Primary tracheal tumors: treatment and results

One hundred ninety-eight patients with primary tracheal tumors were evaluated in 26 years. One hundred forty-seven tumors were excised (74%): 132 (66%) by resection and primary reconstruction, seven by laryngotracheal resection or cervicomediastinal exenteration, and eight by staged procedures. Eleven more were explored. Forty-four squamous cell carcinomas were resected, 60 adenoid cystic, and 43 assorted tumors, benign and malignant. Eighty-two patients underwent tracheal resection with primary reconstruction, and 50 had carinal resection and reconstruction. Surgical mortality for resection with primary reconstruction was 5%, with one death after tracheal and six after carinal repair. Six patients had stenosis after tracheal or carinal resection; all underwent reresection successfully. Nearly all patients with squamous or adenoid cystic carcinoma were irradiated postoperatively. Twenty of 41 survivors of resection of squamous cell carcinoma are living free of disease (some for more than 25 years), 39 of 52 with adenoid cystic carcinoma (up to nearly 19 years), and 35 of 42 with other lesions (5 lost to follow-up). Comparison of length of survival of patients with squamous cell carcinoma and adenoid cystic carcinoma who are alive without disease with those who died with carcinoma supports surgical treatment (usually followed by irradiation). Positive lymph nodes or invasive disease at resection margins appear to have an adverse effect on cure of squamous cell carcinoma; such an effect is not demonstrable with adenoid cystic carcinoma.     

Clinicopathologic assessment of primary thymic carcinoma based on seven cases

In order to study clinicopathologic characteristics of thymic carcinomas, seven patients experienced in our department were reviewed in this paper; 6 patients underwent thoracotomy and one did not receive surgical treatment. Among 6 who received operation, the tumor was resected totally in 3, subtotally in one, partially in one. One patient underwent exploratory thoracotomy. There have been no distinctive clinical features including clinical symptoms and radiographical findings from invasive thymomas in 7 primary thymic carcinomas, however, in these malignant tumors there have been no tumor-associated disorders not infrequently observed in thymomas. Postoperatively, distant metastasis was common in patients with thymic carcinomas, even though the primary tumor was resected totally in the operation. However, one patient with squamous cell carcinoma of the thymus who underwent subtotal tumor resection followed by radiotherapy and chemotherapy are surviving over 6 years postoperatively. Intensive treatment including pre- and postoperative radiation, tumor resection and postoperative chemotherapy is absolutely necessary for thymic carcinoma. Histologically, there were 4 squamous cell carcinomas and 3 large cell carcinomas. One of 3 large cell carcinomas showed squamous cell differentiation histologically. Two of 4 squamous cell carcinomas demonstrated concomitant entity of residual thymus tissue as well as thymoma in one specimen. However, further studies are necessary to determine precise etiology and tumor characteristics of thymic carcinoma.     

Oral squamous cell carcinoma of the mandibular region: A survival study

BACKGROUND: Oral squamous cell carcinomas (SCC) of the mandibular region present the lowest survival rates of the whole oral cavity. The purpose of this analysis was to evaluate the prognostic significance of several diagnostic and therapeutic variables in the survival rates of these carcinomas. METHODS: Forty-nine patients with oral cancers were treated by primary site surgery, involving mandibular resection in all cases. Thirty-one patients underwent postoperative adjuvant radiotherapy. RESULTS: Overall mean survival time and 5-year survival rate were 56.5 months and 44%, respectively. Patients in stages III and IV showed a statistically significant (p = .01) lower survival rate than those in stage II, and positive surgical margins had an adverse effect on survival (p = .03). No differences were found between patients treated by marginal or segmental mandibulectomy. CONCLUSIONS: Among the prognostic predictors studied, only the status of the surgical resection margin (odds ratio, 5.7) and tumor stage (III and IV vs II showed odds ratios of 2.1 and 3.6, respectively) affected the prognosis for SCC of the mandibular region. Tumor site was not associated with prognosis but was related with the probability that surgical margins were involved.     

