Node status in transmural esophageal adenocarcinoma and outcome after en bloc esophagectomy

OBJECTIVE: Adenocarcinoma has replaced squamous cell as the most common esophageal cancer in the United States. The purpose of this study was to determine the prevalence and location of lymph node metastases, the feasibility of performing an R0 resection, and disease recurrence and survival in patients with transmural adenocarcinoma of the lower esophagus and gastroesophageal junction. METHODS: Forty-four patients with transmural adenocarcinoma underwent en bloc esophagectomy with systematic thoracic and abdominal lymphadenectomy. They were followed up for a median of 23 months. RESULTS: Actuarial survival for the entire group was 26% at 5 years. The most important predictors of the likelihood of recurrent disease and 5-year survival were the presence and number of lymph node metastases and the ratio of involved to total removed nodes. Seven patients (16%) were found to have no lymph node metastases and had an 85% 5-year survival. In contrast, patients with more than 4 involved nodes or a node ratio greater than 0.1 had a high likelihood of recurrence and death. Location of involved lymph nodes did not predict the likelihood of recurrence or death. Despite all patients having transmural tumors, recurrence within the field of the en bloc resection occurred in only 1 patient (2%). CONCLUSIONS: En bloc esophagectomy in patients with transmural esophageal adenocarcinoma is required to obtain the survival benefit of an R0 resection, to adequately assess lymphatic tumor burden, and to be able to predict the likelihood of recurrence and death and thereby guide the use of postoperative adjuvant therapy.     

Adenocarcinoma of the gastroesophageal junction: influence of esophageal resection margin and operative approach on outcome

OBJECTIVE: To determine whether the length of esophageal resection or the operative approach influences outcome for patients with adenocarcinoma of the gastroesophageal junction (GEJ). SUMMARY BACKGROUND DATA: While R0 resection remains the mainstay of curative treatment of patients with GEJ cancer, the optimal length of esophageal resection remains controversial. METHODS: Patients with Siewert I, II, or III adenocarcinoma who underwent complete gross resection without neoadjuvant therapy were identified from a prospectively maintained database. Proximal margin lengths were recorded ex vivo as the distance from the gross tumor edge to the esophageal transection line. Operative approaches were grouped into gastrectomy (limited esophagectomy) or esophagectomy (extended esophagectomy). RESULTS: From 1985 through 2003, 505 patients underwent R0/R1 gastrectomy (n = 153) or esophagectomy (n = 352) without neoadjuvant treatment. There were no differences in R1 resection rate, number of nodes examined or operative mortality between gastrectomy and esophagectomy. Univariate analysis found >3.8 cm to be the ex vivo proximal margin length (approximately 5 cm in situ) most predictive of improved survival. Multivariable analysis in patients who underwent R0 resection with >or=15 lymph nodes examined (n = 275) found the number of positive lymph nodes, T stage, tumor grade, and ex vivo proximal margin length >3.8 cm to be independent prognostic factors. Subset analysis found that the benefit associated with >3.8 cm margin was limited to patients with T2 or greater tumors and 相似文献   

Results of en bloc resection for bronchogenic carcinoma with chest wall invasion

OBJECTIVE: Lung cancer invading the chest wall without lymph node metastasis has recently been downstaged to stage IIb. To validate this reclassification, we reviewed our experience with en bloc lung and chest wall resection for bronchogenic carcinoma. METHODS: From February 1985 to November 1999, 95 en bloc lung and chest wall resections were performed on 94 patients (62 men and 32 women). The median age was 66 years (range, 38-93 years). Pancoast tumors were excluded. Factors that may affect survival were analyzed with univariate analysis, and factors found to be significant univariately were analyzed multivariately to determine whether the significant association remained after adjusting for other significant factors. RESULTS: Presenting symptoms included chest wall pain in 42 patients, cough in 17 patients, and "other" in 16 patients. Twenty patients were asymptomatic. Ninety-two patients were current or former smokers (median pack-years, 50; range, 8-150 pack-years). Seventy-five lobectomies, 12 pneumonectomies, 5 bilobectomies, 2 wedge excisions, and 1 segmentectomy were performed. The number of ribs resected ranged from 1 to 5 (median, 3). Sixty-one patients required chest wall reconstruction (prostheses in 60 and bovine pericardium in 1). Operative morbidity and mortality were 44.2% and 6.3%, respectively. Sixty-five cancers were classified as T3 N0 M0, 16 as T3 N1 M0, and 14 as T3 N2 M0. Squamous cell carcinoma was present in 56 tumors, adenocarcinoma in 25, large cell carcinoma in 11, and "other" in 3. Follow-up was complete in 86 (96.6%) of 89 operative survivors and ranged from 1 month to 15 years (median, 19 months). Overall 5-year actuarial survival was 38.7%. Five-year survival for patients with stage IIb disease (T3 N0 M0) was 44.3% compared with only 26.3% for those with stage IIIa disease (T3 N1 M0 or T3 N2 M0, P =.0082). Women had a better 5-year survival than men (52.9% vs 31.0%, P =.0122). The best 5-year survival was observed in women with stage IIb disease (61.2%). All other variables (age, tumor size, histopathology, forced expiratory volume in 1 second, extent of operation, depth of invasion, and adjuvant therapy) did not significantly affect survival. CONCLUSIONS: En bloc resection of lung cancer invading the chest wall is safe but associated with significant morbidity. Long-term survival is stage and sex dependent. The best survival is observed in women who have T3 N0 M0 disease (stage IIb).     

