Skeletal muscle metastasis from esophageal cancer: a report of two cases and a review of the literature

Skeletal muscle metastases from carcinoma are very rare. This report describes two cases of skeletal muscle metastasis from esophageal cancer as the first distant metastasis. Case 1, a 58-year-old man with stage IVa upper thoracic esophageal squamous cell carcinoma (SqCC), underwent chemoradiotherapy (CRT) and a subtotal esophagectomy with a three-field lymph node dissection. After the operation, he complained of a painful mass in his forearm, which was diagnosed to be metastatic SqCC by a biopsy. Local radiation therapy and systemic chemotherapy were performed, but he died 7 months after the first CRT. Case 2, a 61-year-old woman with stage IVa middle thoracic SqCC, underwent CRT. ¹⁸F-Fluorodeoxyglucose positron emission tomography (FDG-PET) after the CRT showed a hot spot in the right gluteus maximus muscle, and it was diagnosed to be metastatic SqCC by a biopsy. Although additional treatment was performed, she died 6 months after the first visit. A short review of the literature concerning skeletal muscle metastasis from esophageal cancer was conducted.     

Esophagectomy and combined lobectomy with a covering latissimus dorsi muscle flap for an esophagopulmonary fistula due to advanced esophageal cancer: report of two cases

We herein describe the successful surgical treatment of two cases of esophagopulmonary fistula (EPF) due to esophageal cancer. Case 1: A 76-year-old man was diagnosed by computed tomography (CT) with an EPF due to esophageal cancer. Initially, antibiotics were given and enteral nutrition was administered. After 12 days, an esophageal stent was implanted. After 20 days, esophagectomy combined with a right middle–lower lobectomy with a covering latissimus dorsi muscle flap (LDMF) was performed. Case 2: A 54-year-old man was given induction chemoradiotherapy (CRT) for advanced esophageal cancer. Forty days after CRT, the patient developed a fever and was diagnosed with an EPF due to esophageal cancer based on CT findings. An emergency esophagectomy combined with a right lower lobectomy with covering by a LDMF was performed. The LDMF was useful to prevent postoperative complications, such as bleeding due to vessel rupture or bronchial stump fistula.     

Mediastinoscopy-assisted esophagectomy for thoracic esophageal cancer after right thoracotomy for lung cancer: report of two cases

We herein report two cases of thoracic esophageal cancer operated on by mediastinoscopy-assisted esophagectomy (MAE) via the neck and the esophageal hiatus after right thoracotomy for primary lung cancer. Case 1 was a 78-year-old man who had undergone a lower lobectomy of the right lung 5 years earlier and had also undergone a pleuroparietopexy for postoperative chylothorax via right thoracotomy again. A squamous cell carcinoma of the middle thoracic esophagus was detected by endoscopy. Although radiotherapy was performed on the patient, the esophageal tumor was locally recurrent. Thus, MAE was performed because it would have been difficult to approach the esophageal tumor by right thoracotomy again, and the patient was successfully treated. Case 2 was a 71-year-old-man who had undergone an upper lobectomy of the right lung 5 years earlier. For a squamous cell carcinoma located between the middle and lower esophagus, MAE was performed. Metastatic lymph nodes surrounding the middle and lower thoracic esophagus were sufficiently dissected. Although esophageal cancer patients with metachronous lung cancer are rare, therapeutic issues for these patients remain. MAE via the neck and the esophageal hiatus for esophageal cancer patients who had previously undergone a lobectomy of the right lung may be considered a tool for surgical approach. Furthermore, MAE may be considered to be a salvage operation such as in case 1.     

Salvage esophagectomy through a transhiatal approach for cancer of the thoracic esophagus after left pneumonectomy for lung cancer

Here we report on a 54-year-old man who had undergone left pneumonectomy for a primary lung cancer 25 years earlier and who underwent salvage blunt esophagectomy for a recurrent esophageal cancer after definitive chemoradiotherapy. The patient received chemoradiotherapy for a cancer in the upper thoracic esophagus at the clinical stage IA (T1bN0M0) because of a past history of left pneumonectomy for lung cancer, and the esophageal cancer showed complete response. At 1 year after chemoradiotherapy, local recurrence was found in the upper thoracic esophagus. Although chemotherapy using docetaxel was administered, this was not effective. Transhiatal esophagectomy as salvage surgery was successfully done by a combination of laparo-mediastinoscopy assisted blunt dissection with the eversion stripping method. The postoperative course was uneventful. The patient died of lung and brain metastasis at 23 months after the salvage surgery. Transhiatal esophagectomy may be an option as a salvage esophagectomy in cases with a history of major lung surgery.     

