Can common hepatic artery lymph node dissection be safely omitted in surgery for clinical T1N0 thoracic esophageal squamous cell carcinoma?

Common hepatic artery lymph node dissection is regarded as a standard procedure in esophageal cancer surgery because of aggressive lymphatic dissemination of esophageal cancer. However, lymph node dissection can prolong operation time and may be associated with complications such as chylous ascites. Here, we aimed to evaluate the effectiveness of common hepatic artery lymph node dissection in clinical T1N0 thoracic esophageal squamous cell carcinoma. Between 1996 and 2009, 1390 patients underwent surgery for esophageal cancer in our institution, and 209 were found to have clinical T1N0 disease. Exclusion criteria were nonsquamous carcinoma, double primary cancer, definite distant metastasis, administration of neoadjuvant treatment, and incomplete abdominal lymph node dissection. We retrospectively analyzed medical records, operative and pathologic data, and follow‐up information. Forty‐two patients were excluded from the study. Among the 167 enrolled patients, preoperative endoscopic ultrasound evaluation was performed in 160 patients. Fifty‐two patients had distal esophageal or esophagogastric junction tumor. Surgery included 2 cases of tri‐incisional esophagectomy, 17 cases of transhiatal esophagectomy, and 148 cases of two‐field esophagectomy (Ivor Lewis operation). Common hepatic artery lymph node dissection was performed in all cases, and none of the patients had metastasis. Mean follow‐up period was 35.4 ± 28.7 months. In‐hospital mortality was one, and 5‐year survival rate was 80.6%. Among the 15 patients with recurrence, there were two distant metastases and five distant and local recurrences but no intra‐abdominal recurrence with common hepatic artery lymph node. Common hepatic artery lymph node dissection may be safely omitted in surgery for clinical T1N0 esophageal squamous cell carcinoma when preoperative evaluations including chest computed tomography, positron emission tomography and computed tomography, and esophagogastroduodenoscopy or endoscopic ultrasound are performed.     

Ivor Lewis approach is superior to transhiatal approach in retrieval of lymph nodes at esophagectomy

SUMMARY.  Lymph node involvement may impact postoperative therapeutic decision-making and prognosis in patients undergoing esophagectomy. This study evaluates which surgical approach yields the most lymph nodes. We undertook a retrospective chart review of esophagectomies performed by six surgeons from April 1994 to February 2004 using a prospective general thoracic surgery database at Mayo Clinic, Rochester, Minnesota, US. Lymph nodes were categorized into one of 17 regions per the American Joint Committee on Cancer, with the total number of lymph nodes, summed over each region, used as the primary outcome. A total of 517 esophagectomies were performed: 68 transhiatal, 392 Ivor Lewis, and 57 extended Ivor Lewis. A mean of 18.7 (SD 8.5) lymph nodes were retrieved with the Ivor Lewis approach as compared to 17.4 (SD 9.2) with the extended Ivor Lewis approach ( P  = 0.30). Since there was no statistical difference between the number of nodes collected in either Ivor Lewis approach, they were collapsed into one group for comparison with the transhiatal cases. Significantly more lymph nodes were collected with an Ivor Lewis approach (mean 18.5, SD 8.6) than with a transhiatal approach (mean 9.0, SD 5.0, P  < 0.001). As expected, more thoracic lymph nodes were retrieved with the Ivor Lewis approach [mean 12.4 (SD 7.0) vs. 4.7 (SD 5.3), P  < 0.001]. The Ivor Lewis approach was also superior for retrieval of abdominal nodes [mean 6.1 (SD 5.6) versus 4.3 (SD 4.4), P  = 0.01]. More lymph nodes are obtained at esophagectomy with an Ivor Lewis than a transhiatal approach.     

The prognostic importance of pathologically involved celiac node metastases in node‐positive patients with carcinoma of the distal esophagus or gastroesophageal junction: a surgical series from the Mayo Clinic

