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.     

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

Background

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

Materials and methods

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

Results

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

Conclusion

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

Factors affecting postoperative course and survival after en bloc resection for esophageal carcinoma

Background

To identify factors affecting postoperative course and survival after esophagectomy for cancer and reasons for improved survival over time.

Methods

Complete esophageal resection was attempted for middle and lower third esophageal carcinomas in 386 consecutive patients between January 1982 and January 2002. Two study periods were analyzed: 1982 to 1993 and 1994 to 2002. Prognostic factors were identified by multivariate analysis and the two periods compared.

Results

Hospital mortality rate decreased from 5.4% to 2.9% (p = 0.245). Both anastomotic leakage and pulmonary complications rates decreased from 9.8% to 2.2% (p = 0.001) and 24.1% to 19.3% (p = 0.295), respectively. An increased proportion of patients had R0 resection in the latter period, 78.5% versus 67.0%, (p = 0.028). Five-year survival rate after R0 resection increased from 29% to 46% (p = 0.001), with a decreased recurrence rate from 65.8% to 44.3% (p = 0.002). Three favorable prognostic factors were identified: low pT stage, pN0 stage, and operation during the 1994 to 2002 study period.

Conclusions

Short-term outcome and survival of patients with resected esophageal cancer have improved over time. Advances in perioperative technique, staging methods, and surgical management combined with higher patient selection and use of neoadjuvant chemoradiation may be responsible for this progress.     

Operative technique aiming at en bloc dissection in esophageal surgery

The lymph node metastases of esophageal cancer occur over a wide area. It is essential for radical surgery of such metastases to aim at en bloc dissection. Otherwise, it can easily become a combination of blunt esophagectomy and lymph node sampling through a right thoracotomy. In the intrathoracic procedure, all the nodes to be dissected can be harvested while attached to the esophagus together with the surrounding connective tissue, except for the pretracheal nodes in front of the cardiac branches of the right vagus nerve and the subaortic arch nodes. It is important to dissect the left paratracheal nodes en bloc, preserving the left recurrent laryngeal nerve. In the abdomen, nodes around the celiac axis and nodes on the common hepatic artery and proximal part of the splenic artery are all removed en bloc with the perigastric nodes in the left gastric arterial basin. The cervical paratracheal and paraesophageal nodes are removed separately from the resected esophagus, but the continuity of dissection can be ensured when the dissection from the neck meets the empty space made by the dissection along the bilateral recurrent laryngeal nerves through the thoracotomy. We believe that such en bloc dissection is the key to improving the long-term results of esophageal cancer surgery.     

Hemodynamic changes after resection of thoracic duct for en bloc resection of esophageal cancer

An en bloc resection of esophageal cancer is one of the most radical forms of esophagectomy, and includes the resection of the thoracic duct, but a relatively high hospital motality rate has been reported. There is very little knowledge on the pathophysiological changes after resection of the thoracic duct. We examined 24 patients who underwent en bloc resection. Some patients developed severe tachycardia or shock postoperatively which subsided after a massive infusion of plasma. Analysis of the fluid balance revealed that much more fluid was necessary during surgery and the postoperative 24 h than in patients treated by a standard esophagectomy. Postoperative lymphangiography or CT revealed abnormal collateral lymphatics around the kidneys or in the pelvic cavity. This suggests the development of the lymphaticovenous shunts, which differed depending on the anatomy of each patient. One patient with chronic hepatitis developed uncontrollable ascites. These are important findings which can hopefully reduce the high rate of hospital death after this operation.     

Disappearance of lung adenocarcinoma after total en bloc spondylectomy using frozen tumor-bearing vertebra for reconstruction

Purpose

Total en bloc spondylectomy (TES) is a surgical procedure performed to achieve complete resection of an aggressive benign spinal tumor or a malignant spinal tumor. When reconstructing the spine after resection, we have been using liquid nitrogen-frozen resected spine bearing tumor as a bone graft, expecting an immunological response to tumor-specific antigen(s). The purpose of this article is to report a successful treatment case of lung adenocarcinoma metastasis with TES and this cryotherapy.

Methods

A 59-year-old male presented with rapid progression of neurological deterioration of the lower limbs due to a spinal metastasis from T8 to T10. The primary lung adenocarcinoma had already been excised under thoracoscopy. The patient underwent TES with reconstruction using frozen tumor-bearing vertebra for the bone graft.

Results

One month after surgery, a new nodule appeared at the right middle lobe of the lung. However, we carried out no biopsy of the newly emerged nodule and the patient received no adjuvant chemotherapy or radiotherapy. Six months after surgery, the tumor vanished. No local recurrence or metastasis of the tumor has been observed until now.

Conclusions

TES with a liquid nitrogen-frozen tumor specimen could be a promising therapeutic option for cancer patients with spine metastasis.