Refining esophageal cancer staging

OBJECTIVE: Cancer staging is dynamic, reflecting accrual of knowledge and experience in treatment. The objectives of this study were to assess current esophageal cancer staging and to determine whether refinements of classification and stage grouping are necessary. METHODS: From 1983 through November 2000, 480 patients underwent esophagectomy without induction therapy. Depth of tumor invasion (T), regional lymph node status (N), distant status (M), number of metastatic regional lymph nodes, and histopathologic type and grade were subjected to survival-tree analysis, multivariable Cox and hazard function analysis, and residual misclassification risk analysis. RESULTS: Inhomogenity of survival was found within and lack of distinction was found between current American Joint Committee on Cancer staging groups, supporting the need for refinement. T1 and N1 were redefined on the basis of survival differences. T1a is intramucosal cancer, T1b is submucosal cancer (P =.008), N1 is 1 or 2 metastatic regional lymph nodes, and N2 is 3 or more metastatic regional lymph nodes (P =.01). Current subclassification of M1 is not warranted (P =.9). Histopathologic type (P =.17) and grade (P =.3) minimally refined staging. Reassignment of staging groups constrained by American Joint Committee on Cancer definitions of stages 0 and IV produced less monotonic, distinctive, and homogeneous survival than free assignment of staging groups. CONCLUSIONS: Current American Joint Committee on Cancer staging of esophageal cancer is inadequate. Refinement requires redefinition of T1, N1, and M1 classifications. Stage grouping within the constraints of American Joint Committee on Cancer definitions produces less accurate prognosis than free assignment based on survival data.     

Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus: five-year survival of a randomized clinical trial

OBJECTIVE: To determine whether extended transthoracic esophagectomy for adenocarcinoma of the mid/distal esophagus improves long-term survival. BACKGROUND: A randomized trial was performed to compare surgical techniques. Complete 5-year survival data are now available. METHODS: A total of 220 patients with adenocarcinoma of the distal esophagus (type I) or gastric cardia involving the distal esophagus (type II) were randomly assigned to limited transhiatal esophagectomy or to extended transthoracic esophagectomy with en bloc lymphadenectomy. Patients with peroperatively irresectable/incurable cancer were excluded from this analysis (n = 15). A total of 95 patients underwent transhiatal esophagectomy and 110 patients underwent transthoracic esophagectomy. RESULTS: After transhiatal and transthoracic resection, 5-year survival was 34% and 36%, respectively (P = 0.71, per protocol analysis). In a subgroup analysis, based on the location of the primary tumor according to the resection specimen, no overall survival benefit for either surgical approach was seen in 115 patients with a type II tumor (P = 0.81). In 90 patients with a type I tumor, a survival benefit of 14% was seen with the transthoracic approach (51% vs. 37%, P = 0.33). There was evidence that the treatment effect differed depending on the number of positive lymph nodes in the resection specimen (test for interaction P = 0.06). In patients (n = 55) without positive nodes locoregional disease-free survival after transhiatal esophagectomy was comparable to that after transthoracic esophagectomy (86% and 89%, respectively). The same was true for patients (n = 46) with more than 8 positive nodes (0% in both groups). Patients (n = 104) with 1 to 8 positive lymph nodes in the resection specimen showed a 5-year locoregional disease-free survival advantage if operated via the transthoracic route (23% vs. 64%, P = 0.02). CONCLUSION: There is no significant overall survival benefit for either approach. However, compared with limited transhiatal resection extended transthoracic esophagectomy for type I esophageal adenocarcinoma shows an ongoing trend towards better 5-year survival. Moreover, patients with a limited number of positive lymph nodes in the resection specimen seem to benefit from an extended transthoracic esophagectomy.     

