal cancer

BACKGROUND

Esophagectomy with three-field lymphadenectomy has been performed for esophageal cancer. Detailed analysis of cause of death and mode of recurrence is required to determine the need for further adjuvant therapy and follow-up.

MATERIALS AND METHODS

A total of 208 patients who underwent esophagectomy through right thoracotomy with three-field lymphadenectomy were enrolled into the present study. Mode of first recurrence was divided into four groups: lymph node, hematogenous, mixed, and local recurrence.

RESULTS

Excluding 16 hospital deaths, the number of deaths and 5-year survival rates were 104 patients and 7.8% for cancer recurrence, 12 patients and 53.8% for second primary cancers in other organs, and 34 patients and 31.0% for causes of death unrelated to carcinoma. In the 104 patients with relapse, 5-year survival rate of patients was 14.3% with lymph node recurrence (n = 29), 9.1% with hematogenous recurrence (n = 32), 3.1% with mixed recurrence (n = 35), and 12.5% with local recurrence (n = 8).

CONCLUSION

To improve outcomes for esophagectomy with three-field lymphadenectomy, early detection of recurrent disease and regular examination of the entire body for secondary cancer is necessary.

Does systematic 2-field lymphadenectomy for esophageal malignancy offer a survival advantage? Results from 178 consecutive patients

More extensive resection for esophageal cancer has been reported to improve survival in several series. We compared results from an unselected consecutive cohort of patients undergoing radical esophagectomy, including removal of all periesophageal tissue with a 2-field abdominal and mediastinal lymphadenectomy for esophageal and gastroesophageal malignancy. A prospective electronic database was reviewed for patients with esophageal malignancy undergoing an open esophagectomy between 1991 and 2004. Data were analyzed on an SPSS file (version 12.0, Chicago, IL, USA) using chi(2) or Fisher's exact test; odds ratio and 95% confidence interval; and the Kaplan-Meier method, log-rank test and Cox's proportional hazards regression for survival analysis. There were 178 patients with a median age of 65 years and a 70/30 male to female ratio. Median follow-up was 20.4 months. Pathology comprised adenocarcinoma in 64% of patients, squamous cell carcinoma 30%, and other malignancies 6%. Seventeen patients had neoadjuvant therapy. Hospital mortality was 3.3%. Complete resection was achieved in 87%. Local recurrence occurred at a median of 13 months in 6.7% of patients. Overall 5-year survival was 42%. For patients with invasive squamous cell carcinoma and adenocarcinoma the 5-year survival was 47% and 40.3%, respectively, and for patients without nodal involvement it was 71.5%, with one to four nodes involved, 23.5% and with >4 nodes, 5% (P < 0.001). Survival decreased with increasing direct tumor spread (P < 0.001) and pathological stage (P < 0.001). Esophageal resection with systematic 2-field lymphadenectomy can be performed with acceptable operative mortality and favorable survival.

Disease proteomics of high-molecular-mass proteins by two-dimensional gel electrophoresis with agarose gels in the first dimension (Agarose 2-DE)

Agarose gel is the preferred electrophoretic medium currently used for separating high molecular mass (HMM) proteins (MW>100 kDa). Agarose gels are widely used for both SDS-agarose gel electrophoresis and agarose isoelectric focusing (IEF). A two-dimensional gel electrophoresis method employing agarose gels in the first dimension (agarose 2-DE) that is sufficiently good at separating up to 1.5mg of HMM proteins with molecular masses as large as 500 kDa has been used to separate proteins from various diseased tissues and cells. Although resolution of the agarose 2-DE pattern always depends on the tissue being analyzed, sample preparation procedures including (i) protein extraction with an SDS sample buffer; (ii) ultracentrifugation of a tissue homogenate; and (iii) 1% SDS in both stacking and separation gels of the second-dimension SDS-PAGE gel, are generally effective for HMM protein detection. In a comprehensive prostate cancer proteome study using agarose 2-DE, the HMM region of the gel was rich in proteins of particular gene/protein expression groups (39.1% of the HMM proteins but only 28.4% of the LMM ones were classified as transcription/translation-related proteins). Examples include transcription factors, DNA or RNA binding proteins, and ribosomal proteins. To understand oxidative stress-induced cellular damage at the protein level, a novel proteomic method, in which protein carbonyls were derivatized with biotin hydrazide followed by agarose 2-DE, was useful for detecting HMM protein carbonyls in tissues of both a diabetes model Ostuka Long-Evans Tokushima Fatty (OLETF) rat and a control Long-Evans Tokushima Otsuka (LETO) rat. In this paper, we review the use of agarose gels for separation of HMM proteins and disease proteomics of HMM proteins in general, with particular attention paid to our proteome analyzes based on the use of agarose 2-DE for protein separation followed by the use of mass spectrometry for protein identification.