     

Comparison of oncological outcomes after laparoscopic transhiatal and open esophagectomy for T1 esophageal adenocarcinoma

Introduction  This study compared pathological characteristics and patterns of disease recurrence for patients with pT1 esophageal adenocarcinoma treated with either laparoscopic transhiatal esophagectomy or open esophagectomy. Methods  From January 2000-December 2006, 44 patients had pT1 esophageal adenocarcinoma after esophagectomy. No patients had neoadjuvant treatment. Twenty-four patients had an Ivor Lewis operation, 4 had an open transhiatal and 16 had a laparoscopic transhiatal operation. Results  There were 37 men. The median age was 64 years (range 35–80 years). Median lymph node yield was 19 (10–51) after an Ivor Lewis operation, 16 (3–28) after an open transhiatal operation and 15 (4–41) after a laparoscopic transhiatal operation. There were two in-hospital deaths (5%), both following open Ivor Lewis operation. All patients in the laparoscopic group had N0 disease; none received adjuvant treatment. Two patients (7%) in the open group had N1 disease, of whom one patient received adjuvant chemotherapy. Eleven patients had submucosal invasion. Alive patients had median follow-up of 36 months (range 5–87 months). One patient in the laparoscopic group had recurrence at 22 months. This patient had poorly differentiated N0 disease which was limited to the mucosa and died at 24 months. Two patients in the open group developed recurrence, at 6 months (N0 disease with submucosal invasion) and 8 months (N1 disease with submucosal invasion) and died at 7 and 14 months, respectively. Both patients had poorly differentiated tumours. The second patient with N1 disease is alive and well at 14 months. Estimated survival (Kaplan–Meier) at 3 years was 93%. Conclusions  As compared with open transthoracic esophagectomy, there is no oncological detriment in the treatment of pT1 esophageal adenocarcinoma by laparoscopic transhiatal esophagectomy. The incidence of recurrence is small (7%) but can occur even in patients with tumour limited to the mucosa or N0 disease.     

Axial symptoms after en bloc cervical laminoplasty.

Eighty-two patients were evaluated after cervical laminoplasty to explore measures that could minimize future postoperative axial complaints. Patients were divided into two groups: Group A--severe postoperative axial symptoms, and Group B--mild axial complaints. Japanese Orthopaedic Association outcomes scores were similar for the two groups. Radiologic studies demonstrated greater restriction of range of motion in Group A patients who had undergone longer and more extensive surgical procedures.     

Long-term outcome of cadaveric pediatric en bloc transplantation--a 15-year experience

Pediatric en bloc transplantation of infant organs into adult recipients is a recognized technique to expand the number of kidneys available for transplantation. We reviewed our experience with this technique over a 15-year period to determine the long-term outcomes. Twelve patients underwent pediatric en bloc transplantation from donors aged <4 years. All transplants functioned immediately with no graft thrombosis. Two patients died 12 and 10 years posttransplant with functioning grafts. The remaining 10 recipients experienced excellent graft function with a mean follow-up time of 73.8 months (range, 10 to 169 months) with no evidence of hyperfiltration injury. We conclude that pediatric en bloc transplantations achieve excellent long-term allograft function in selected recipients.     

Rod fracture and related factors after total en bloc spondylectomy

BACKGROUND CONTEXTSeveral studies have reported favorable oncosurgical outcomes after total en bloc spondylectomy (TES) for treatment of primary malignant tumors or oligometastatic tumors. Considering that TES is indicated for patients with longer life expectancy, long-term instrumentation-related issues such as rod fracture needs to be addressed.PURPOSETo investigate delayed rod fracture and related factors after TES.STUDY DESIGNMulticenter, retrospective study.PATIENT SAMPLEThirty-two patients who survived for more than 2 years after TES.OUTCOME MEASURESRod fracture and related factors.METHODSThe relationships between rod fracture and related factors were investigated using Kaplan-Meier survivorship analysis with log-rank test. The analyzed factors were sex, age (<60 or ≥60), tumor histology (primary or metastatic), location of resected tumor (thoracic [above T11], thoracolumbar [cases including T12-L1], or lumbar [below L2]), number of resected vertebrae (1, 2, or 3), anterior support method (expandable cage, mesh cage, or strut bone graft), rod diameter (5.5 mm or 6.0 mm), and history of radiotherapy including preoperative or postoperative radiotherapy.ResultsThe study population consisted of 18 men and 14 women, with a mean age of 49.0 years. Nineteen patients had primary tumors and 13 patients had metastatic tumors. The mean follow-up duration was 49.8 months (range, 24–166 months). Twelve of 32 patients (37.5%) experienced rod fractures at an average of 29.2 months (range, 8–93 months) after TES. Of these 12 patients, 8 underwent revision surgery caused by back pain aggravation (n = 7) or nonunion on computed tomography scan (n = 4). Location of resected tumor and history of radiotherapy were significantly associated with rod fracture (p = .004 and p = .019, respectively).CONCLUSIONRod fracture was not a rare complication after TES surgery. History of radiotherapy and TES at lumbar level were significant risk factors related to rod fracture. A robust strategy to obtain solid osseous fusion should be considered when planning TES.     