Curative resection for esophageal adenocarcinoma: analysis of 100 en bloc esophagectomies

OBJECTIVE: To document what can be accomplished with surgical resection done according to the classical principles of surgical oncology. METHODS: One hundred consecutive patients underwent en bloc esophagectomy for esophageal adenocarcinoma. No patient received pre- or postoperative chemotherapy or radiation therapy. Tumor depth and number and location of involved lymph nodes were recorded. A lymph node ratio was calculated by dividing the number of involved nodes by the total number removed. Follow-up was complete in all patients. The median follow-up of surviving patients was 40 months, with 23 patients surviving 5 years or more. RESULTS: The overall actuarial survival rate at 5 years was 52%. Survival rates by American Joint Commission on Cancer (AJCC) stage were stage 1 (n = 26), 94%; stage 2a (n = 11), 65%; stage 2b (n = 13), 65%; stage 3 (n = 32), 23%; and stage 4 (n = 18), 27%. Sixteen tumors were confined to the mucosa, 16 to the submucosa, and 13 to the muscularis propria, and 55 were transmural. Tumor depth and the number and ratio of involved nodes were predictors of survival. Metastases to celiac (n = 16) or other distant node sites (n = 26) were not associated with decreased survival. Local recurrence was seen in only one patient. Latent nodal recurrence outside the surgical field occurred in 9 patients and systemic metastases in 31. Tumor depth, the number of involved nodes, and the lymph node ratio were important predictors of systemic recurrence. The surgical death rate was 6%. CONCLUSION: Long-term survival from adenocarcinoma of the esophagus can be achieved in more than half the patients who undergo en bloc resection. One third of patients with lymph node involvement survived 5 years. Local control is excellent after en bloc resection. The extent of disease associated with tumors confined to the mucosa and submucosa provides justification for more limited and less morbid resections.     

Selection of operation for esophageal cancer based on staging.

The concept of en bloc removal of tissue surrounding the esophagus was applied to intrathoracic esophageal cancers, and the first 80 cases were operated on by this technique between 1969 and 1981. Analysis of prognostic factors showed that only penetration through the esophageal wall and lymph node spread influenced survival. Since 1981, a new staging system based on wall penetration (W) and lymph nodes (N), as well as systemic metastases (M), and similar to the modified Dukes' system for colon cancer has been used to select patients before and during surgery for en bloc resection if favorable pathology (W1, N0, or N1) could be anticipated. When curative resection was not attainable, based on preoperative and operative staging, a standard esophagectomy was considered for relief of symptoms when necessary. From July 1981 to June 1984, 68 esophageal cancers were referred to us, and 31 were resected by the en bloc method, 21 by standard esophagectomy, and 16 were not resected. The success of preoperative staging was confirmed, as only nine of the 31 en bloc cases demonstrated both W2 and N2 pathology. The proportion of W2N2 cases subjected to en bloc esophagectomy was less (p less than 0.01) than that in the preceding series. This selection of cases showed a favorable deviation in the survival curve following en bloc esophagectomy since 1981 compared to the earlier interval. Patients treated by en bloc esophagectomy had a significantly greater survival than they did following standard esophagectomy at all time intervals after 6 months. There was no difference in hospital mortality or complications between the two operations. Further evidence for the value of the new staging system was shown by the significant difference in survival curves between those with favorable versus unfavorable staging and treated by en bloc esophagectomy. Among all cases resected between 1981 and 1984, 18-month survival in W1 stage was 67% compared to 35% for W2 disease. Survival with N0 disease was 58% versus 43% for N1 stage and 21% for N2 stage. The favorable survival rates after en bloc resection in those with limited (less than W2N2) disease support the concept of selecting patients for curative surgery based on preoperative and operative staging. Preoperative radiation therapy caused a significant decline in patient survival at 6 and 12 months and has been abandoned.(ABSTRACT TRUNCATED AT 400 WORDS)     