Location and clinical impact of solitary lymph node metastasis in patients with thoracic esophageal carcinoma

BACKGROUND

The location and clinical impact of solitary lymph node metastasis from thoracic esophageal carcinoma have not been evaluated sufficiently.

METHODS

A consecutive series of 91 patients with a solitary positive lymph node who underwent curative surgery for thoracic esophageal carcinoma was investigated. The prognostic impact was evaluated by univariate analysis and multivariate analysis using Cox's proportional hazards model.

RESULTS

A total of 52 (57%) of the 91 patients showed a solitary positive node beyond the thorax. While 29% of the patients with an upper thoracic tumor showed a cervical node, 13% of the patients with a middle tumor and none of the patients with a lower tumor showed a cervical node. Tumor depth and venous invasion were found to be independent risk factors for poor survival.

CONCLUSIONS

The solitary positive lymph nodes were broadly distributed depending on the tumor location and tumor depth. Tumor depth and venous invasion were risk factors for poor survival in these patients.

Proteomic analysis of primary esophageal squamous cell carcinoma reveals downregulation of a cell adhesion protein, periplakin

Recent advances in two-dimensional electrophoresis (2-DE) such as fluorescent 2-D differential gel electrophoresis (2-D DIGE) has made it possible to detect and quantitate the critical changes involved in disease pathogenesis. We have previously identified novel proteins with altered expression in primary colorectal cancer using agarose 2-DE that has a higher loading capacity than immobilized pH gradient gel. The aim of this study is to identify novel proteins with altered expression in primary esophageal cancer using the powerful method of agarose 2-DE and agarose 2-D DIGE. Excised tissues from 12 patients of primary esophageal cancer were obtained. Proteins with altered expression between cancer and adjacent non-cancer tissues were analyzed by agarose 2-D DIGE and identified by mass spectrometry. Thirty-three proteins out of 74 spots with altered expression in tumors were identified. Among them, a 195-kDa protein, periplakin, was significantly downregulated in esophageal cancer, which was confirmed by immunoblotting. Immunohistochemistry showed that periplakin was mainly localized at cell-cell boundaries in normal epithelium and dysplastic lesions, while it disappeared from cell boundaries, shifted to cytoplasm, in early cancers and scarcely expressed in advanced cancers. These results suggest that periplakin could be a useful marker for detection of early esophageal cancer and evaluation of tumor progression.

Pre-tracheal lymph node metastasis in squamous cell carcinoma of the thoracic esophagus

AIMS

To clarify the incidence of pre-tracheal lymph node metastasis in squamous cell carcinoma of the esophagus, and their impact on survival.

METHODS

A cohort of 101 patients with squamous cell carcinoma of the thoracic esophagus who underwent esophagectomy together with 2-field lymphadenectomy including the pre-tracheal region was analysed, retrospectively. The p-TNM staging included stage I in 9, stage IIa in 33, stage IIb in 4, stage III in 43, and stage IV in 12 cases.

RESULTS

Nodal metastases were identified in 56 patients (55.4%). Subcarinal lymph node and pre-tracheal lymph-node metastases were found in 24 patients (23.8%) and 15 patients (14.9%), respectively. The 5-year cumulative survival rates were 26.5 and 2.5% in nodal negative and nodal positive patients, respectively. Patients with pre-tracheal nodal metastasis all died within 2 years. Cox proportional hazards model in patients with nodal involvement revealed T-factor (p=0.0017), pre-tracheal nodal involvement (p=0.0055) and distant metastasis (p=0.0024) as independent prognostic factors.