Post-esophagectomy chylothorax successfully treated with the combination of thoracic duct clipping and octreotide administration

We herein describe the case of a 61-year-old man with stage II esophageal cancer who experienced chylothorax after esophagectomy. He was successfully treated with thoracic duct clipping and octreotide administration. Previously the patient had had a head and neck cancer treated with multimodality treatment: neoadjuvant chemoradiation therapy, operation, and adjuvant CRT. Then, esophagectomy with lymph node dissection without resection of the thoracic duct was performed via a right thoraco-abdominal approach. On postoperative day 1, enteral nutrition was started. On day 5, the chest tube drainage increased to 2000?ml per day. On day 7, the drainage fluid increased to 3000?ml per day, and its color turned cloudy white. We then performed lymphoscintigraphy and diagnosed the patient as having chylothorax. Immediately we administered intermittent subcutaneous octreotide 100???g?×?3 per day; however, it could not stop the leakage. On day 13, we performed an operation: a fat-rich supplement was administered through the jejunostomy tube before the operation, the thoracic duct injury was readily identified, and we clipped the thoracic duct in the superior mediastinum, followed by 300???g per day octreotide treatment. On day 16, however, 400?ml per day of chyle leaked from the drain again, and we increased the dose of octreotide to 600???g per day. On day 18, the drainage stopped, and the patient was discharged on day 38. Octreotide administration combined with surgical treatment should be considered as a treatment option for chylothorax, which is a rare complication of esophagectomy.     

Synchronous double primary cancer of the esophagus and ampulla of Vater successfully treated by a two-stage operation: report of a case

A 68-year-old man was diagnosed with local recurrent cancer of the ampulla of Vater by follow-up endoscopy 3 years after an endoscopic papillectomy. A screening endoscopy found superficial middle thoracic esophageal cancer. The patient required an esophagectomy and pancreatoduodenectomy. We chose a two-stage operation for the esophageal cancer and the local recurrent cancer of the ampulla of Vater, both to reduce surgical invasiveness and to circumvent the lower curability. The first-stage operation consisted of a right transthoracic subtotal esophagectomy with mediastinal and cervical lymph node dissection, external esophagostomy of the neck, and gastrostomy. Forty days after the first surgery, a gastroduodenal artery- and right gastroepiploic vessel-preserving pancreatoduodenectomy with Child’s reconstruction was performed as the second-stage surgery. Esophageal reconstruction was achieved using a gastric tube via the percutaneous route with vascular anastomosis.     

Upper gastrointestinal bleeding secondary to an aberrant right subclavian artery-esophageal fistula: a case report and review of the literature.

An aberrant right subclavian artery (ARSA) is a common aortic arch abnormality. A case of a 57-year-old man presenting with melena and hypotension secondary to an ARSA-esophageal fistula is reported. The current report is unique because it is the first reported case of ARSA-esophageal fistula associated with prior esophagectomy and gastric pull-up. A MedLine search was performed for ARSA-esophageal fistula cases, which were then compared with the present case. Because this patient had no vascular conduits, nasogastric or endotracheal tubes, the fistula likely occurred secondary to the previous surgery. This case is unusual because the patient survived the original hemorrhage associated with the ARSA-esophageal fistula. An ARSA-esophageal fistula is a rare, but potentially fatal cause of upper gastrointestinal bleeding. A high index of suspicion is needed to make the diagnosis. This condition should be considered in patients with risk factors combined with hemodynamically significant gastrointestinal bleeding.     

Thoracoscopic esophagectomy in the prone position for corrosive stricture after esophageal perforation due to balloon dilatation

An 18-year-old man was referred to our hospital because of chest pain after ingestion of a strong hydroxide in an attempted suicide. On post-ingestion day 25, an esophageal endoscopy and esophagram revealed at least three strictures, one each in the cervical, upper, and lower thoracic esophagus. In particular, the upper thoracic esophageal stricture was severe and was 5 cm long. Repeated balloon dilatation was employed, but resulted in perforation of the upper thoracic esophagus on the fourth attempt. On post-ingestion day 95, thoracoscopic esophagectomy in the prone position was performed. The esophagus was reconstructed using a subtotal gastric tube and cervical esophagogastric anastomosis in the supine position. Although the periesophageal adhesions were severe, esophagectomy was successfully performed. Anastomotic leakage developed after surgery, but the patient was discharged on postoperative day 47 on a regular diet.     