The management of esophageal cancer with involvement of celiac lymph nodes is controversial. The purpose of this retrospective study was to evaluate the clinical importance of metastases to celiac lymph nodes in patients with carcinoma of the distal esophagus or gastroesophageal junction (GEJ) who undergo surgical treatment with curative intent. We reviewed the medical records of 310 patients who underwent definitive esophagectomy at the Mayo Clinic, Rochester, Minnesota, between 1976 and 1999 for carcinoma of the distal esophagus or GEJ. The disease location was distal esophagus in 163 and GEJ in 147. Fifty‐two patients (17%) were found to have celiac node involvement. The survival of these patients was compared with that of 97 N0 patients and 161 N1 patients without celiac node involvement. Squamous cell carcinoma and adenocarcinomas were found in 24% and 76%, respectively. Ivor Lewis esophagectomy was the most common surgical procedure (76%), followed by transhiatal resection (14%) and modified Ivor Lewis procedure (5%). The median number of nodes resected was 15 (range, 2–45). The median survival of the entire group was 18.8 months. The median survival was 48 months (range, 1.6 months–22 years) for N0 patients and 15.9 months (range, 0.03 months–14.4 years) for N1 patients without celiac node disease (P < 0.001). The median survival was 11.7 months (range, 2.2 months–15.7 years) for celiac node–positive patients, and this difference was statistically significant when compared with survival in N0 patients (P= 0.001) but not when compared with that in N1 patients without celiac node disease (P= 0.57). Survival at 3 and 5 years was 61% and 45% for N0 patients, 21% and 9% for N1 patients without celiac node disease, and 18% and 11% for patients with celiac node disease, respectively. At 10 years, 7% of patients with celiac node involvement in their resected specimen were alive. By multivariate analysis, patients with 4 or more positive lymph nodes had the worst prognosis (risk ratio [RR], 2.63; 95% confidence interval [CI], 1.98–3.48), regardless of their location. We concluded that celiac node metastases were not an adverse prognostic indicator in patients with celiac node involvement compared with N1 patients without celiac node disease. Overall, the number of positive nodes, not their location, correlated best with survival. Although median survival was poor, a small number of patients with resected celiac node disease had long‐term survival. Patients with undetected celiac node disease at the time of surgical resection who were subsequently found to have celiac node involvement appeared to have a prognosis similar to that of patients with stage III disease. Therefore, treatment with curative intent should be considered for fit patients with celiac node disease.     

Therapeutic strategy for the treatment of postoperative recurrence of esophageal squamous cell carcinoma: clinical efficacy of radiotherapy

We investigated the effectiveness of chemoradiotherapy for the treatment of lymph node recurrence and hematogenous metastasis after esophagectomy for esophageal squamous cell carcinoma. Between 2001 and 2006, 216 patients with thoracic esophageal squamous cell carcinoma had curative esophagectomy. Of those, 23 with lymph node recurrence received chemoradiotherapy (50.0–68.8 Gy). In addition, five patients had isolated recurrences in a distant organ and received chemoradiotherapy (50.0–60.0 Gy). We analyzed outcomes from the radiotherapy for recurrent esophageal cancer. The 1‐, 2‐, and 5‐year survival rates after recurrence for the 23 patients whose lymph node recurrence was treated with chemoradiotherapy were 52, 31, and 24%, respectively, and the median survival time was 13 months. Among the five patients with recurrent tumors in a distant organ, chemoradiotherapy produced a complete response in two patients, a partial response in one patient, and stable disease in two patients, giving an effectiveness rate of 60% (complete response + partial response). Chemoradiotherapy has a beneficial prognostic effect in patients with lymph node recurrence of esophageal squamous cell carcinoma. Chemoradiotherapy for a metastatic tumor in a distant organ may be the treatment of choice in cases where systemic chemotherapy has proven ineffective.     

From McKeown to Ivor Lewis,the learning curve for thoracic lymphadenectomy over the first 100 robotic esophagectomy cases: a retrospective study

BackgroundLymphadenectomy is an essential but challenging part of the surgical treatment for esophageal cancer. However, the previously reported learning curve for robotic esophagectomy primarily focused on only one surgical approach (McKeown or Ivor Lewis). However, both approaches must be mastered by a mature robotic surgical team to deal with different clinical conditions and satisfy patients’ needs. This study aimed to show how an experienced esophageal surgical team became proficient in both McKeown and Ivor Lewis robotic esophagectomy.MethodsA retrospective review of the first 100 cases of robot-assisted minimally invasive esophagectomy (RAMIE) by a single surgical team was performed. The cumulative sum (CUSUM) analysis was used to distinguish the change point during the learning course. A subgroup analysis was performed according to a surgical approach (McKeown or Ivor Lewis) to determine the effect of experience from one surgical approach on learning the other RAMIE technique.ResultsAccording to the tendency of the CUSUM plot, the learning curve was divided into four phases. The subgroup analysis indicated the decline of the CUSUM plot in the 3rd phase originated from the start of the Ivor Lewis approach. The attending surgeon took 23 cases to achieve a significant improvement in the number of harvested thoracic lymph nodes using the McKeown approach. Regardless of the acquired experience of McKeown RAMIE, it took another 18 cases for the surgical team to achieve significant improvement in harvesting thoracic lymph nodes using the Ivor Lewis approach.ConclusionsTwenty-three cases were needed for an experienced surgical team to improve thoracic lymphadenectomy results using McKeown RAMIE. There was another learning phase during the transition from McKeown to Ivor Lewis esophagectomy. Importantly, the acquired experience from performing McKeown RAMIE could shorten how long it takes to learn Ivor Lewis RAMIE.     