Management of tracheal tumors

Since 1962, 110 primary tracheal tumors have been seen including 43 squamous cell carcinomas, 38 adenoid cystic, and 29 varied. Sixty-nine patients underwent resection of their primary tumors; an additional 33 patients with secondary tumors involving the trachea also underwent resection. Seventy-three of these 102 patients underwent primary reanastomosis. In 17, laryngotracheal resection was required; staged resections were done for the rest. Survival data indicate that benign tumors are cured by resection with reconstruction and that patients with squamous cell carcinoma, adenoid cystic carcinoma, and other types of malignant lesions obtained either long-term palliation or cure if surgical resection was possible. In patients with selected types of secondary tumors, resection and reconstruction provide prolonged palliation.     

Histologic tumor type is an independent prognostic parameter in esophageal cancer: lessons from more than 1,000 consecutive resections at a single center in the Western world

OBJECTIVE: To analyze the changing pattern in tumor type and postoperative deaths at a national referral center for esophageal cancer in the Western world and to assess prognostic factors for long-term survival after resection. SUMMARY BACKGROUND DATA: During the past two decades, the epidemiology and treatment strategies of esophageal cancer have changed markedly in the Western world. The influence of these factors on postoperative deaths and long-term prognosis has not been adequately evaluated. METHODS: Between 1982 and 2000, 1,059 patients with primary esophageal squamous cell cancer or adenocarcinoma had resection with curative intention at a single center. Patient and tumor characteristics and details of the surgical procedure and outcome were documented during this period. Follow-up was available for 95.8% of the patients. Changing patterns in tumor type and postoperative deaths were analyzed. Prognostic factors for long-term survival were assessed by multivariate analysis. RESULTS: The prevalence of adenocarcinoma in patients with resected esophageal cancer increased markedly during the study period. The postoperative death rate decreased from about 10% before 1990 to less than 2% since 1994, coinciding with the introduction of a procedure-specific composite risk score and exclusion of high-risk patients from surgical resection. In addition to the well-established prognostic parameters, tumor cell type "adenocarcinoma" was identified as a favorable independent predictor of long-term survival after resection. The independent prognostic effect of tumor cell type persisted in the subgroups of patients with primary resection and patients with primary resection and R0 category. CONCLUSION: Esophagectomy for esophageal cancer has become a safe procedure in experienced hands. Esophageal adenocarcinoma has a better long-term prognosis after resection than squamous cell carcinoma.     

Results of tracheal or esophageal resections in invasive thyroid carcinomas

STUDY AIM: The aim of this retrospective study was to report results of 21 tracheal or esophageal resections for invasive thyroid carcinomas. PATIENTS AND METHODS: Between January 1988 and August 2000, 21 patients (mean age: 66 years) had a tracheal (n = 10) or esophageal (n = 11) resection for involvement by an invasive thyroid carcinoma. There were eight undifferentiated carcinomas, 11 papillary, one follicular and one epidermoid carcinomas. RESULTS: One patient died from pulmonary embolism during the postoperative period. Complications were: tracheal fistula (n = 2), tracheal stenosis (n = 1), esophageal fistula (n = 2), recurrent nerve palsies (n = 8) and hypoparathyroidism (n = 4). Seven patients presented local recurrence and seven presented distant metastases. Ten patients were alive and ten patients died of their carcinoma. The mean survival in this study was 26 months (21 months for anaplastic carcinomas and 41 months for differentiated carcinomas). CONCLUSION: Differentiated thyroid carcinomas have to benefit from a complete tumoral resection; tracheal or esophageal resection is indicated in case of involvement. Anaplastic carcinomas have a poor prognosis; complete resection is indicated only for selected patients; radiotherapy and chemotherapy are used, because surgery is often impossible.     

Primary tracheal tumors: experience with 14 resected patients.