Skeletonizing En Bloc Esophagectomy for Cancer

OBJECTIVE: To evaluate the long-term outcome of patients with esophageal cancer after resection of the extraesophageal component of the neoplastic process en bloc with the esophageal tube. SUMMARY BACKGROUND DATA: Opinions are conflicting about the addition of extended resection of locoregional lymph nodes and soft tissue to removal of the esophageal tube. METHODS: Esophagectomy performed en bloc with locoregional lymph nodes and resulting in a real skeletonization of the nonresectable anatomical structures adjacent to the esophagus was attempted in 324 patients. The esophagus was removed using a right thoracic (n = 208), transdiaphragmatic (n = 39), or left thoracic (n = 77) approach. Lymphadenectomy was performed in the upper abdomen and lower mediastinum in all patients. It was extended over the upper mediastinum when a right thoracic approach was used and up to the neck in 17 patients. Esophagectomy was carried out flush with the esophageal wall as soon as it became obvious that a macroscopically complete resection was not feasible. Neoplastic processes were classified according to completeness of the resection, depth of wall penetration, and lymph node involvement. RESULTS: Skeletonizing en bloc esophagectomy was feasible in 235 of the 324 patients (73%). The 5-year survival rate, including in-hospital deaths (5%), was 35% (324 patients); it was 64% in the 117 patients with an intramural neoplastic process versus 19% in the 207 patients having neoplastic tissue outside the esophageal wall or surgical margins (P <.0001). The latter 19% represented 12% of the whole series. The 5-year survival rate after skeletonizing en bloc esophagectomy was 49% (235 patients), 49% for squamous cell versus 47% for glandular carcinomas (P =.4599), 64% for patients with an intramural tumor versus 34% for those with extraesophageal neoplastic tissue (P <.0001), and 43% for patients with fewer than five metastatic nodes versus 11% for those with involvement of five or more lymph nodes (P =.0001). CONCLUSIONS: The strategy of attempting skeletonizing en bloc esophagectomy in all patients offers long-term survival to one third of the patients with resectable extraesophageal neoplastic tissues. These patients represent 12% of the patients with esophageal cancer suitable for esophagectomy and 19% of those having neoplastic tissue outside the esophageal wall or surgical margins.     

Salvage esophagectomy for recurrent tumors after definitive chemotherapy and radiotherapy.

OBJECTIVES: Some patients and oncologists choose to treat localized esophageal cancer with definitive chemotherapy and radiation therapy rather than surgery. A subset of these patients have local relapse without distant metastases and therefore have no other curative intent treatment option but salvage esophagectomy. METHODS: We reviewed our experience with salvage esophagectomy from 1987 to 2000 at M.D. Anderson Cancer Center (n = 13, salvage after chemotherapy and radiotherapy group) and compared the data with those of patients receiving esophagectomy in a planned fashion 4 to 6 weeks after preoperative chemotherapy and radiation therapy (n = 99, preoperative chemotherapy and radiotherapy group). RESULTS: Increases in morbidity were seen after resection in the salvage after chemotherapy and radiotherapy group relative to the preoperative chemotherapy and radiotherapy group: mechanical ventilation (9.0 days vs 3.3 days, P =.08), intensive care unit stay (11.2 days vs 5.1 days, P =.07), hospital stay (29.4 days vs 18.4 days, P =.03), and anastomotic leak rates (5/13 [39%] vs 7/99 [7%], P =.005). Operative mortality (within 30 days) also tended to be increased statistically nonsignificantly (2/13 [15%] vs 6/99 [6%], P =.2). Salvage esophagectomy resulted in long-term survival (25% 5-year survival) in a subset of patients. Improved survival after salvage esophagectomy was associated with early pathologic stage (T1 N0, T2 N0), prolonged time to relapse, and R0 surgical resection. CONCLUSION: Patients who undergo salvage esophagectomy for relapse of tumor after definitive chemoradiation therapy have increased morbidity, mortality, and hospital use relative to patients undergoing planned esophagectomy after preoperative chemoradiation. Nevertheless, long-term survival can be achieved in this group, and such treatment should be considered for carefully selected patients at an experienced center.     

Chest wall invasion in non-small cell lung carcinoma: a rationale for en bloc resection

OBJECTIVE: The choice of surgical approach to non-small cell lung cancer invading the chest wall, extrapleural resection versus en bloc chest wall resection, is much more related to the experience of the surgeon than to objective criteria. The aim of the present study is to help to establish a rationale for en bloc chest wall resection in lung cancer invading the chest wall. METHODS: From January 1990 to June 1999, of 1855 patients having major pulmonary resections for non-small cell lung carcinoma, 104 (5.6%) patients with neoplasms involving the chest wall underwent en bloc chest wall and lung resection plus radical mediastinal lymphadenectomy. RESULTS: All patients underwent complete resection with microscopically disease-free tissue margins. Depth of invasion was into the parietal pleura only in 28 (26.92%), into the pleura and soft tissue in 36 (34.62%), and into the pleura, soft tissue, and bone in 40 (38.46%). No operative mortality was reported. Follow-up was completed in 96 patients. One patient had a local recurrence. The overall 5-year estimated survival was 61.4%. Survival in the subsets T3 N0 and T3 N2 were, respectively, 67.3% and 17.9% (P =.007). The 5-year survival was 79.1% in involvement of parietal pleura only and 54.0% in involvement of soft tissue with or without bone invasion (P =.014). Five-year survival was 53.0% in adenocarcinoma versus 71.8% in squamous cell carcinoma (P =.329) and 74.1% in patients who did undergo radiation therapy versus 46.7% in patients who did not undergo radiation therapy (P =.023). CONCLUSIONS: En bloc resection of the chest wall and lung is the procedure of choice to obtain complete resection in lung carcinoma invading the chest wall. Survival is highly dependent on the completeness of resection, nodal involvement, and depth of chest wall invasion.     