CONCLUSIONS

Our findings suggest that pre-tracheal lymph node metastasis indicates a dismal prognosis. Its occurrence is not unusual, especially in tumour of upper or middle thoracic esophagus. The subcarinal node cannot be regarded as a sentinel node of the pre-tracheal nodal station. Complete lymphadenectomy excluding the pre-tracheal lymph nodes in treating esophageal cancers is only a myth.

Two-field lymph-node dissection may be enough to treat patients with submucosal squamous cell carcinoma of the thoracic esophagus

Significance of extended radical surgical treatment including three-field lymph node dissection for squamous cell carcinoma (SCC) of the esophagus remains debatable. The aim of the current study was to reconsider the merits and demerits obtained by three-field lymph node dissection for esophageal carcinoma and also to attempt to elucidate an appropriate surgical strategy for submucosal SCC of the thoracic esophagus. Thirty-one patients with SCC of the thoracic esophagus who had been treated with esophagectomy and two-field (thoracic and abdominal) lymph node dissection without preoperative therapies were enrolled. Five-year survival rate was 75.0% and the incidence proportion of postoperative complication was 9.7%. These data regarding postoperative outcome of patients were by no means inferior to those in the previous reports referring the prognosis of patients with esophageal carcinoma who had been treated with three-field lymph node dissection. Authors would like to mention that two-field lymph node dissection associated with reduced incidence of postoperative complications might be enough to treat the submucosal SCC of the thoracic esophagus.

Clinical outcomes of extended esophagectomy with three-field lymph node dissection for esophageal squamous cell carcinoma

OBJECTIVE

Opinions are conflicting about 3-field lymph node dissection (3FLND) during esophagectomy for esophageal cancer. In the current study, we sought to determine the prevalence of cervical and upper thoracic lymph node metastasis in patients with squamous cell carcinoma of the thoracic esophagus and to determine the impact of 3FLND on mortality, morbidity, survival, and recurrence rate.

MATERIALS AND METHODS

Among 287 patients with squamous cell carcinoma of the thoracic esophagus seen between November 1985 and December 2001, 141 (49%) underwent extended esophagectomy with 3FLND (cervical, mediastinal, and abdominal lymph node dissection). Patients were observed and clinicopathologic information collected prospectively on all patients until death or August 2002. The median follow-up was 41 months, ranging from 10 to 173 months.

RESULTS

Hospital mortality and morbidity rates were 6.4% and 80%, respectively. Thirty-four of 70 node-positive patients had cervicothoracic nodal involvement. Sixteen patients (11%) had nodal involvement confined only to the cervicothoracic nodes, and no patients with lower thoracic esophageal carcinoma showed cervicothoracic involvement alone. The frequency of cervical nodal disease was correlated with nodal status within the mediastinum (P <0.01). The 1-, 3-, and 5-year overall survival rates for all 141 patients were 76%, 58%, and 48%, respectively. Among significant variables verified by univariate analysis, independent prognostic factors for overall survival determined by multivariate analysis were number of lymph node metastasis (P <0.01), amount of blood transfusion (P <0.05), length of operation (P <0.05), and presence of pulmonary complications (P <0.05).

CONCLUSIONS

Extended esophagectomy with 3FLND can be performed with an acceptable mortality. Metastases frequently involved the upper thoracic and cervical lesions, and cervical nodal disease was correlated with thoracic nodal status. 3FLND proved to be an important staging system in 11% of patients. An excellent overall survival suggests a superiority of 3FLND when performed at experienced centers.

Two-step three-field lymph node dissection is beneficial for thoracic esophageal carcinoma