OBJECTIVE: Primary tracheal tumors are rare. Management includes interventional endoscopy, surgery and radiotherapy. METHODS: Between 1987 and 1996, 14 patients treated by resection and reconstruction of the trachea and bifurcation for primary tracheal tumors were retrospectively analyzed. RESULTS: The most common histological finding was adenoid cystic carcinoma (n=7), followed by a squamous cell carcinoma (n=2), a mucoepidermoid carcinoma (n=2), a carcinoid tumor (n=1) and two benign tumors (xanthogranuloma, pleomorphic adenoma). Various reconstruction techniques were used and one prosthesis was implanted. Eight of the patients required preoperative Nd-YAG laser recanalisation. Six were treated by postoperative external beam radiotherapy, in three cases combined with endoluminal brachytherapy. Two major postoperative wound-healing impairment at the anastomosis occurred. Four minor wound-healing disorders were successfully treated by interventional endoscopy. Two patients died postoperatively with mediastinitis respectively with bilateral pneumonia. A local recurrence was observed in only two cases. At the last follow-up in January 1998, nine patients were still alive. We observed five long-term survivors (>6 years) with an adenoid cystic carcinoma or mucoepidermoid carcinoma. CONCLUSIONS: Extensive segmental resection of the trachea is the treatment of choice for primary malignant and occasionally for benign tracheal tumors. Interventional endoscopy is a part of modern tracheal surgery.     

A clinical study of surgical treatment of patients with carcinoma of the cervical esophagus extending to the thoracic esophagus.

OBJECTIVE: We studied optimum surgery for carcinoma of the cervical esophagus extending to the thoracic esophagus (Ce-Ut carcinoma). METHODS: Subjects were 13 patients diagnosed with Ce-Ut carcinoma treated at our institute from January 1989 to December 1998. Clinicopathologic information such as surgical procedures, pathologic findings, and postoperative complications were analyzed. RESULTS: In 10, laryngoesophagectomy was conducted due to tracheal invasion by the tumor. In 7, mediastinal tracheostomy was done because of the extended resection of the proximal trachea. In 3, the larynx was preserved and, in 2, cricopharyngeal myotomy was added. Lymph node metastasis was found only in the neck and the upper mediastinum at surgery and recurrences were all lung metastasis. The incidence of postoperative complications was very high (76.9%), and 1 patient died due to widespread tracheal necrosis. The cumulative 5-year survival rate for the group was 33.3% and that for the 9 curative cases was 50%, but most of the cases who underwent noncurative resection and/or who received preoperative therapy for widespread invasion to surrounding organs died within a year. CONCLUSION: The prognosis of patients who undergoing curative extended resection of the proximal trachea and suitable lymph node dissection in the neck and upper mediastinum may improve, and larynx-preserving surgery is recommended for patients without tracheal invasion. Despite preoperative chemoradiotherapy, the prognosis of patients with widespread invasion to surrounding organs was very poor, and clinical studies on new therapeutic strategies for these advanced cases are needed to improve the prognosis of Ce-Ut carcinoma patients.     

原发性甲状腺鳞状细胞癌的临床特征与诊治：附7例报告

目的:探讨原发性甲状腺鳞状细胞癌(SCCT)的临床、超声及病理特征以及治疗和预后。方法:回顾性分析2010年1月—2015年12月收治的7例原发性SCCT患者的临床表现、超声声像图特征、术后病理结果和综合治疗效果。结果:7例原发性SCCT占同期全部甲状腺癌的0.96%(7/728),其中男3例,女4例,平均年龄62.7岁。所有患者均可触及颈部肿块,4例伴呼吸困难,2例伴声音嘶哑,1例伴吞咽困难。病灶超声声像图均表现为形态不规则的实性混合性回声光团,5例肿块侵透甲状腺被膜,2例伴有微钙化,4例有异常颈部淋巴结。手术治疗5例(甲状腺癌联合根治术2例,局部广泛切除术2例,姑息性切除术并同时行预防性气管切开1例),2例仅行粗针穿刺活检。患者病理均证实为SCCT,3例合并结节性甲状腺肿,2例合并甲状腺乳头状癌,7例肿瘤细胞P63免疫组化均阳性。5例手术患者术中,4例术后行放疗或放疗+化疗,1例未行综合治疗;2例粗针穿刺活检患者行单纯放疗或放疗+化疗。仅1例行根治性切除术联合术后放疗的患者生存期超过1年,其余均在半年内死亡。结论:原发性SCCT恶性程度高,病情发展迅速,预后差。其临床表现及超声声像图具有一定的特征性,有助于术前诊断,免疫组化对鉴别诊断非常重要,积极的综合治疗可能改善患者预后。     