Clinical implications of p53 tumor suppressor gene mutation and protein expression in esophageal adenocarcinomas: results of a ten-year prospective study

OBJECTIVE: This study was undertaken to characterize the spectrum of p53 alterations (mutations and protein expression) in surgically resected esophageal adenocarcinomas, and to correlate molecular alterations with clinicopathologic findings and outcome. METHODS: Between 1991 and 2001, 91 consecutive patients with esophageal adenocarcinomas underwent subtotal esophagectomy. No patient received induction therapy. Strict clinicopathologic criteria were used to define primary esophageal adenocarcinomas. Genomic DNA was extracted from esophageal tumors, each matched with histologically normal esophageal epithelium (internal control) from the resection margin. Polymerase chain reaction was used to amplify p53 exons 4 through 10. Mutations were studied by single-strand conformation polymorphism analysis and direct DNA sequencing. Immunohistochemical testing (monoclonal antibody DO7) was used to evaluate p53 protein distribution. RESULTS: Five-year overall survival was 27.3%. No p53 alterations (mutations and/or protein overexpression) were found in normal esophageal epithelium. A total of 57.1% (n = 52) of tumors had p53 alterations (mutations and/or protein overexpression), which on univariate analysis were associated with poor tumor differentiation (P =.001), advanced pTNM stage (P =.009), and number of involved lymph nodes (0, 1-3, >3; P =.04). Patients with p53 alterations had significantly reduced 5-year overall survival relative to patients with wild-type p53 (15% vs 46%; P =.004). The p53 mutations were predominantly G:C to A:T transitions at CpG dinucleotides (52.2%, 24/46) CONCLUSIONS: We conclude that p53 alterations (mutations and/or protein overexpression) are a predictor of reduced postoperative survival after surgical resection of esophageal adenocarcinomas and that p53 may be a clinically useful molecular marker for stratifying patients in future clinical trials. Patterns of p53 mutations suggest endogenous mutational mechanisms.     

Surgery for gallbladder cancer: a population-based analysis

BACKGROUND: Gallbladder cancer is an aggressive neoplasm, and resection is the only curative modality. Single institutional studies report an aggressive surgical approach improves survival. This analysis was performed to examine the components of surgical resection and resultant survival. STUDY DESIGN: From 1988 to 2003, patients aged 18 to 85 years, resected of T1-3 M0 gallbladder cancer, were identified from the Surveillance, Epidemiology, and End Results (SEER) registry. Resections were classified as en bloc (cholecystectomy + at least one adjacent organ) or simple (cholecystectomy only); lymphadenectomy was defined as three or more lymph nodes assessed. RESULTS: Of the 2,835 resected patients with T1-T3 M0 cancer, only 8.6% underwent an en bloc resection, and 5.3% had a lymphadenectomy. In multivariable analysis, age, year of resection, region, and advanced T-stage were associated with more aggressive resection. In univariate analysis, improved survival was associated with en bloc resection for T1/2 cancers, and lymphadenectomy for T2/3 cancers. In multivariable analysis, the following were associated with improved survival: for T1 cancers, en bloc resection, younger age, lower grade, and recent year of resection; for T2 cancers, Caucasian race (versus African-American), lower grade, and node negative disease, with trends for en bloc resection and lymphadenectomy; and for T3 cancers, female gender, Caucasian race (versus American Indian), lower grade, node negative disease, and recent year of resection, with a strong trend for lymphadenectomy. CONCLUSIONS: Very few patients underwent aggressive surgery. En bloc resection and lymphadenectomy may have stage-specific effects on survival. Additional studies should explore the underuse of aggressive operations, verify survival advantages, and define stage-specific resection strategies.     

Surgical Treatment of Cancer of the Thoracic Esophagus in Association With a Major Pulmonary Operation

Background: Pulmonary complications have been a major cause of mortality after operations for cancer of the thoracic esophagus. Although the risk involved in esophagectomy associated with a major pulmonary operation is expected to be high, it has seldom been evaluated on the basis of clinical experience.