Aggressive surgery including extensive lymph node dissection is considered necessary to improve the long-term survival of patients with esophageal carcinoma. While three-field lymph node dissection is widely performed for patients with thoracic esophageal carcinoma, cervical lymph node metastasis is uncommon. In order to reduce surgical stress, we have developed a two-step three-field lymph node dissection procedure for thoracic esophageal carcinoma. In the first-step operation, total thoracic esophagectomy through a right thoracotomy is performed. Mediastinal and abdominal lymph node dissection is performed synchronously. When recurrent nerve lymph node metastasis is pathologically positive, cervical lymph node dissection is performed about 3 weeks after the first operation (second step). Of 343 patients with carcinoma of the esophagus surgically treated in our department between 1990 and 2001, 146 underwent the operation described above. Three-field dissection was performed in 68 patients (group A), while two-field dissection was performed in 78 patients (group B). In the 68 group A patients, cervical lymph node metastasis was positive in 15 patients (22%). There was no marked difference in the onset of major complications between the two groups. The 5-year survival rate was 58% for group A and 61% for group B, not a statistically significant difference. In 78 of the 146 patients, it was possible to avoid cervical lymph node dissection without negatively affecting therapeutic outcomes. Two-step three-field lymph node dissection can reduce surgical stress of patients with good clinical outcome.

Development of less invasive surgical procedures for thoracic esophageal cancer

In order to minimize the invasiveness of the operative procedure for thoracic esophageal cancer, several procedures have been introduced since January 1997. They included: (i) perioperative use of steroids; (ii) muscle-sparing thoracotomy without costectomy; (iii) preparation of the gastric tube with preservation of sufficient blood supply; (iv) reconstruction of the alimentary tract via posterior-mediastinal route; and (v) formation of anastomosis between the remaining esophagus and the gastric tube at a location between the gastroepiploic arteries of the gastric greater curvature. Twenty-one patients who did not receive preoperative chemoradiotherapy underwent the newly developed procedure, and were compared with those receiving the original procedure. Hospital mortality was zero, and postoperative systemic inflammatory response syndrome was suppressed. The mean postoperative hospital stay was 21.5 days, and the actuarial 3-year survival rate was 76.2%. From the comparison with those receiving the original procedure, it can be concluded that the newly developed procedures were effective in minimizing surgical invasiveness and were sufficiently curative in terms of cancer treatment.

The width of a gastric tube has no impact on outcome after esophagectomy

BACKGROUND

We evaluated the impact of the size of gastric tubes on tissue blood flow of the anastomotic site, the frequency of leakage and the postoperative nutritional status.

METHODS

Forty-four patients were randomly allocated to either reconstruction using subtotal stomach (n = 22) or to reconstruction using slender gastric tube (n = 22) after esophagectomy. The tissue blood flow at the anastomotic site was measured. The postoperative nutritional status of 17 patients without recurrence was examined. Possible correlations between the type of esophageal substitute and the tendency to leakage as well as postoperative nutritional status were examined.

RESULTS

There was no significant difference in the tissue blood and the frequency of leakage between the types of gastric tubes. There was no significant difference noted between the two in the postoperative nutritional status at 6 and 12 months after operation.

CONCLUSIONS

The width of gastric tube has no impact on tissue blood flow, the frequency of leakage, and the postoperative nutritional status after esophagectomy.

Clinical benefit of chemosensitivity test for patients with regional lymph node-positive esophageal squamous cell carcinoma

BACKGROUND AND OBJECTIVES

Patients who have undergone resection for lymph node-positive esophageal squamous cell carcinoma are at high risk of recurrence and early death. The role of the postoperative adjuvant chemotherapy in this population needs to be determined. The present study was designed to determine whether the chemosensitivity test in fresh human esophageal squamous cell carcinoma, using highly purified tumor cells, correlates with the clinical response.

METHODS

A retrospective review of all patients with resected squamous cell carcinoma of the thoracic esophagus between 1993 and 2000 was performed. We determined the chemosensitivity for cisplatin (CDDP), 5-fluorouracil (5-FU), mitomycin C, and adriamycin in vitro in fresh human esophageal squamous cell carcinoma using the MTT assay. Regional lymph node-positive (N1) patients who received sequential postoperative chemotherapy were compared with lymph node positive patients who underwent surgery alone.

RESULTS

A total of 50 patients were reviewed, and chemosensitivity tests were successfully performed in 46 patients: 20 patients received surgery alone (S group), and 26 patients received surgery plus postoperative chemotherapy (SC group) according to results of MTT assay using highly purified tumor cells. When the SC group was divided into an SC-low group (inhibition rate of CDDP + 5-FU was below 85%, n = 15) and an SC-high group (over 85%, n = 11), the SC-high group showed more significant survival prolongation than the S group or the SC-low group (P < 0.01).