Resectional management of thyroid carcinoma invading the airway.

Fifty-two patients had thyroid carcinoma invading the airway. Thirty-four underwent resection; 18 were male and 16 female. Age ranged from 17 to 79 years. Twenty-seven had resection with airway reconstruction (1 wedge excision, 10 sleeve tracheal resections, 6 tracheal resections with a portion of the cricoid cartilage, and 10 complex laryngotracheoplastic resections). Seven required cervicomediastinal exenteration with mediastinal tracheostomy; 3 of these had esophagectomy with colon interposition. Nineteen tumors were papillary, 6 follicular, 4 mixed papillary and follicular, 1 squamous, 2 undifferentiated giant cell, 1 anaplastic spindle cell carcinoma, and 1 carcinosarcoma. Three postoperative deaths occurred. Thirteen of the 31 survivors died of cancer from 1/4 to 10 1/4 years postoperatively (average, 4.4 years). Four died of other diseases. Fourteen are alive from 1/12 to 14 1/3 years postoperatively (average, 5.3 years). Only 2 patients had airway recurrence. Resection of the airway invaded by thyroid malignancy in the absence of extensive metastases offers prolonged palliation, avoids suffocation due to bleeding or obstruction, and may produce cure. Airway reconstruction should be performed whenever technically feasible.     

Problems concerning the diagnosis and treatment of multiple primary carcinoma of the lung

Data on 44 patients with multiple primary carcinoma of the lung are presented. Twenty had metachronous tumors, and 24 had synchronous tumors. Twenty-one patients had undergone complete resection for both tumors, and 14 had undergone resection for only one of two tumors. The remaining 9 patients underwent no operation and were treated with photodynamic, radiation and/or chemotherapy. Long-term survival of more than 3 years was achieved for 11 patients, nine of whom had synchronous lesions. Furthermore, they included 3 patients who underwent nonsurgical therapy for both lesions. On the other hand, the prognosis after resection of the second tumor in patients with metachronous lesions was poor. This was thought to be the result of failure to diagnose the second lesion due to incomplete long-term follow-up. We conclude that careful attention to the operative indications is necessary for patients with multiple lesions, particularly lesions such as early squamous cell carcinomas.     

Second primary lung cancer after bronchial sleeve resection. Treatment and results in eleven patients.

During the years 1960 to 1989, 145 patients underwent sleeve lobectomy or sleeve resection of a main bronchus. Follow-up was complete except for one patient, who was no longer available for follow-up 4 years after operation. Eleven patients (7.6%) had a second primary cancer in the lung; 10 of these patients (90.9%) were men. Mean age at sleeve operation was 61.2 +/- 11.6 years. Mean interval between sleeve operation and development of second primary cancer was 53.8 months (range, 6 to 197 months). All second primary cancers occurred on the contralateral side. In five cases there was squamous cell carcinoma, in two there was adenocarcinoma, in one there was adenosquamous carcinoma, in two there was small cell carcinoma, and in one patient no definite histologic type could be established. Five patients had different histologic type from the initial, resected primary tumor. Seven patients (64%) were operated on: five underwent lobectomy and two underwent segmentectomy. In one patient the tumor was judged to be unresectable. Chemotherapy was given to the two patients with small cell carcinoma and radiotherapy was given to one patient with bone metastases. Follow-up was complete for these 11 patients. Data were calculated from detection of second primary cancer. There was one postoperative death from myocardial infarction. Eight other patients died during follow-up: five died of recurrent tumor or metastases, two died of acute cardiac failure, and one died of a perforated ulcer. The 1- and 4-year actuarial survivals were 41% and 30%, respectively. For the patients operated on, 1- and 4-year survivals were 57% and 43%, respectively. There were no survivors at 5 years. Sleeve resection is a valuable method of preserving functional lung tissue. It offers a chance of subsequent resection in patients who have second primary cancer, with acceptable results.     