Study Design: Of 408 patients who underwent esophagectomy, 8 had previously undergone major pulmonary operation (7 for tuberculosis and 1 for pulmonary cancer) and 10 underwent concurrent major pulmonary resection (7 for pulmonary invasion of esophageal cancer, 2 for synchronous pulmonary cancer, 1 for extensive bronchiectasia). All patients underwent systematic lymph node dissection for esophageal cancer, except one patient with mucosal cancer. To prevent postoperative complications, the operative approach and dissection procedures for esophageal cancer were modified according to the associated pulmonary operation and the extent of cancer invasion. All thoracotomies for esophagectomy were performed on the same side as the major pulmonary operation. Additional median sternotomy was performed when necessary. In the most recent 8 patients who underwent major pulmonary resection concurrent with esophagectomy, the bronchial stump was covered with a pedicle flap.

Results: Of the 18 patients who underwent pulmonary operation, postoperative complications developed in 13 of the 18 object patients, but none was fatal. The 3-year survival rate was 45%. All deaths were caused by esophageal cancer or another cancer.

Conclusions: Aggressive esophagectomy associated with major pulmonary operation is not contraindicated in patients with fair risk conditions. The operative procedures for esophagectomy should be appropriately modified to minimize the effect of the associated pulmonary operation. Special care should be taken with respect to the approach for mediastinal dissection and closure of the bronchial stump.     

Colonic interposition after esophagectomy for cancer

HYPOTHESIS: The use of colonic interposition in esophageal replacement after esophagectomy for cancer results in similar morbidity, mortality, and long-term outcome compared with gastric transposition. DESIGN: Prospectively collected database on patients with esophageal cancer from January 1, 1982, through December 31, 2000. SETTING: Academic university hospital department of surgery. PATIENTS: We compared 42 patients who underwent colonic interposition (colon group) with 959 patients who underwent gastric transposition (stomach group) after esophagectomy. MAIN OUTCOME MEASURES: Morbidity, mortality, and long-term survival. RESULTS: Greater blood loss (median, 1000 vs 700 mL; P<.001) and longer operation duration (median, 270 vs 225 minutes; P<.001) were encountered in the colon group. We found no difference in cardiopulmonary complications, but we found significantly greater incidences of anastomotic leakage (14.3% vs 3.9%; P =.007) and intra-abdominal septic complications (9.5% vs 0.2%; P<.001) in the colon group. Conduit ischemia developed in 5 patients (0.5%) in the stomach group, 3 of whom underwent successful staged reconstruction with colon. One patient (2.4%) in the colon group was found to have conduit ischemia and died. Hospital mortality rates included 7 patients (16.7%) from the colon group and 102 (10.6%) from the stomach group (P =.21). These figures improved to 0 and 27 (5.5%), respectively, in the second half of the study period (P>.99). Median survival was 12.8 and 10.4 months in the stomach and colon groups, respectively (P =.4). CONCLUSIONS: Colonic interposition is a more complex procedure with increased morbidity, compared with gastric transposition. Overall mortality and survival, however, were similar to those for gastric transposition.     

Extracapsular lymph node involvement is a negative prognostic factor in T3 adenocarcinoma of the distal esophagus and gastroesophageal junction

OBJECTIVE: To assess prognosis according to whether lymph node involvement is intracapsular or with extracapsular breakthrough in adenocarcinoma of the distal esophagus and gastroesophageal junction.Materials and methods One hundred ninety-five consecutive patients with T3 adenocarcinoma of the distal esophagus and gastroesophageal junction between 1990 and 1999 were studied. All patients underwent primary R0 esophagectomy. The mean number of resected nodes per patient was 36.9. Survival was analyzed according to intracapsular and extracapsular involvement. RESULTS: In N0 patients 5-year survival was 57% and 9-year survival was 38.7%. In patients with positive nodes these figures were 26.2% and 18.1%, respectively (P =.0069). Intracapsular and extracapsular node involvement showed 5- and 10-year survival of 40.9% and 21.7% versus 18% and 15.7%, respectively. There was no significant difference in 5- and 10-year survival between N0 and intracapsular node involvement (P =.43). However, there was a significant difference in survival between N0 and extracapsular node involvement (P =.002) and between intracapsular and extracapsular node involvement (P =.0001). CONCLUSIONS: This study shows a significant difference in survival according to whether lymph node involvement was intracapsular or extracapsular. Patients with intracapsular lymph node involvement have similar survival rates as N0 patients. Extracapsular lymph node involvement is a bad prognostic factor, independent of the number of involved lymph nodes. The number of involved lymph nodes has an additive negative effect. These data may have an impact on treatment strategies.     