Therapeutic effectiveness of chemoradiotherapy for carcinosarcoma of the esophagus: two case reports and a review of the literature

Esophageal carcinosarcoma is an extremely rare tumor, and surgery is the mainstay of treatment. We report two patients with carcinosarcoma of the esophagus who received neoadjuvant chemoradiotherapy and underwent curative resection. Patient 1 was a 50-year-old man with a type 2 lesion in the upper thoracic esophagus; clinical stage was T3 or partial T4N1M0. After chemoradiotherapy the tumor and the lymph nodes become smaller, and subtotal esophagectomy was performed. Patient 2 was a 66-year-old man with a protruding lesion in the lower thoracic esophagus. Preoperative chemoradiotherapy was administered, and he had a partial response. However, surgery was postponed because of pneumonia; 11 months later, tumor enlargement was confirmed and we then performed subtotal esophagectomy. The therapeutic role and effectiveness of both chemotherapy and radiotherapy remain unclear. We reviewed 26 previously reported cases of esophageal carcinosarcoma treated by chemotherapy, radiotherapy, or both. These findings suggest that preoperative chemoradiotherapy may be effective for downstaging the primary tumor in patients with advanced esophageal carcinosarcoma.     

Minimally invasive esophageal resection and intrathoracic anastomosis for lower thoracic esophageal cancer with single position

There are various esophagectomy approaches for lower thoracic esophageal cancer, and the minimally invasive esophagectomy (MIE) approach shows the advantages of less discomfort, shorter length of stay and a faster recovery to baseline status than open approaches. The current study reports a case of lower thoracic esophageal cancer was treated using a single-position, minimally invasive surgical technique with laparoscopy and thoracoscopy. A 68-year-old man, whose gastroscopy identified the esophageal carcinoma, came to our medical center due to dysphagia for over 1 year. The patient underwent tumor radical resection and intrathoracic anastomosis by laparoscopy and thoracoscopy with single position. The patient has recovered well after the surgery.     

Ivor-Lewis esophagectomy for esophageal cancer after distal gastrectomy

We report the use of gastric remnant for esophageal substitution after distal gastrectomy in a 53-year-old man with esophageal cancer. This patient had a 4-month history of progressive dysphagia for solid food. An upper gastrointestinal endoscopy showed a 7.0 cm bulge tumor in the middle-lower esophagus, wherein the upper margin was located 28 cm from the dental arcade. Computed tomography (CT) of the chest revealed wall thickening in the middle-lower esophagus. In this case, radical en bloc esophagectomy with a two-field lymph node dissection was performed in the upper abdomen and mediastinum via a posterolateral right thoracotomy through the fifth intercostal space. Esophagogastric anastomosis was performed mechanically in the apex of the chest using a circular stapler. The gastric remnant was used for reconstruction of the esophago-gastrostomy and placed in the right thoracic cavity. The patient was discharged on the 12th postoperative day without complications. The gastric remnant may be used for reconstruction in patients with esophageal cancer as a substitute organ after distal gastrectomy.     

胸段食管癌的微创手术治疗(附145例报告)

目的 探讨手辅助电视胸腔镜（HVATS）行胸段食管癌切除术的可行性及优缺点。方法 施行HVATS食管癌切除胃食管颈部吻合术124例、食管癌切除胃食管右胸内吻合术21例。结果 两组患者均能够达到常规手术切除效果,手术创伤小、恢复快,无围术期死亡。结论 在HVATS下采用胃食管颈部吻合术或右胸内吻合术能够实现对胸段食管任何位置的肿瘤进行根治性手术治疗。     

Thoracic duct injury during esophagectomy: 20 years experience at a tertiary care center in a developing country