Resectional treatment for thyroid cancer with tracheal invasion: a long-term follow-up study

HYPOTHESIS: Transmural invasion of the trachea by well-differentiated thyroid carcinomas is a locally advanced disease condition. It frequently causes deaths owing to airway obstruction. We hypothesized that resection of the invaded trachea followed by primary anastomosis provides the opportunity for cure. DESIGN: A retrospective review study of medical records. SETTING: The surgical department of a tertiary referral center. PATIENTS: Eight patients with well-differentiated thyroid carcinomas, complicated with tracheal invasion resulting in bleeding and airway obstruction, operated on by tracheal resection and immediate anastomosis, were included. INTERVENTIONS: All patients received total thyroidectomy and neck lymph node dissection as well as segmental tracheal resection followed by primary reconstruction. Postoperative radioactive sodium iodine I 131 treatment and suppression therapy with thyroxine were applied to all of them. MAIN OUTCOME MEASURE: Postoperative follow-up of serum levels of human thyroglobulin and abnormal radioactive iodine 131I from whole body scan. RESULTS: Seven patients are alive. Of these patients, 5 had no evidence of disease: (3 had no evidence of cancer for more than 10 years' follow-up), 2 had regional lymph node metastasis, and 1 had lung metastases. The remaining patient had anastomotic site recurrence with airway obstruction and needed tracheostomy to relieve stridor. She was lost to follow-up 39 months after undergoing the initial operation. CONCLUSIONS: Patients with mucosal invasion of the trachea by well-differentiated thyroid carcinomas should be treated by surgical resection followed by primary reconstruction when technically feasible. This facilitates postoperative care, and it is possible to achieve long-term survival with improvement of the quality of life and possible cures.     

Nonmelanoma cutaneous malignancy with regional metastasis.

OBJECTIVE AND STUDY DESIGN: We performed a retrospective study of 28 patients to evaluate the management and outcome of regional metastasis from nonmelanoma cutaneous malignancies. RESULTS: There were 25 squamous cell, 1 basal cell, and 2 eccrine carcinomas. The most common primary locations were the temple, ear, and cheek. Median interval from primary resection to regional metastasis was 9 months, and such were commonly of the parotid, level IB, and level IIA nodes. Twenty-four patients underwent parotidectomy and/or neck dissection; 19 patients, postoperative radiation. Ten patients (36%) died from the disease, 2 patients (7%) have persisting disease, 5 (18%) have died from intercurrent disease, and 11 (39%) have no evidence of disease (minimum follow-up, 22 months; median, 34 months). CONCLUSIONS AND SIGNIFICANCE: Nonmelanoma cutaneous malignancies with regional metastasis have a poor prognosis despite aggressive therapy. When high-risk characteristics are detected, examination of the nearest "sentinel node," prophylactic lymphadenectomy, and/or regional irradiation might be justified; further study is warranted.     

Surgical treatment of 'short stump' bronchial fistula.