Comparison of salvage chemoradiation versus salvage surgery for recurrent esophageal squamous cell carcinoma after definitive radiochemotherapy or radiotherapy alone

A consensus treatment strategy for esophageal squamous cell carcinoma (ESCC) patients who recur after definitive radiochemotherapy/radiotherapy has not been established. This study compared the outcomes in ESCC patients who underwent salvage surgery, salvage chemoradiation (CRT) or best supportive care (BSC) for local recurrence. Ninety‐five patients with clinical stage I to III ESCC who had completely responded to the initial definitive radiochemotherapy or radiotherapy alone and developed local recurrence were enrolled in this study. Fifty‐one of them received salvage esophagectomy, and R0 resection was performed in 41 patients, 36 underwent salvage CRT, and the remaining eight patients received BSC only. The 5‐year overall survival was 4.6% for the 87 patients receiving salvage surgery or CRT, while all patients in the BSC group died within 12.0 months, the difference was statistically significant (P = 0.018). The 1‐, 3‐, 5‐year survival rates in the salvage surgery and salvage CRT groups were 45.1%, 20.0%, 6.9% and 51.7%, 12.2%, 3.1%, respectively, there was no difference of overall survival between the two groups (P = 0.697). Patients also presented with lymph node relapse had inferior survival compared to those with isolated local tumor recurrence after salvage therapy. In the salvage surgery group, infections occurred in eight patients, and three developed anastomotic leakage. In the salvage CRT group, grade 2–4 esophagitis and radiation pneumonitis was observed in 19 and 3 patients, respectively. Seven patients (19.4%) developed esophagotracheal fistula or esophageal perforation. This study of salvage CRT versus salvage surgery for recurrent ESCC after definitive radiochemotherapy or radiotherapy alone did not demonstrate a statistically significant survival difference, but the frequency of complications including esophagotracheal fistula and esophageal perforation following salvage CRT was high.     

Neoadjuvant chemoradiotherapy followed by esophagectomy for initially resectable squamous cell carcinoma of the esophagus with multiple lymph node metastasis

Neoadjuvant chemoradiotherapy (CRT) was expected to improve surgical curability and prognosis for advanced esophageal cancer. However, the clinical efficacy of neoadjuvant CRT followed by esophagectomy with three-field lymphadenectomy (3FL) for initially resectable esophageal squamous cell carcinoma (SCC) remains unclear. Since 1998, we have defined the status of metastases to five or more nodes, or nodal metastases present in all three fields as multiple lymph node metastasis, which was previously shown to be associated with poor prognosis. Between 1998 and 2002, 83 patients with initially resectable esophageal SCC were prospectively allocated into two groups, according to the clinical status of nodal metastasis. Nineteen patients clinically accompanied by multiple lymph node metastasis initially underwent neoadjuvant CRT followed by curative esophagectomy with 3FL (CRT group). The other 64 patients clinically without multiple lymph node metastasis immediately received curative esophagectomy with 3FL (control group). Although the overall morbidity rate was significantly higher in the CRT group, no in-hospital death occurred in either group. Patients without pathologic multiple lymph node metastasis in the CRT group showed a significantly better disease-free survival rate than either patients pathologically with multiple lymph node metastasis in the control group or those in the CRT group. However, the differences in the overall survival rate among the groups were not significant. Thus, the significant survival benefit by neoadjuvant CRT in addition to esophagectomy with 3FL was not confirmed, although it may have been advantageous, without increase in mortality, to at least some patients who responded well to neoadjuvant CRT. Therefore, neoadjuvant CRT can be an initial treatment of choice for resectable esophageal SCC clinically with multiple lymph node metastasis. The prediction of response to CRT and the development of alternative treatment for hematogenous recurrence could achieve a further survival benefit of this trimodality treatment.     

Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for squamous cell carcinoma of the lower thoracic esophagus

AIM： To evaluate the clinical outcome of Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for patients with squamous cell carcinoma of the lower thoracic esophagus. METHODS： From January 1998 to December 2001, 73 patients with lower thoracic esophageal carcinoma underwent Ivor-Lewis subtotal esophagectomy with two-field lymphadenectomy. Clinicopathological information, postoperative complications, mortality and long term survival of all these patients were analyzed retrospectively. RESULTS： The operative morbidity and mortality was 15.1% and the mortality was 2.7%. Lymph node metastases were found in 52 patients （71.2%）. Nodal metastases to the upper, middle, lower mediastini and upper abdomen were found in 13 （17.8%）, 15 （20.5%）, 30 （41.1%）, and 25 （34.2%） patients, respectively. Postoperative staging was as follows： stage Ⅰ in 5 patients, stage Ⅱ in 34 patients, stage Ⅲ in 32 patients, and stage Ⅳ in 2 patients, respectively. The overall 5-year survival rate was 23.3%. For NO and N1 patients, the 5-year survival rate was 38.1% and 17.3%, respectively （X^2 = 22.65, P 〈 0.01）. The 5-year survival rate for patients in stages Ⅱ a, Ⅱ b and Ⅲ was 31.2%, 27.8% and 12.5%, repsectively （X^2 = 29.18, P 〈 0.01）. CONCLUSION： Ivor Lewis subtotal esophagectomy with two-field （total mediastinum） lymphadenectomy is a safe and appropriate operation for squamous cell carcinoma of the lower thoracic esophagus.     

A prospective comparison of totally minimally invasive versus open Ivor Lewis esophagectomy

The majority of esophagectomies in Western parts of the world are performed by a transthoracic approach reflecting the prevalence of adenocarcinoma of the lower esophagus or esophagogastric junction. Minimally invasive esophagectomy (MIE) has been reported in a variety of formats, but there are no series that directly compare totally minimally invasive thoracolaparoscopic 2 stage esophagectomy (MIE‐2) with open Ivor Lewis (IVL). A prospective single‐center cohort study of patients undergoing elective MIE‐2 or IVL between January 2005 and November 2010 was performed. Short‐term clinicopathologic outcomes were recorded using validated systems. One hundred and six patients (median age 66, range 36–85, 88 M : 18 F) underwent two‐stage esophagectomy (53 MIE‐2 and 53 IVL). Patient demographics (age, sex, body mass index, American Society of Anesthesiologists grade, tumor characteristics, neoadjuvant chemotherapy, and TNM stage) were comparable between the two groups. Outcomes for MIE‐2 and IVL were comparable for anastomotic leak rates (5 [9%] vs. 2 [4%], P= 0.241), resection margin clearance (R0) (43 [81%] vs. 38 [72%], P= 0.253), median lymph node yield (19 vs. 18, P= 0.584), and median length of stay (12 [range 7–91] vs. 12 [range 7–101] days), respectively. Blood loss was significantly less for MIE‐2 compared with IVL (median 300 [range 0–1250] mL vs. 400 [range 0–3000] mL, respectively, P= 0.021). MIE‐2 in this series of selected patients supports its efficacy, when performed by an experienced minimally invasive surgical team. A well‐designed multicenter trial addressing clinical effectiveness is now required.     

Original article: The expression of CFL1 and N‐WASP in esophageal squamous cell carcinoma and its correlation with clinicopathological features

Cofilin1 (CFL1) is an actin‐modulating protein, which belongs to the ADF/Cofilin family. Neural Wiskott–Aldrich syndrome protein (N‐WASP) is the key regulator of the actin cytoskeleton, a member of Wiskott‐Aldrich syndrome protein family. They have been suggested to be involved in cancer cell invasion and metastasis. In this study, the expression patterns of CFL1 and N‐WASP in normal esophageal mucosa and esophageal squamous cell carcinoma (ESCC) and their correlation with clinical characteristics were investigated. Immunohistochemical staining showed that CFL1 was expressed in nuclear and cytoplasm of cancer cells. However, N‐WASP was mainly found in the cytoplasm of the cancer cells. There were significant evidences that proved that CFL1 is correlated with clinicopathological factors in ESCC, such as infiltration depth, lymph node metastasis and pathological staging (P < 0.05). It is also proved that N‐WASP is related to lymph node metastasis and pathological staging in ESCC (P < 0.05). Kaplan–Meier analysis showed that there was no correlation between CFL1 and N‐WASP protein expression and survival (P > 0.05). Moreover, the mRNA expression of CFL1 and N‐WASP was detected by quantitative real time PCR in 70 tissue specimens. The results showed that CFL1 mRNA level was over‐expressed in ESCC tissue (P < 0.05), while N‐WASP mRNA expression level was not different between cancerous tissues and adjacent normal esophageal mucosa (P > 0.05). Also, CFL1 mRNA expression was significantly associated with regional lymph node metastasis and pathological staging (P < 0.05). Kaplan–Meier analysis showed that there was no correlation between CFL1 and N‐WASP mRNA expression and survival (P > 0.05). Our findings suggested that CFL1 and N‐WASP may play an important role in the tumorigenesis of ESCC, and to be the candidate novel biomarkers for the diagnosis and prognosis of ESCC. These findings may have implications for targeted therapies in patients with ESCC.     

