Two-step three-field lymph node dissection is beneficial for thoracic esophageal carcinoma

Aggressive surgery including extensive lymph node dissection is considered necessary to improve the long-term survival of patients with esophageal carcinoma. While three-field lymph node dissection is widely performed for patients with thoracic esophageal carcinoma, cervical lymph node metastasis is uncommon. In order to reduce surgical stress, we have developed a two-step three-field lymph node dissection procedure for thoracic esophageal carcinoma. In the first-step operation, total thoracic esophagectomy through a right thoracotomy is performed. Mediastinal and abdominal lymph node dissection is performed synchronously. When recurrent nerve lymph node metastasis is pathologically positive, cervical lymph node dissection is performed about 3 weeks after the first operation (second step). Of 343 patients with carcinoma of the esophagus surgically treated in our department between 1990 and 2001, 146 underwent the operation described above. Three-field dissection was performed in 68 patients (group A), while two-field dissection was performed in 78 patients (group B). In the 68 group A patients, cervical lymph node metastasis was positive in 15 patients (22%). There was no marked difference in the onset of major complications between the two groups. The 5-year survival rate was 58% for group A and 61% for group B, not a statistically significant difference. In 78 of the 146 patients, it was possible to avoid cervical lymph node dissection without negatively affecting therapeutic outcomes. Two-step three-field lymph node dissection can reduce surgical stress of patients with good clinical outcome.     

Three-field dissection or two-field dissection?--A proposal of new algorithm for lymphadenectomy

BACKGROUND/AIMS: There are no systematic criteria for cervical lymphadenectomy in esophageal carcinoma. We provide a new algorithm for deciding whether to use three-field dissection or two-field dissection. METHODOLOGY: Ninety-eight patients underwent curative esophagectomies with three-field lymph node dissections for squamous cell carcinoma of the thoracic esophagus. We examined the outcomes and predictors for survival of these patients. Therefore, we devised a new decision tree for deciding whether to use three-field dissection or two-field dissection. RESULTS: The overall 5-year survival rate for the 98 patients was 41.3%. The number of positive nodes was the only significant predictor for survival in the multivariate Cox proportional hazard model. The outcomes of patients with positive supraclavicular/internal jugular nodes were poor. On the other hand, positive cervical paraesophageal nodes do not worsen prognosis. We provided a new algorithm for selecting procedure of lymphadenectomy based on the presence of lymph node metastases. This algorithm is decided by the number of positive nodes, the presence of cervical node metastasis and recurrent nerve node metastasis. According to this decision tree, there were a few patients who needed absolutely three-field dissections. CONCLUSIONS: The new algorithm may be helpful for deciding three-field dissection or two-field dissection for thoracic esophageal carcinoma.     

Lymph node metastasis along the recurrent nerve chain is an indication for cervical lymph node dissection in thoracic esophageal cancer

This study examined whether recurrent nerve chain node metastasis serves as an indicative factor for cervical lymph node dissection in thoracic esophageal cancer. The association of recurrent nerve chain lymph node metastasis and cervical node metastasis was analyzed for 91 patients with thoracic esophageal cancer who had undergone three-field lymph node dissection. In patients with upper thoracic esophageal cancer, the incidence of cervical lymph node metastasis was similar regardless of recurrent nerve chain node metastasis. On the other hand, in patients with middle or lower esophageal cancer, the incidence was significantly higher in recurrent nerve-positive (16/31, 51.6%) than in recurrent nerve-negative (5/43, 11.6%) patients. The prognosis of patients with recurrent nerve chain node metastasis was significantly better in the three-field dissection group than in the two-field dissection group, while in patients with no recurrent nerve chain node metastasis, survival was similar between the two groups. In conclusion, cervical lymphadenectomy can be omitted for recurrent nerve chain node-negative patients with middle and lower thoracic esophageal cancer.     

Three-field lymph node dissection in the treatment of thoracic esophageal carcinoma: the Turkish experience

SUMMARY.  The role of extended lymphatic dissection on the prognosis and outcome of thoracic esophageal carcinoma is still controversial. The aim of this study was to determine the impact of three-field lymphatic dissection on the survival and recurrence rates of patients with thoracic carcinoma of the esophagus. Forty-six patients with primary squamous cell carcinoma of the thoracic esophagus underwent esophagectomy with three-field lymphatic dissection between 1992 and 2003. Recurrence and survival rates were examined as well as complications. Overall survival for the patients was 45.6 months and 5-year survival rate was 56%. Five-year survival rates for patients with Stage 2A, 2B, 3 and 4 were 68%, 0%, 53% and 33%, respectively. There was no Stage 1 patient. Mean disease-free survival was 41.4 months. Sixty three percent of patients had node-negative disease (5-year survival rate, 68.9%) and 37% had nodal metastases (5-year survival rate, 33.7%) ( P  = 0.002). Surgical morbidity was seen in 35 patients (76.1%). Conclusively, lymph node involvement in patients with thoracic esophageal carcinoma is the major determinant of prognosis and survival. Extended lymphatic dissection provides higher disease-free and overall survival rates and our study revealed the highest survival rate for thoracic esophageal carcinoma, to best of our knowledge.     