CONCLUSIONS

Our results suggest that the results of the conventional MTT assay may be useful in evaluating the optimum adjuvant chemotherapy for patients with regional lymph node positive (pN1) esophageal squamous cell carcinoma.

The role of surgery in the management of oesophageal cancer

In the absence of medical contraindications to surgery, resection is the mainstay of treatment for localised oesophageal cancer. Advancements in preoperative staging and imaging, anaesthesia delivery, surgical technique, and postoperative care, now enable the surgeon to safely operate on patients with oesophageal tumours and to tailor the procedure on the basis of performance status, tumour location, and extent of disease. During the past 10 years, several "minimally invasive" techniques, which aim to limit the extent of resection, have been introduced; these procedures are currently being investigated for use in both staging and treatment of oesophageal malignant diseases. Despite these accomplishments however, overall 5-year survival remains disappointing: less than 25% of patients live for 5 years after oesophagectomy. For patients with locally or regionally advanced disease (stage IIa, IIb, III, and IVa), combining several treatment approaches, either with or without surgery, can result in good objective responses and, in some patients, durable survival. The role of surgery in such combined modality approaches is still evolving and some investigators have challenged its worth. To provide a definitive review of the issues involved, we outline the types of surgery used to treat cancer of the oesophagus and summarise the available data about their effectiveness. Clinical outcomes, the value of preoperative chemoradiotherapy, and the use of surgery are all considered.

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.

Prognostic evaluation of patients with clinical T1 and T2 squamous cell carcinomas of the thoracic esophagus after 3-field lymph node dissection

BACKGROUND

Clinicopathologic characteristics and outcomes with clinical T1 and T2 squamous cell carcinomas requiring surgical resection have not been well investigated. The purpose of this study was to evaluate results for patients undergoing 3-field lymph node dissection and to elucidate predictors of survival.

METHODS

From January 1988 to January 1998, 336 patients with carcinomas of the thoracic esophagus underwent transthoracic esophagectomy with 3-field lymph node dissection. Of these, 325 (97%) patients had squamous cell carcinomas. A total of 139 (41%) with clinical T1 and T2 tumors were retrospectively analyzed based on the prospectively established database.

RESULTS

Among the 139 patients with clinical T1 and T2 squamous cell carcinomas, 90 (65%) had T1 and 49 (35%) had T2 tumors. The operative morbidity, and 30-day and in hospital mortality rates were 70%, 0%, and 2%, respectively. Macroscopic and microscopic complete resection of the primary tumor and removal of metastatic nodes were accomplished in 90% of the cases. The overall 1-, 3-, and 5-year survival rates were 88%, 72%, and 61%. Significant prognostic factors, determined by multivariate analysis, were number of lymph node metastases, pathologic T status, and completeness of resection. Number of lymph node metastases most strongly affected survival. Eighty-six percent of patients with 5 or more metastatic nodes occurred recurrence of disease.

CONCLUSION

Esophagectomy with 3-field lymph node dissection accomplishes a high feasibility of complete resection of primary tumor and removal of metastatic nodes in patients with clinical T1 and T2 squamous cell carcinomas. Five or more metastatic nodes can be considered as an indicator of systemic disease with a high likelihood of distant organ metastasis. This variable must be taken into consideration for deciding clinical disease stage and treatment strategy.

Locally advanced esophageal cancer

Patients diagnosed with adenocarcinoma or squamous cell carcinoma of the esophagus should undergo computed tomography of the chest and abdomen and positron emission tomography to look for evidence of distant metastatic disease. In the absence of systemic metastases, locoregional staging should be performed with endoscopic ultrasonography and fine needle aspiration of accessible periesophageal lymph nodes and any detectable celiac lymph nodes. Patients found to have T3 tumors (transmural extension), T4 tumors (invasion of adjacent structures), or N1-M1a (lymph node-positive) disease do poorly when treated with surgery alone; 5-year survival is less than 20%. These patients should be considered for combined modality therapy. Patients with T4 disease are generally not deemed candidates for surgical resection; they may be considered for definitive chemoradiotherapy. Patients with T3 disease or lymph node-positive disease may be treated with neoadjuvant chemoradiotherapy followed by surgery or definitive chemoradiotherapy alone. Patients considered for trimodality therapy should be fully restaged before surgery to assess their response to neoadjuvant treatment. This should include repeat endoscopic ultrasound and fine needle aspiration of lymph nodes. Patients whose lymph node metastases do not completely respond to neoadjuvant therapy are unlikely to benefit from the addition of surgery. Patients with persistently positive celiac lymph nodes have a very poor prognosis and should not undergo surgery. Patients with persistent nodal disease who have good performance status may be considered for additional chemotherapy. Patients with locally advanced esophageal cancer who have poor performance status are not good candidates for combined modality therapy. These individuals are best managed with palliative intent. Particular attention should be given to alleviating the common problem of dysphagia, which causes significant morbidity.