Long‐term outcome of esophagectomy for primary malignant melanoma of the esophagus: a single‐institute retrospective analysis

Primary malignant melanoma of the esophagus (PMME) is a highly malignant tumor with a poor prognosis. Because PMME is an extremely rare disease, therapeutic strategies against the tumor have yet to be established, and the efficacy of esophagectomy remains unclear. The objective of this study was to evaluate the post‐esophagectomy survival of PMME patients. Ten patients who underwent esophagectomy for PMME between March 2005 and April 2013 at the Department of Gastroenterological Surgery, Cancer Institute Hospital, Tokyo, Japan, were identified from the institutional database. We retrospectively retrieved clinical information and data on the long‐term outcomes from the patients' records. Survival rates after esophagectomy were calculated by the Kaplan–Meier method, and the hazard ratios of mortality were determined using the Cox's model. A follow‐up study of the 10 patients revealed 7 cancer recurrences and 5 deaths. Median survival time was 34.5 months, and 5 of 10 patients survived longer than 2 years. The 1‐year disease‐free survival rate was 40%, and the 1‐ and 3‐year overall survival rates were 70% and 60%, respectively. Importantly, all three of the non‐relapsing patients were histologically confirmed as free of lymph node involvement. The four patients with lymph node metastasis relapsed within 1 year. The disease‐free survival was significantly shorter in patients with lymph node involvement than in those without lymph node involvement (univariate hazard ratio = 13.3, 95% confidence interval 1.85–266.4; P = 0.009). In conclusion, esophagectomy might benefit PMME patients with no lymph node metastasis. Further large‐scale cohort studies are needed to establish the treatment strategy for PMME.     

Clinical outcomes of two-field lymphadenectomy for patients with clinical stage IA carcinoma of the thoracic esophagus

Background

The optimal treatment for early stage carcinoma of the thoracic esophagus is undecided and remains debatable. This report documents the results of a series of patients with clinical stage IA carcinoma of the thoracic esophagus treated at our institute with esophagectomy and two-field lymphadenectomy (2FL).

Methods

We analyzed 70 patients with clinical stage IA carcinoma who underwent radical esophagectomy with 2FL.

Results

The overall 5-year survival rate of the 70 patients was 81 %. Seventeen of the 70 patients (24 %) had lymph node metastasis. The overall 5-year survival rate of the 53 patients with no metastatic nodes (87 %) was significantly better than that of the 17 patients with positive nodes (65 %; p = 0.022). The operative morbidity was 44 %. Recurrence was recognized in 17 patients (24 %). The median disease-free interval (DFI) until recurrence was 20.5 months. With respect to the initial tumor recurrence, among the 16 patients with a recurrence, there were 9 with a cervical lymph node recurrence, 3 with a hematogenous recurrence, 2 with a combined recurrence, 1 with an abdominal lymph node recurrence in the paraaortic site, and 1 in the anastomotic site. The median DFI and survival times of the patients with a cervical lymph node recurrence were 26 and 55 months, respectively. Of the 9 patients with a cervical lymph node recurrence, 3 disease-free patients survived: 2 received surgery and 1 received radiotherapy.

Conclusions

Two-field lymphadenectomy might be enough for patients with clinical stage IA carcinoma of the middle and lower thoracic esophagus in regard to prognosis, but close follow-up for lymph node recurrence, especially at the cervical site, should be conducted.     