Thoracic duct injury is an uncommon complication of esophagectomy. Experience in managing these cases is limited to large centers performing esophagectomies in good numbers. We analyzed the prospectively maintained esophageal diseases database of patients presenting to a surgical unit between 1982 and 2002. Among 552 esophagectomies during this period we had encountered 14 cases of chylothorax (2.54%). We analyzed the type and site of lesion and the impact of neoadjuvant therapy on the incidence of thoracic duct injury. Among 459 patients of transhiatal esophagectomy, 11 developed postoperative chylothorax (2.40%). In 93 transthoracic resections, there were three cases of chylothorax (3.23%; (P = 0.9185)). The incidence following preoperative radiotherapy was 2.17%. None of the 31 patients, who had undergone esophagectomy for benign diseases had developed chylothorax. In the carcinoma group the incidence in middle third lesions was 5.85% and in lower third lesions was 0.80% (P = 0.0018). Seven patients were managed conservatively. Two of these patients, for whom surgery had been planned, died before they could be taken up for surgery. In the remaining seven patients transthoracic ligation of the thoracic duct was performed. Two patients in this group died. The average hospital stay was 20 days in the conservative group and 12 days in the surgery group. Among the factors studied, patients with middle third lesions were at increased risk of developing postoperative chylothorax, when compared to upper or lower third lesions.     

Pseudotumor by asymptomatic pulmonary infarction diagnosed by video-assisted thoracic surgery]

Two cases of asymptomatic pulmonary infarction were diagnosed by open lung biopsy with video-assisted thoracic surgery (VATS). Case 1: A pulmonary nodule in right S8b was pointed out in a 62-year-old man undergoing hemodialysis on chest x-ray film and CT. Case 2: A 50-year-old woman had undergone left mastectomy for mammary cancer 3 years previously and total hip replacement 1 year before. Chest X-ray film and CT revealed a pulmonary nodule in the left lower lung field and it was suspected to be metastasis of the mammary cancer. Both cases underwent open lung biopsy by VATS, and asymptomatic pulmonary infarction was revealed. When chest X-ray film shows a nodule in the lower-peripheral lung field in patients with risk factors, pulmonary infarction should be considered.     

Lymph node dissection with cervical approach as a salvage surgery for locoregional failure after definitive chemoradiotherapy in a patient with recurrent esophageal carcinoma: report of a case

Salvage surgery is one important therapeutic option after locoregional failure of definitive chemoradiotherapy (dCRT) in patients with advanced or recurrent esophageal carcinoma. We have performed cervical lymph node dissection as a salvage surgery after chemoradiotherapy in a patient with recurrent esophageal carcinoma. A 54-year-old Japanese man was admitted to our hospital because of multiple lymph node metastases after endoscopic submucosal dissection (ESD) for early-stage esophageal carcinoma. The patient underwent a circumferential ESD of early-stage esophageal carcinoma in another hospital. The esophageal carcinoma, measuring 75 × 60 mm in size, was a superficial spreading type located in the middle portion of the thoracic esophagus. Histology of the resected specimen revealed a moderately to poorly differentiated squamous cell carcinoma, and the depth of invasion was limited within the mucosal layer associated with a small area being attached to the muscularis mucosae. Five months after ESD, lymph node metastases in the regions of right recurrent nerve and the left tracheobronchus were found, for which dCRT was performed. These metastatic lymph nodes disappeared in the chest CT scan images. Lymph node metastasis in the region of the right recurrent nerve then reappeared 8 months after the completion of CRT. Considering the solitary lymph node metastasis and surgical invasiveness, lymph node dissection using a cervical approach was selected as a salvage surgery. Cervical approach for the lymph node dissection in the region of right recurrent nerve may be one feasible option as a minimally invasive salvage surgery for patients with recurrent esophageal carcinoma after dCRT.     

Esophageal cancer associated with the right aortic arch: a case study

A case of esophageal cancer associated with the right aortic arch in a 62-year-old Japanese male is described herein. Endoscopy performed after an initial complaint of dysphagia revealed cancer at the upper third of the esophagus. The right aortic arch was located by routine chest X-ray and an irregularly-shaped tumor defect and a shadow defect due to right aortic arch were detected on the right side of the thoracic esophagus by barium study. Computed tomography and magnetic resonance imaging offered useful information for surgical procedure. The patient underwent a subtotal esophagectomy and regional lymphadenectomy though a left thoracotomy. The clinical features of cases previously reported in Japan are reviewed following the presentation of this case.     