Gender differences in prognosis after esophagectomy for esophageal cancer

Purpose

The purpose of this study was to clarify the gender differences in the prognosis, as well as mortality and morbidity, of patients who have undergone esophagectomy for esophageal cancer.

Methods

The clinical results of esophagectomy were compared between 975 male and 156 female patients with esophageal cancer.

Results

The male to female ratios of cervical and thoracic esophageal cancer were 1.87 and 7.38, respectively (P < 0.01). The incidence of preoperative comorbidities was 32.4 and 17.4 %, respectively, and the rates of both tobacco and alcohol abuse were significantly lower in the females than in the males. The mortality rate was lower in the females (3.8 %) than in the males (5.7 %), although the differences were not significant. The overall survival was significantly better in the female than in the male patients (P = 0.039). The 5- and 10-year overall survival rates were 32.6 and 20.5 % in the males and 39.5 and 32.5 % in the females, respectively. A multivariate analysis revealed gender to be an independent prognostic factor. However, no significant differences were recognized in disease-specific survival.

Conclusions

These results suggest that the prognosis of females with esophageal cancer is better than that of males after esophagectomy, most likely due to multiple clinical factors, such as a more favorable lifestyle and general status.     

En bloc vs transhiatal esophagectomy for stage T3 N1 adenocarcinoma of the distal esophagus

HYPOTHESIS: En bloc esophagectomy (EBE) provides improved survival over transhiatal esophagectomy (THE) in patients with similarly sized transmural tumors (T3) and lymph node metastases (N1). DESIGN: A retrospective case-control study of 2 methods of esophageal resection for cancer. SETTING: University hospital (tertiary referral center for esophageal disease). PATIENTS: There were 49 patients (27 who underwent EBE and 22 who underwent THE) with similar T3 N1 disease and the following matched criteria: tumors of similar size and location, more than 20 lymph nodes in the surgical specimen, R0 resection, no previous chemotherapy or radiation therapy, and follow-up until death or for a minimum of 5 years.Main Outcome Measure Survival adjusted for differences in demographic and patient characteristics. RESULTS: The number of nodes harvested was greatest after EBE vs THE (median, 52 vs 29 [range, 21-85 vs 20-60]; P<.001). The median number of involved nodes was similar after EBE vs THE (median, 5 vs 7 [range, 1-19 vs 1-16]). The only 2 independent factors that affected survival in a Cox analysis were the number of involved lymph nodes (P =.01) and the type of resection (P =.03). Patients who underwent EBE had a survival benefit over those who underwent THE (P =.01). The survival benefit of EBE was seen only in patients with fewer than 9 involved lymph nodes (P<.001). CONCLUSION: En bloc esophagectomy confers a better survival than THE in patients with T3 N1 disease and fewer than 9 lymph node metastases.     

Current status and evaluation of thoracoscopic esophagectomy for thoracic esophageal cancer

The current status and evaluation of esophagectomy by thoracoscopic approach for thoracic esophageal cancer are described. The esophagectomy by thoracoscopic approach for thoracic esophageal cancer have been reported in some Instituts since 1996 in Japan. In 10 years, series consisting a large number of esophageal cancer patients have been treated with esophagectomy by thoracoscopic approach and evaluated about operative safety, curabirity and postoperative morbidity. Now, the establishment of training system is the most important subject to achieve the standardization of thoracoscopic esophagectomy for thoracic esophageal caner.     

Gastric tube perforation after esophagectomy for esophageal cancer

We searched for cases of perforation of the gastric tube after esophagectomy for esophageal cancer by reviewing the literature. Only 13 cases were found in the English literature, and serious complications were seen in all cases, especially in cases of posterior mediastinal reconstruction. However, in the Japanese literature serious complications were also frequently seen in retrosternal reconstruction. Gastric tubes are at a higher risk of developing an ulcer than the normal stomach, including an ulcer due to Helicobacter pylori infection, insufficient blood supply, gastric stasis, and bile juice regurgitation. H. pylori eradication and acid-suppressive medications are important preventive therapies for ordinary gastric ulcers, but for gastric tube ulcers the effects of such treatments are still controversial. We tried to determine the most appropriate treatment to avoid serious complications in the gastric tubes, but we could not confirm an optimal route because each had advantages and disadvantages. However, at least in cases with severe atrophic gastritis due to H. pylori infection or a history of frequent peptic ulcer treatment, the antesternal route is clearly the best. Many cases of gastric tube ulcers involve no pain, and vagotomy may be one of the reasons for this absence of pain. Therefore, periodic endoscopic examination may be necessary to rule out the presence of an ulcer.