A preliminary experience with minimally invasive Ivor Lewis esophagectomy

With several small series examining minimally invasive Ivor Lewis esophagectomies, we look to contribute to a growing experience. In reporting our initial results, safety, initial oncologic completeness, and preliminary outcomes with a minimally invasive Ivor Lewis esophagectomy were demonstrated. From 2007 to 2010, 40 minimally invasive Ivor Lewis esophagectomies were carried out. The approach was a laparoscopic mobilization of the stomach and a thoracoscopic esophageal mobilization and creation of a high intrathoracic anastomosis. Indications included esophageal cancer in 39 patients and esophageal gastrointestinal stromal tumor in one patient. Median age was 62 (range 39-77) with 31 (78%) male patients. Non-emergent conversion was required in two (5%) patients. Twenty-five (63%) patients underwent neoadjuvant therapy. Mean operative time was 364 minutes (range 285-455), and mean blood loss was 205 cc (range 100-400). All patients underwent an R0 resection including the removal of all Barrett's esophagus, and mean number of nodes harvested was 21 (range 11-41). Median intensive care unit stay was 1 day (range 1-3), and hospital stay was 7 days (range 6-19). There were no anastomotic leaks and no 30-day mortality. Postoperative complications included eight (21%) patients with atrial fibrillation and two (5%) chylothorax, one requiring ligation. At a mean follow-up of 16.5 months (range 1-39 months), five (13%) patients have had a distant recurrence; there have been no local recurrences. Minimally invasive Ivor Lewis esophagectomy, although technically challenging, can be carried out with reasonable operative times, a short length of stay, and minimal complication. Final oncologic validity is pending longer follow-up and a larger series.     

Cancer stem cell marker ALDH1 expression is associated with lymph node metastasis and poor survival in esophageal squamous cell carcinoma: a study from high incidence area of northern China

Tumor recurrence and metastasis is the leading cause of death in esophageal squamous cell carcinoma (ESCC). Cancer stem cell (CSC) may be responsible for tumor growth and maintenance of aggressive behavior. Aldehyde dehydrogenase 1 (ALDH1) has been proposed as one of the possible candidates for a CSC marker. The expression of ALDH1 may be correlated with the clinicopathologic factor and clinical outcome of patients with ESCC. The purpose of this study was to investigate the expression of ALDH1 protein in human ESCC tissues, and evaluated the clinical implication of ALDH1 expression for these patients. All 79 patients who underwent esophagectomy for ESCC between January 2005 and June 2006 were enrolled in this study. The expression of ALDH1 in ESCC and adjacent noncancerous tissues was analyzed by immunohistochemistry. ALDH1 was mainly expressed in ESCC cell nucleus. For the 79 ESCC patients, increased nuclear accumulation of ALDH1 was found in 12 (15.2%) specimens. ALDH1 expression was correlated with poor histological differentiation (P= 0.003), lymph node metastasis (P= 0.011), and late pathologic TNM classification (pTNM) staging (P= 0.003). Patients in ALDH1 positive group had a significantly poor 5-year overall survival than those in the negative group (8.3% vs. 52.2%, P= 0.025). We have demonstrated for the first time that the CSC marker, ALDH1, is expressed in human ESCC. The expression of ALDH1 protein in nucleus of the ESCC is significantly associated with lymph node metastasis and poor survival. Our results highly indicate the involvement of ALDH1 in the aggressive behavior of ESCC.     

Two-field radical lymphadenectomy in the treatment of esophageal carcinoma

This paper retrospectively compares post-operative complications, mortality and long-term survival of patients with esophageal carcinoma who were treated with standard esophagectomy or with extended two-field lymph node clearance. Fifty-seven patients with resectable esophageal carcinoma were included in the study. Twenty-eight patients were submitted to a radical two-field esophagectomy and lymphadenectomy, while the remaining 29 were submitted to a standard, more conservative, esophagectomy performed mostly through a transhiatal route. The two groups of patients were similar in all clinical, laboratory and pathologic features. There was a significant lower anastomotic leakage rate in the group of patients submitted to a radical lymph node resection; post-operative respiratory complication rate and mortality were similar in both groups. The overall 5-year survival was 20%. When lymph node resection was performed, the 5-year survival rate rose to 36%; it was 44% when nodal involvement was negative and 19% for N1 patients; when standard esophagectomy was the procedure, these figures were 9% (p < 0.05), and 6% respectively.     

The significance of abdominal para‐aortic lymph node metastasis in patients with lower thoracic esophageal cancer