Outcome of histologically node-negative esophageal squamous cell carcinoma

The outcome of node-negative esophageal carcinoma and the prognostic significance of lymph node micrometastasis remain unknown. The aim of this retrospective study was to clarify these two points. A series of 98 patients who underwent curative operation for histologically node-negative (pN0 in TNM classification) esophageal carcinoma were enrolled in the study. We reviewed the cause of death of these patients. The survival curves were calculated and compared after stratifications according to clinicopathologic parameters. Lymph node micrometastasis in the patients with recurrences was examined using immunohistochemical staining of cytokeratin. Their ages ranged from 45 to 83 years (mean 64.3 years). There were 83 men and 15 women. Altogether, 54 patients were still alive, and 44 had died. A total of 9 patients died from recurrence of their esophageal carcinoma, 33 died from other causes (pneumonia 11, extraesophageal carcinoma 7, and so on), and 2 died from unknown causes. Eight patients had locoregional recurrences, and two patients had distant recurrences. The overall survival rate for the 98 patients was 58.2%. The survival for patients with pT2 or pT3 tumors was significantly worse than for those with pTis or pT1 tumors (p = 0.02, log-rank test). Other clinicopathologic factors did not affect the prognosis. Immunohistochemical study found no lymph node micrometastasis in 365 lymph nodes resected from the patients with recurrences. Only the depth of tumor invasion affected the outcome of patients with node-negative esophageal carcinoma. Altogether, 75% of patients died of other causes without recurrence, with the two main causes of death being pulmonary complications and extraesophageal carcinoma in these patients. Lymph node micrometastasis was not associated with recurrence in this series.

Prognostic factors after oesophagectomy and extended lymphadenectomy for squamous oesophageal cancer

BACKGROUND

The prognosis of patients without nodal metastasis of oesophageal cancer is generally good, but recurrence develops in some cases.

METHODS

Data on 88 consecutive patients with squamous oesophageal cancer who underwent three-field lymph node dissection from 1986 to September 1998 and who had no evidence of nodal disease were reviewed retrospectively. Disease status was based on histological examination of the section of each node with the largest surface area, stained with haematoxylin and eosin.

RESULTS

The 3- and 5-year survival rates of patients without lymph node metastasis were 85 and 81 per cent respectively, better than in patients with metastasis. Twelve patients died from recurrence. Recurrence was haematogenous in nine patients and locoregional in three. Survival was worse in men, for patients with lesions located in the upper thoracic oesophagus, and in those with lymphatic or blood vessel invasion. Only the presence of lymphatic invasion correlated with survival on multivariate analysis (P = 0.04).

CONCLUSION

Although survival was generally good in patients without nodal metastasis from oesophageal cancer following three-field lymph node dissection, patients with lymphatic invasion remained at risk for haematogenous dissemination.

Wide-spread distribution of sentinel lymph nodes in esophageal cancer

Sentinel lymph nodes are the first draining nodes that contain tumor cells. Identification of sentinel nodes may help to determine the suitable extent of lymphadenectoy. To assess the location of sentinel lymph nodes, a series of 41 patients with single and two metastatic lymph nodes who underwent esophagectomy and 3-field lymphadenectomy between 1991 and 1999 were investigated retrospectively. Only 29 (47.5%) of 61 metastatic nodes showed correspondence between the tumor site and the regional metastatic lymph nodes by routine histologic examination. In the patients with tumors in the upper and middle thoracic esophagus, metastatic lymph nodes were distributed in the cervix, mediastinum and abdomen. Although sentinel nodes were limited to the regional and adjusting compartments in 82%, nodes were found beyond the adjusting compartments in 18%. The sentinel nodes were broadly distributed depending on the location of the tumor in esophageal cancer.