OBJECTIVE: The optimal management of bronchial fistulae remains a surgical challenge. To assess the relative efficacy of the transsternal approach in the treatment of short stump bronchial fistula we analyzed a cohort of patients who underwent this type of surgery in our department during an almost 19 year period. METHODS: Of a series of 49 patients with short stump bronchial fistula who were treated via the transsternal approach, 15 underwent bifurcational sleeve resection and 34 had tracheal wedge resections. In 19 cases the tracheal defects was up to 30 mm in diameter, in the remaining 30 cases the length was less than 10 mm. In all cases tracheobronchial fistulae were associated with concomitant empyema. Surgical debridement of the empyema cavity was achieved by VATS application. In five patients who underwent primary surgery for lung cancer tumor recurrence was seen in distal margins of the resected defect. RESULTS: There was no intraoperative mortality. Two patients died from acute pneumonia at postoperative day 3 and adult respiratory distress syndrome (ARDS) at postoperative day 7, respectively. Two further patients died due to anastomotic dehiscence from sepsis and respiratory failure the overall hospital mortality being 8 (16%). Major complications included one right pulmonary artery injury (2%), two healing disturbances after tracheal wedge resection and five after sleeve resection of the bifurcation. Late complication occurred in six patients (13.3%) with delayed healing at the suture site who later required treatment, two of these required additional stent applications. CONCLUSIONS: Surgical treatment of patients with short stump tracheobronchial fistulae by means of a transsternal approach allows reliable closure with low mortality and morbidity.     

膀胱非尿路上皮性肿瘤的诊治(附46例报告)

目的:探讨膀胱非尿路上皮性肿瘤的诊断、治疗方法和预后。方法:回顾性分析2002年1月～2010年12月收治的46例膀胱非尿路上皮性肿瘤患者的临床资料:男34例,女12例。年龄30～82岁,平均61.3岁。术前辅助检查主要包括B超、盆腔CT、膀胱镜加病理活检以及131I-MIBG。42例行手术治疗,4例放弃手术。结果:46例术前或术后病理检查诊断为膀胱鳞状细胞癌19例,膀胱腺癌18例(单纯性非脐尿管腺癌8例,脐尿管腺癌5例,转移性腺癌5例),膀胱小细胞癌4例,膀胱嗜铬细胞瘤5例。术后40例随访12～72个月,膀胱嗜铬细胞瘤5例均健在,膀胱鳞癌及腺癌各2例随访至14～26个月仍存活,其余患者平均存活时间13.2个月。结论:膀胱非尿路上皮恶性肿瘤恶性程度高,确诊时大多已是晚期,预后差。膀胱根治性切除术是除转移性癌和小细胞癌外的膀胱非尿路上皮性恶性肿瘤的推荐手术方案,小细胞癌以化疗为主,转移性癌以改善尿路症状为主,良性嗜铬细胞瘤以膀胱部分切除为主。     

Ösophagektomie als chirurgisches Therapieprinzip beim Plattenepithelkarzinom des Ösophagus

The fatalistic approach towards surgical therapy of esophageal squamous cell cancer has been replaced in recent years by a more differentiated view. This was triggered by the establishment of individualized therapeutic modalities based on tumor stage, tumor location, general patient status, and comorbidity. Despite advances in nonsurgical therapy of squamous cell esophageal cancer, esophagectomy remains the central therapeutic modality. Primary subtotal en-bloc esophagectomy with lymphadenectomy is the only curative option with a high likelihood of success for resectable tumors (uT1-3 categories) located below the level of the tracheal bifurcation and for early more proximal tumors. In patients with locally advanced tumors at or above the level of the tracheal bifurcation, surgical resection can still cure those who respond to neoadjuvant radiochemotherapy. Preoperative "conditioning" of risk patients, surgical safety strategies in risk situations, and standardization of both the operative procedure and the perioperative management have resulted in a marked reduction of the previously substantial postoperative mortality to below 3% in experienced centers. In our own experience of 900 esophagectomies for squamous cell esophageal cancer, the 5-year survival rate rose from about 20% to more than 50% in the last two decades. Esophagectomy thus has become a safe operation and remains the only therapeutic option offering cure for a substantial proportion of patients with squamous cell cancer of the esophagus.     