Advantages of a latissimus dorsi muscle flap to close a gastric tube-to-tracheal fistula and prevent tracheobronchial complications after salvage surgery for esophageal cancer: report of three cases

Tracheobronchial fistulae after esophagectomy are rare but critical complications because they frequently cause severe pneumonia. In three cases with esophageal cancer, we used the latissimus dorsi muscle after esophagectomy to reinforce the fragile tracheobronchus. In cases 1 and 2 with gastric tube-to-tracheal fistula, the gastric tube was pulled out from the posterior mediastinum, the fistula was excised, and the trachea was covered with the pedicle latissimus dorsi muscle flap followed by reconstruction of the digestive conduit by the subcutaneous route. Case 3 had relapsed esophageal cancer after definitive chemoradiotherapy for T4 (trachea) esophageal cancer; we performed salvage surgery and covered the fragile tracheobronchus using the muscle. Various muscles have been used as reinforcement for the tracheobronchus. The latissimus dorsi muscle is especially useful to reinforce tissue with extensive lesions from the upper trachea to the bilateral bronchi because of this large and highly vascularised tissue.     

An esophageal cancer case unresectable due to tuberculous fibrosing mediastinitis: report of a case

We present a case of esophageal carcinoma in which esophagectomy was not possible because of tuberculous fibrosing mediastinitis. A 77-year-old man was diagnosed with carcinoma of the thoracic esophagus and admitted to our hospital. Chest radiography on admission revealed no abnormality except pleural thickening of the pulmonary apices, suggesting a history of subclinical infection of tuberculous pleurisy. The patient underwent surgery with a curative intent. Thoracotomy revealed that the mediastinum had been replaced with dense fibrous tissues and was widely encased with laminar calcification. Esophagectomy was not performed because it was considered impossible to do so safely. Although diagnosis of fibrous mediastinitis was not made preoperatively, review of the preoperative computed tomographic scans revealed proliferation of mediastinal soft tissues that were associated with patchy and laminar calcifications. Tuberculous fibrosing mediastinitis is an uncommon but clinically important disease for physicians who are involved in the diagnosis and treatment of esophageal cancer.     

Clinical presentation of pulmonary edema following esophagectomy on chest radiograph

BACKGROUND/AIMS: To determine whether the clinical presentation of pulmonary edema following esophagectomy can be objectively determined by changes in X-ray density in the lung field on chest radiography. METHODOLOGY: Sixteen patients who underwent esophagectomy for thoracic esophageal cancer and five patients who underwent less radical surgery at Akita University Hospital between July 2000 and March 2001 were recruited to the thoracic esophageal cancer and control groups, respectively. Chest radiography was carried out using five aluminum disks (15, 20, 25, 30 and 35 mm thickness) placed in upper right corner of the film and X-ray density for the disks and chest lung field was measured using a densitometer until POD 7. RESULTS: In the thoracic esophageal cancer group, X-ray density in the lung field, body weight, and respiratory index increased significantly in the immediate postoperative period. The X-ray density in the lung field peaked on POD 2, and remained constant to POD 6. Correlations were found among changes in X-ray density in the lung field, body weight, and respiratory index. CONCLUSIONS: The measurement of X-ray density on a chest radiograph is useful for prediction as well as early management of patients with pulmonary edema following esophagectomy for thoracic esophageal cancer.     

A case of esophageal cancer with mesojejunal lymph node metastasis after total gastrectomy

A 56-year-old man was diagnosed with esophageal cancer by upper gastrointestinal endoscopy for examination of dysphagia. The patient had undergone total gastrectomy and jejunal interposition 4 years previously for a gastric cancer at the pT1N0M0 stage according to the UICC-TNM classification. Enhanced CT findings revealed a 3-cm-diameter mass located near the superior mesenteric artery. We conducted subtotal esophagectomy associated with partial jejunectomy including mesojejunectomy. The mass was histologically diagnosed to be mesojejunal lymph node metastasis from esophageal cancer. Mesojejunal lymph node metastasis from esophageal cancer developing after total gastrectomy has been reported in only three cases including ours. The present lymph node metastases may have occurred via the newly developed lymphatic drainage route through the esophagojejunostomy, and this metastatic lymph node can be considered the regional lymph node. Therefore, resection of the interposed jejunal limb with mesojejunectomy may be rational in surgery on esophageal cancer developing after total gastrectomy.