Esophageal cancer with distant lymph node metastasis: prognostic significance of metastatic lymph node ratio

The cervical and celiac lymph node metastases are defined as distant metastasis (Mlym) from thoracic esophageal carcinoma by TNM (primary tumor, regional lymph nodes, and distant metastasis) classification. The prognostic factors, however, of such distant node metastases are not fully understood. Of 85 patients with node-positive thoracic esophageal carcinoma who were treated with the same modalities of treatment, 31 (37%) had Mlym. Prognostic factors for long-term survival were analyzed by univariate and multivariate analyzes. Three patients are alive and free of cancer, and two patients survived over 5 years. Fifteen patients died of recurrent esophageal cancer and 11 patients succumbed to causes unrelated to esophageal cancer. Two patients with a single Mlym died without recurrence of esophageal cancer at 1.4 years and after more than 5 years, respectively. The 1-, 2-, 3-, and 5-year overall survival rates of all 31 patients were 64.5%, 24.8%, 17.0%, and 12.8%, respectively. The factors influencing survival rate were depth of invasion (pT1,2 vs. pT3,4) and metastatic lymph node ratio (< or =0.104 vs. > or =0.105). The survival rates were not influenced by number of lymph node metastasis, number of Mlym, or by metastatic lymph node ratio of Mlym. Among those two significant variables verified by univariate analysis, independent prognostic factor for survival determined by multivariate analysis was the metastatic lymph node ratio (risk ratio = 3.4, p = 0.0345). The results of this study indicate that a significant number of patients can be cured of esophageal carcinoma by extensive resection along with extended lymph node dissection even when the disease metastasizes to distant nodes.

Biologic and clinical significance of lymphadenectomy

Interest in the lymphatic system and its relationship to metastases has developed owing to renewed interest in sentinel node biopsy. This article summarizes the anatomy, physiology, and biology of the lymphatic system and lymph node metastases, and reviews studies of lymph node metastases and surgical resection of cancers in different anatomic sites. On the basis of these studies, the authors conclude that lymph node metastasis functions as an indicator of prognosis, not the controlling or determining factor of prognosis. Thus, varying degrees of treatment of regional lymph nodes and metastases do not seem to be controlling factors in the outcome of cancer.

Accelerated growth signals and low tumor-infiltrating lymphocyte levels predict poor outcome in T4 esophageal squamous cell carcinoma

BACKGROUND

Little is known about the biological nature of T4 esophageal carcinoma growth signals and host defenses.

METHODS

Paraffin-embedded sections from 78 patients with T2 to T4 esophageal squamous cell carcinoma who underwent operation were analyzed with immunohistochemistry.

RESULTS

Positive cyclin A showed a significantly greater increase in T4 tumors than in those of other stages, and negative p27 showed a significantly greater decrease in T4 tumors than in large T3 stage tumors (tumor size > or = 4.0 cm). Patients with low-grade tumor-infiltrating lymphocyte (TIL) density showed a significantly greater decrease in T4 than in T2. The combination of p27 and cyclin A was a significant independent prognostic factor among T and N factors in multivariate analysis. TIL density was an independent prognostic factor among immunonutritional variables such as serum albumin concentration and the number of total blood lymphocytes.

CONCLUSIONS

T4 esophageal squamous cell carcinoma has a poor prognosis, which is associated with increased p27-negative and cyclin A-positive growth signals in the tumor and with low TIL density in the host.

Recurrent nerve nodal involvement is associated with cervical nodal metastasis in thoracic esophageal carcinoma

BACKGROUND

Because three-field dissection for esophageal carcinoma is one of the most invasive operations, this procedure should be selected only when strictly indicated; but there are no useful criteria for it. The goal of this study was to identify the useful clinicopathologic factors for indicating three-field dissection.