Patterns of spread in recurrent head and neck squamous cell carcinoma.

OBJECTIVE: To examine the pattern of spread regarding recurrent disease in primary head and neck squamous cell carcinoma. STUDY DESIGN AND SETTING: A retrospective study reviewed 128 patients who underwent primary tumor resection and postoperative radiation and/or chemoradiation for squamous cell carcinoma at Loyola University Medical Center from July 1993 to August 1998. Patterns of spread of recurrent disease were grouped according to site of recurrence and compared with the histopathology. RESULTS: Of 128 patients, 40 (32%) had recurrent disease, 22 (17%) died without disease, and 66 (51%) are disease free. Although the recurrences in patients who were N0 were primarily local-regional (8/11), the majority of recurrences in patients that were N+ with extracapsular nodal spread involved distant sites (18/24); 17/18 involved metastasis to the lung. SIGNIFICANCE: This study gives the first report at our institution of patterns of spread in recurrent head and neck squamous cell cancer and compares these patterns within subgroups of patients based on the extent of neck disease at the time of primary surgical resection. CONCLUSION: Not only was there a higher rate of recurrent disease in patients with extracapsular nodal spread, there was a much higher involvement of distant metastatic sites as opposed to local-regional recurrence more often seen with the N0 neck. The most common site of distant metastasis was the lung.     

Squamous cell carcinoma of the thyroid gland

We present the clinical manifestations and details of treatment and outcome for eight patients with squamous cell cancer arising in the thyroid gland, which is a rare entity. All patients had advanced disease, with primary tumors invading adjacent structures (the trachea, esophagus, and major vessels). In two patients, pulmonary metastases were also present. Six patients died 6 months or less after diagnosis, five from the effects of local disease. Transient palliation was obtained in four patients who underwent partial excision (three patients) and radical radiotherapy (one patient). Two patients remained free of disease at last follow-up more than 4 years after gross total tumor resection and radical radiotherapy and were presumably cured. One patient treated by partial resection and radical radiotherapy died from other causes 17 months later. His disease status was unknown. Complete excision with postoperative radiotherapy may be curative, and debulking followed by external irradiation may provide short-term palliation. Patients with unresectable tumors are best managed by supportive measures only unless a truly effective chemotherapeutic regimen is developed for squamous cell cancer of the head and neck.     

What is the optimal distal resection margin for esophageal carcinoma?

BACKGROUND: Whereas a proximal resection margin of 12 cm is recommended for complete resection of esophageal cancer, the extent of distal resection is unclear. METHODS: We examined distal resection margins in a consecutive series of patients who underwent esophagectomy for squamous cell carcinomas (n = 50), primary esophageal adenocarcinomas (n = 100), and adenocarcinomas of the cardia (n = 39), in whom all macroscopic tumor was judged to be completely resected. RESULTS: Microscopic tumor was found at a 3-cm distal resection margin for one multifocal squamous cell carcinoma. Positive distal resection margins were seen in 12% (12 of 100 patients) of primary esophageal adenocarcinomas (median, 2 cm versus 4 cm if negative; p = 0.002, Wilcoxon) and 28% (11 of 39 patients) of cardia adenocarcinomas (median, 1 cm versus 3 cm if negative; p = 0.02, Wilcoxon). Although pathologic stage was shown to be the only significant predictor of overall survival (Hazard ratio [HR] 1.8; 95% confidence interval 1.2 to 2.6; p = 0.007), there was a trend toward reduced postoperative survival for patients with histologically positive distal resection margins, in particular for patients with cardia adenocarcinomas (median, 15.4 months versus 5.7 months if negative; p = 0.0001). CONCLUSIONS: To achieve consistently negative distal resection margins, we recommend resection of at least 5 cm of macroscopically normal foregut below the distal margin of the primary tumor.