Comparison of mutational changes in involved N1 lymph nodes with those in primary tumors in stage II non-small cell lung cancer: a pilot study

OBJECTIVES: Surgical resection is the standard treatment for stage II non-small cell lung cancer, but recurrence rates approach 60%. This study compared mutational changes in involved lymph nodes and primary tumors from patients with stage II non-small cell lung cancer to determine whether risk factors for recurrence could be identified. METHODS: Forty patients with resected stage II non-small cell lung cancer (excluding T3 N0 disease) were studied. Microdissection was performed on primary tumors and lymph nodes. Analysis was performed across 9 genomic loci by using polymerase chain reaction amplification. The ratio of fractional allelic loss between involved lymph nodes and primary tumors was used to stratify patients into high-risk (fractional allelic loss ratio of >or=1) and low-risk (fractional allelic loss ratio of <1) groups. RESULTS: The median age of the patients was 68 years (range, 42-85 years). Median follow-up was 30 months. Fractional allelic loss was greater in patients with squamous carcinomas compared with that in adenocarcinomas, but survival was similar (35 vs 39 months). The median survival was 35 months in high-risk patients and was not reached in low-risk patients (P =.3). Disease-free survival was 24 months in high-risk patients and was not reached in low-risk patients (P =.35). In the subset with adenocarcinoma (n = 18), median survival was 24 months in the high-risk group; no deaths occurred in low-risk patients (P =.01). Also, disease-free survival was 14 months in high-risk patients and was not reached in the low-risk patients (P =.05). CONCLUSIONS: Squamous cancers demonstrate greater mutational changes than adenocarcinomas; this does not affect outcome. The patients with low-risk adenocarcinomas demonstrated superior outcomes compared with those of other patients. These results should be confirmed in larger studies.     

Endodissection of the thoracic esophagus. Technique and clinical results in transhiatal esophagectomy.

OBJECTIVE: Transhiatal esophagectomy (THE), mostly performed in patients with adenocarcinoma of the esophagus, bears the risk of damage to mediastinal structures because the physician's vision is poor during esophageal dissection. The authors report a new endoscopic technique, which enables microsurgical dissection of the esophagus under visual control, that can be performed simultaneously to the abdominal approach. The clinical results in unselected patients with malignant esophageal disease were compared with those of patients undergoing conventional THE. METHODS: Thirty unselected patients (24 men and 6 women; median age, 60 years; age range, 35 to 80 years), mostly with adenocarcinoma of the esophagus, underwent endodissection between April 1991 and July 1992. Thirty patients, who underwent conventional THE between January 1986 and December 1990, were selected using a matched pair algorithm. RESULT: Three significant intraoperative complications were recorded during endodissection (one case of mediastinal bleeding; one case of postoperative bleeding; and one case of a lesion of the right main bronchus), and all were managed without further patient morbidity. The mortality rate (30 days) was 6.6% in the endodissection group (vs. 9.9% THE; not significant [NS]). The frequency of postoperative severe pulmonary complications was 13.3% in the endodissection group (vs. 30% in THE; p < 0.05). The rate of recurrent nerve palsy was only 6.6% in the endodissection group (vs. 13.3% in THE; NS). CONCLUSIONS: Endodissection is especially helpful during esophageal dissection at or above the trachea. It allows identification of mediastinal structures and controlled biopsy of mediastinal lymph nodes. This study showed that endodissection eliminates the "blind angle" during conventional THE, prevents recurrent nerve damage, and reduces pulmonary distress during transhiatal esophagectomy.     

En bloc resection for locally advanced cancer of the pancreas: Is it worthwhile?