STUDY DESIGN

In this study, we reviewed the survival of patients after three-field dissection and identified factors associated with metastases in cervical nodes (CN), especially internal jugular nodes and supraclavicular nodes. Eighty-six patients who underwent curative esophagectomy with three-field dissection for squamous cell carcinoma of the thoracic esophagus were enrolled in this study. Survival rates were compared with respect to the presence of nodal metastasis. The relationship between recurrent nerve nodal (RNN) involvement and CN metastasis (bilateral internal jugular nodes, supraclavicular nodes, or both) was examined. Clinicopathologic factors possibly influencing CN metastasis were studied by multivariate logistic regression analysis.

RESULTS

The overall 5-year survival rate was 45.1%. The 5-year survival rate for patients without metastatic nodes was 67.5%, for patients with one to four metastatic nodes it was 53.1%, and for patients with five or more it was 9.1 %. The prognosis of those with five or more metastatic nodes was significantly poorer than those of the other two groups. In the positive-node group, the 5-year survival rate for patients with RNN metastasis was 21.7%, and for patients with negative RNN it was 47.0% (p = 0.2). In the positive-node group, the 5-year survival rate for patients with positive CN was 13.7% and for patients with negative CN it was 45.8% (p = 0.01). Fifty-six (88.9%) of 63 patients without RNN metastasis had no CN metastasis in contrast to 13 of 23 patients (56.5%) with RNN metastasis who had no CN metastasis (p = 0.001). The positive predictive value, negative predictive value, sensitivity, and specificity were 43.5%, 88.8%, 58.8%, and 81.2%, respectively. The number of metastatic nodes (5 or more versus 0-4) (odds ratio: 2.9, 95% Confidence Interval (CI) = 1.6-5.5, p = 0.0008) and RNN involvement (odds ratio: 4.5, 95% CI = 1.3-15.9, p = 0.02) were the significant factors associated with CN metastasis in the multivariate analysis.

CONCLUSIONS

RNN involvement is associated with CN metastasis as is the number of metastatic nodes and may be an indicator for the selection of three-field dissection in thoracic esophageal carcinoma.

Esophageal cancer

Papers published in the English literature on esophageal cancer in 1999 were retrieved by a MEDLINE search. Selective publications were reviewed in light of current knowledge. Many studies were performed to refine staging methods of esophageal cancer, especially in the use of endoscopic ultrasound. Although better designs have overcome the problem of nontraversable tumors, its use in staging after neoadjuvant therapies remains suboptimal. Important studies on various surgical techniques were reported, including randomized trials on different routes of reconstruction after esophageal extirpation, and the updated results of transhiatal resections. In contrast to the minimalist approach of transhiatal resection, investigators from both East and West have also described the pathologic basis of lymphatic spread of esophageal cancer and its implications, favoring more radical lymphadenectomy. Another avenue that was explored is the use of neoadjuvant therapies to improve outcome. Different regimens were studied, and many papers focused on the molecular prediction of favorable response to such therapies. Overenthusiastic adoption of multimodality treatments is cautioned, however, in that they have not been validated. Further work is much needed in this area of research.

Surgery, radiotherapy, and chemotherapy in carcinoma of the esophagus

Esophageal carcinoma remains a highly lethal disease that has shown a recent profound increase in prevalence and an equally dramatic epidemiologic shift. There is a well recognized causal association between gastroesophageal reflux disease and adenocarcinoma of the esophagus, 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 all have significant limitations. Fortunately, chemoprevention strategies and the identification of clinically useful molecular biomarkers that may be used to stage disease and select appropriate therapy are on the horizon. The extent of surgical resection for esophageal carcinoma remains an area of great controversy. Disease that is confined to the mucosa is being diagnosed more commonly, and endoscopic ablative techniques have been proposed. To date, however, preoperative discrimination of tumor depth and presence of regional nodal metastases remains inadequate in these very early lesions, and caution is urged before adopting therapies that may compromise cure. For disease penetrating the mucosa, the extent of surgical therapy must be tailored by the objectives of treatment (cure vs palliation) and preoperative stage. Surgical resection is the current standard of care, with combined-modality therapy reserved for prohibitive surgical candidates. No clear survival benefit has been documented for neoadjuvant radiotherapy or chemotherapy alone. The results of preoperative combined-modality therapy, including three prospective, randomized trials, are encouraging but to date have not shown a definite benefit.