Para‐aortic lymph node (PALN) recurrence is often seen in patients with lower thoracic esophageal cancer treated by esophagectomy with extended lymph node dissection. However, the clinicopathological characteristics of patients with PALN metastasis and the significance of PALN dissection are unknown. A total of 283 patients with lower thoracic esophageal cancer underwent esophagectomy with lymphadenectomy at our hospital between April 1984 and March 2007. Among these 283 patients, 60 patients were enrolled in this retrospective study according to following criteria: (i) clinical T2 to T4 tumor, (ii) no clinical PALN metastasis, and (iii) received PALN dissection. PALN dissection was indicated by a tumor depth of at least T2 and no severe complications. The clinicopathological data, recurrence pattern, and overall survival were compared between patients with PALN and without PALN metastasis. The mean length of surgery was 587 min and the mean blood loss was 1383 mL. The morbidity was 33.3% and mortality was 5% in this series. Sixteen patients (26.7%) had PALN metastasis; these showed significantly more lymph node metastases (15.8 ± 13.2 vs. 3.0 ± 3.2, P < 0.0001) and significantly worse survival rates (53.3% vs. 79.9% at 1 year, 6.7% vs. 62.0% at 3 years, P < 0.0001) than patients without PALN metastasis. The incidence of lymph node recurrence (P < 0.0001) and hematogenous recurrence (P= 0.0487) was also higher in patients with PALN metastasis than in patients without PALN metastasis. Among the 16 patients with PALN metastasis, a univariate analysis revealed total number of metastatic nodes < 8 (P= 0.0325) to be a significant prognostic factor. A multivariate logistic regression analysis of the regional lymph nodes identified the invasion of the lower mediastinal nodes (hazard ratio = 6.120) and retroperitoneal nodes (hazard ratio = 15.167) to be significantly correlated with PALN metastasis. PALN metastasis is suggested to be related to the systemic spread of lymphatic metastasis even in lower thoracic esophageal cancer. PALN dissection for pathological PALN(+) patients should not be performed. It remains to be determined in future prospective studies whether patients without pathological PALN metastasis, but showing PALN micrometastasis, could achieve improved survival with PALN dissection.     

Impact of body mass index on postoperative complications and long‐term survival in patients with esophageal squamous cell cancer

Undernutrition and cachexia have been suggested to be risk factors for postoperative complications and survival in cancer patients. The aim of this study was to investigate whether body mass index (BMI) is related to the short‐term and long‐term outcomes in patients who undergo an esophagectomy for the resection of esophageal squamous cell cancer (ESCC). Three hundred forty patients who underwent an esophagectomy for the resection of ESCC between 2003 and 2008 were retrospectively reviewed. The patients were divided into two groups: an L‐BMI group characterized by a BMI < 18.5 kg/m² and an N‐BMI group characterized by a BMI ≥ 18.5 kg/m². Clinical and pathological outcome were compared between groups. The study included 40 patients in the L‐BMI group and 300 patients in the N‐BMI group. A clinicopathological assessment showed that nodal involvement was seen more frequently in the L‐BMI group (P = 0.016). Pulmonary complications seemed to occur more frequently in the L‐BMI group (P = 0.006). The 5‐year overall survival rate was higher in the N‐BMI group (63.6%) than in the L‐BMI group (32.3%) (P < 0.001). The 5‐year disease‐free survival rate was also higher in the N‐BMI group (58.0%) than in the L‐BMI group (33.6%) (P = 0.001). In multivariate analysis, the BMI (hazard ratio, 2.154; 95% CI, 1.349–3.440, P = 0.001) was found to be an independent prognostic factor for overall survival. Our data suggested that a lower BMI not only increased pulmonary complications but also impaired overall and disease‐free survival after an esophagectomy for the resection of ESCC.     

Impact of lymph node micrometastasis on gastric carcinoma prognosis:A meta-analysis

AIM:To investigate the prognostic significance of lymph node micrometastasis(LNMM) in patients with gastric carcinoma.METHODS:Two reviewers independently searchedelectronic databases including Pub Med,EMBASE,the Cochrane Database of Systematic Reviews,the Cochrane Controlled Studies Register,and the China National Knowledge Infrastructure electronic database between January 1996 and January 2014.Strict literature retrieval and data extraction were performed to extract relevant data.Data analysis was conducted using Rev Man 5.2.4 software,and relative risks(RRs) for patient death in five years and recurrence were calculated.A fixed- or random-effects model was selected to pool and a forest plot was used to display RRs.RESULTS:Twelve cohort studies containing a total of 1684 patients were identified.LNMM positivity was worse than LNMM negativity with regards to the number of patients who died in five years.The effects of LNMM positivity in patients with gastric cancer of different T-stages remain unclear.LNMM in patients with gastric carcinoma was also associated with a higher recurrence rate.With regards to the number of patients who died in five years,Asian patients were worse than European and Australian patients.CONCLUSION:We recommend that LNMM should not be used as a gold standard for prognosis evaluation in patients with gastric cancer in clinical settings until more high quality trials are available.     