The benefit of radical surgical resection of contiguously involved structures for locally advanced pancreatic cancer is unclear. The aim of this study was to examine patient outcome after extended pancreatic resection for locally advanced tumors and to determine if any subset of extended resection affected outcome. We retrospectively reviewed the records of 116 patients with adenocarcinoma of the pancreas, who underwent extirpative pancreatic surgery between 1987 and 2000. Of the 116 patients, 37 (32%) required resection of surrounding structures (group I), and 79 patients (68%) underwent standard pancreatic resections (group II). In all cases, all macroscopic disease was excised. In group I a total of 46 contiguously involved structures were resected: vascular in 25 patients (54%), mesocolon in 16 (35%) (colic vessels in 3, colon in 13), adrenal in three (7%), liver in one (2%), stomach in one (2%) (for a tumor in the tail of the pancreas), and multiple structures in four. Excision of regional blood vessels included the superior mesenteric vein and/or portal vein in 16, hepatic artery in five, and celiac axis in four. No differences between groups I and II were detected for any of the following parameters: age, sex, history of previous operation, estimated blood loss, or hospital stay. For the entire cohort the morbidity and mortality were 38% and 1.7%, respectively, and these rates were similar in the two groups. Adjuvant therapy was administered to more than 90% of patients in both groups. However, patients in group I were more likely to have received neoadjuvant therapy (76% vs. 42%, P = 0.001). Total pancreatectomy and distal pancreatectomy were more often performed in group I (P = 0.005). Additionally, the median operative time was longer (8.5 hours compared to 6.9 hours (P = 0.0004)). Both groups had similar rates of microscopically positive margins and involved lymph nodes, as well as total number of lymph nodes removed. The median survival was 26 months for patients in group I and 16 months for patients in group II (P = 0.08). The median disease-free survival for groups I and II was 16 months and 14 months, respectively (P = 0.88). In comparing patients in group I, who underwent vascular resection vs. mesocolon (colon or middle colic vessels) resection, the median survival was 26 months and 19 months, respectively (P = 0.12). We were unable to detect a difference in outcome for patients with locally advanced cancers requiring extended pancreatic resections compared to patients with standard resections. En bloc resection of involved surrounding structures, to completely extirpate all macroscopic disease, may be of benefit in selected patients with locally advanced disease, particularly when combined with preoperative chemoradiation therapy. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2002 (oral presentation).     

Impact of Total Lymph Node Count and Lymph Node Ratio on Staging and Survival after Pancreatectomy for Pancreatic Adenocarcinoma: A Large, Population-Based Analysis

Background Based on data from other malignancies, the number of lymph nodes evaluated and the ratio of metastatic to examined lymph nodes (LNR) may be important predictors of survival. LNR has never been investigated in a large population-based study of patients with pancreatic adenocarcinoma. Methods The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 4005 patients who underwent resection for pancreatic adenocarcinoma from 1988 to 2003. The effect of total lymph node count and LNR on survival was examined using univariate and multivariate analyses. Results The median number of lymph nodes examined was seven; 390 (10.1%) patients had no lymph nodes examined. Of those patients who had at least one lymph node examined, 1507 (43.3%) had no lymph node metastases (N0) and 1971 (56.7%) had metastatic nodal disease (N1). Overall median survival was 13 months, and 5-year survival was 6.8%. N1 disease was associated with a worse 5-year survival compared with N0 disease (4.3 vs 11.3%, respectively, P < .001). Patients with N0 disease could be further stratified based on the number of lymph nodes evaluated (median survival: 1–11 nodes, 16 months vs 12 or more nodes, 23 months; P < .001). For N1 patients, LNR was one of the most powerful factors associated with survival (LNR > 0–0.2, 15 months; LNR > 0.2–0.4, 12 months; LNR > 0.4, 10 months) (P < .001). Conclusions Most patients have an inadequate number of lymph nodes evaluated following pancreatic surgery. N0 patients who have fewer than 12 lymph nodes examined may be understaged. In patients with N1 disease, LNR may better substratify patients with regard to prognosis. Presented at the 60th Annual Cancer Symposium, The Society of Surgical Oncology, March 17, 2007.     

Radical cystectomy with extended lymphadenectomy: evaluating separate package versus en bloc submission for node positive bladder cancer

PURPOSE: To provide future mapping analysis of lymph node positive disease we modified our lymphadenectomy at radical cystectomy for bladder cancer from an en bloc packet to 13 separate nodal packets. We evaluated the clinical and pathological findings resulting from this modification. MATERIALS AND METHODS: A total of 1,359 patients underwent en bloc radical cystectomy and extended lymphadenectomy for bladder cancer. They were compared to 262 patients who underwent radical cystectomy and extended lymphadenectomy with lymph nodes submitted in 13 distinct nodal packets. Overall 317 patients (23%) of the en bloc group (group 1) and 66 of the 262 (25%) in the separately packaged group (group 2) had node positive disease. Clinical and pathological findings were analyzed to compare these 2 groups of patients. RESULTS: Although the incidence of lymph node positivity was not different, the median number of total lymph nodes removed in group 2 was significantly higher than that in group 1 (68, range 14 to 132 vs 31, range 1 to 96, p<0.001). A trend toward more lymph nodes involved was observed in group 2 compared to group 1 (3, range 1 to 91 vs 2, range 1 to 63, p=0.062). These findings significantly lowered median lymph node density in group 2 compared to that in group 1 (6% vs 9%, p=0.006). CONCLUSIONS: Although the overall incidence of lymph node positive disease was not different, the submission of 13 separate nodal packets at radical cystectomy significantly increased the total number of lymph nodes removed/analyzed and identified a slightly higher number of positive lymph nodes compared to en bloc submission.