Totally minimally invasive Ivor‐Lewis esophagectomy with single‐utility incision video‐assisted thoracoscopic surgery for treatment of mid‐lower esophageal cancer

The study aims to evaluate the safety and availability of totally minimally invasive Ivor‐Lewis esophagectomy (MIIE) with single‐utility incision video‐assisted thoracoscopic surgery. Forty‐one patients with mid‐lower thoracic esophageal cancer were prospectively treated with totally MIIE. Two stages of laparoscopic‐thoracoscopic procedures were performed. The first 29 patients were treated with four‐port video‐assisted thoracoscopic surgery (Group 1); the others were treated with single‐utility incision video‐assisted thoracoscopic surgery (Group 2). Short‐term clinicopathological outcomes were examined. All patients had negative tumor margins and were pathologically staged from T1N0M0 to T3N2M0. Among Group 1, there was one conversion to open surgery. The mean duration of surgery was 268.4 ± 37.8 minutes, and mean blood loss was 207.2 ± 74.1 mL without significant differences between groups. The average thoracic or abdominal lymph node yield was 12.6 ± 7.1 or 6 ± 5.8, respectively. The median postoperative hospital stay was 7 days. No mortalities occurred. Minor morbidity complicated by late‐stage gastroparesis occurred in two patients (4.9%) after discharge. Major morbidities, including intestinal obstruction and anastomotic leakage, occurred in three patients (7.3%) after discharge. Among Group 2, the average operative duration was 275.4 ± 31.2 minutes, and the mean blood loss was 220 ± 94.9 mL. One patient developed late‐stage anastomotic leakage. The average thoracic or abdominal lymph node yield was 14.7 ± 8.8 and 6.3 ± 5.7, respectively. No statistically significant differences were identified between Group 1 and Group 2. MIIE with single‐utility incision video‐assisted thoracoscopic surgery is feasible in patients with mid‐lower thoracic esophageal cancer without compromising the extent of surgical resection and perioperative outcomes.     

Quality of life after three kinds of esophagectomy for cancer

AIM:To evaluate quality of life(QOL) following Ivor Lewis,left transthoracic,and combined thoracoscopic/laparoscopic esophagectomy in patients with esophageal cancer.METHODS:Ninety patients with esophageal cancer were assigned to Ivor Lewis(n = 30),combined thoracoscopic/laparoscopic(n = 30),and left transthoracic(n = 30) esophagectomy groups.The QOL-core 30 questionnaire and the supplemental QOL-esophageal module 18 questionnaire for patients with esophageal cancer,both developed by the European Organization for Research and Treatment of Cancer,were used to evaluate patients' QOL from 1 wk before to 24 wk after surgery.RESULTS:A total of 324 questionnaires were collected from 90 patients;36 postoperative questionnaires were not completed because patients could not be contacted for follow-up visits.QOL declined markedly in all patients at 1 wk postoperatively:preoperative and 1-wk postoperative global QOL scores in the Ivor Lewis,combined thoracoscopic/laparoscopic,and left transthoracic groups were 80.8 ± 9.3 vs 32.0 ± 16.1(P 0.001),81.1 ± 9.0 vs 53.3 ± 11.5(P 0.001),and 83.6 ± 11.2 vs 46.4 ± 11.3(P 0.001),respectively.Thereafter,QOL recovered gradually in all patients.Patients who underwent Ivor Lewis esophagectomy showed the most pronounced decline in QOL;global scores were lower in this group than in the combined thoracoscopic/laparoscopic(P 0.001) and left transthoracic(P 0.001) groups at 1 wk postoperatively and was not restored to the preoperative level at 24 wk postoperatively.QOL declined least in patients undergoing combined thoracoscopic/laparoscopic esophagectomy,and most indices had recovered to preoperative levels at 24 wk postoperatively.In the Ivor Lewis and combined thoracoscopic/laparoscopic groups,pain and physical function scores were 78.9 ± 18.5 vs 57.8 ± 19.9(P 0.001) and 59.3 ± 16.1 vs 70.2 ± 19.2(P = 0.02),respectively,at 1 wk postoperatively and 26.1 ± 28.6 vs 9.5 ± 15.6(P = 0.007) and 88.4 ± 10.5 vs 95.8 ± 7.3(P = 0.003),respectively,at 24 wk postoperatively.Scores in the left transthoracic esophagectomy group fell between those of the other two groups.CONCLUSION:Compared with Ivor Lewis and left transthoracic esophagectomies,combined thoracoscopic/laparoscopic esophagectomy enables higher postoperative QOL,making it a preferable surgical approach for esophageal cancer.