The pattern of lymphatic metastases in superficial squamous cell carcinoma of the esophagus

BACKGROUND/AIMS: Lymphatic spread patterns in relation to the location of primary tumors of the superficial thoracic esophageal squamous cell carcinoma have not been well established. We therefore analyzed patterns of lymph node metastasis in these patients. METHODOLOGY: We reviewed medical records of 65 patients who underwent systematic three-field dissection for superficial squamous carcinoma of the thoracic esophagus from 1993 through 2000. RESULTS: Lymph node involvement was found in 0% (0/13) and 44% (23/52) of patients whose tumor invaded the muscularis mucosa and submucosal layer, respectively. The 5-year survival rate was 77% in the node-negative group and 59% in the node-positive group (P<0.05). None of the patients with upper thoracic esophageal cancer had metastasis to the mediastinal and abdominal nodes. Patients with lower thoracic esophageal tumors (Lt) had no metastasis to the cervical nodes. Patients with middle thoracic esophageal tumors (Mt) and Lt patients rarely had metastasis (2-5%) in the lower mediasinal nodes (Nos. 108-112). No patient with superficial thoracic esophageal cancer had metastasis to the subcarinal nodes in this study. CONCLUSIONS: In our series, no patient with intramucosal carcinoma had lymphatic metastases. Some patients with submucosal cancers metastasized beyond regional lymph nodes. However, this study suggests that subcarinal nodes might not need to be sampled or dissected in patients with superficial carcinoma of the thoracic esophagus. In Mt and Lt patients, metastases to the mediastinal nodes were infrequent (2-7%). Mediastinal nodes other than #107 can easily be sampled through cervical and abdominal incisions. Therefore, combined with lymph node sampling in cervical, mediasinal and abdominal stations through cervical and abdominal incisions, esophagectomy without thoracotomy might be acceptable in Mt and Lt patients with superficial squamous cell carcinoma of the esophagus.     

Selective three-field lymphadenectomy for thoracic esophageal squamous carcinoma

The purpose of this study was to examine metastasis in different nodal stations and the extent of lymphadenectomy for esophageal carcinoma. Eighty-seven thoracic esophageal squamous carcinoma patients underwent esophagectomy with two-field or three-field lymphadenectomy based on cervical ultrasonography. Thirty-five patients (40.2%) with ultrasonography-detected cervical nodes underwent cervical dissection. Significantly more patients with primary tumors in the upper thoracic esophagus had cervical dissection than patients with tumors in the middle and lower esophagus (66.7%vs. 30.2%, P=0.002). Metastasis to cervical, superior mediastinal, mid-mediastinal, and abdominal nodes were 19.5%, 25.3%, 23%, and 24.1%, respectively. Cervical metastasis was 29.2%, 20.8%, and 10% for upper, middle, and lower thoracic esophageal tumors. Regional lymphadenopathy was found in 48 patients (55.2%) and was significantly related to cervical metastasis (31.3%vs. 5.1%, P=0.002). It was significantly less in upper (37.5%) than in middle (62.3%) and lower (60%) thoracic esophageal tumors (P=0.041). When cervical metastasis was included into regional lymphadenopathy, the difference was no longer significant (45.8%vs. 63.5%, P=0.135). Cervical dissection was associated with significantly more morbidities (60%vs. 34.6%, P=0.020), especially recurrent laryngeal nerve palsy (22.9%vs. 9.6%, P=0.089). Recurrent laryngeal nerve palsy was related significantly to anastomotic leakage (53.8%vs. 13.5%, P=0.001). There was no significant difference between the 2-year survivals for patients with or without cervical metastasis (50.0 vs. 72.0%, P=0.094). We conclude that cervical metastasis is of a similar rate as metastasis to mediastinal or abdominal nodes. Cervical nodes should be taken as regional lymph nodes for thoracic esophageal cancer. Cervical dissection is associated with increased morbidity and should be reserved for patients who may benefit from the procedure. Selective three-field dissection based on ultrasonography is helpful in reducing surgical morbidity while increasing the completeness of resection.     

Long-term survival after resection of paraaortic lymph node metastasis that developed 6 years after the esophagectomy

A 62-year-old man underwent subtotal esophagectomy with an extended three-field lymph node dissection for squamous cell carcinoma of the lower thoracic esophagus (histological stage pT3N1M0, pStage III). Computed tomography showed a swollen paraaortic lymph node about 6 years later. Positron emission tomography also indicated lymph node metastasis. The patient was treated with surgery, and the lymph node was diagnosed to be metastasis of esophageal cancer. Surgery was followed by chemotherapy with nedaplatin and 5-fluorouracil. The patient has remained alive more than 5 years after surgery without any evidence of recurrence. Although the optimal treatment for the recurrence region of esophageal cancer remains controversial, the current case suggests the possibility of performing a salvage resection for a lymph node recurrence of esophageal cancer in selected patients.     

CASE OF A SEVERE AND LONG BENIGN STRICTURE OF THE ESOPHAGUS

A unique case of a severe and long benign stricture of the esophagus was experienced by the authors. A 50‐year‐old alcoholic man was admitted to our hospital complaining of dysphagia as well as severe and continuous retrosternal burning pain of acute onset after abrupt vomiting. His previous medical history included alcoholic liver dysfunction, renal dysfunction, Klinefelter’s syndrome and a surgically treated duodenal ulcer. Ingestion of foreign body or acid/alkali substances was excluded. Although histopathologic examination of the endoscopic biopsy specimen was reported to be an esophageal squamous cell carcinoma, endoscopic findings and a barium esophagogram were not typical for a malignant disease. Since this study demonstrated a smooth surface of the lumen in spite of it being approximately 10 cm long, severe stricture of the esophagus was diagnosed. Because the stricture was very long and severe, and was not conservatively treatable, it was decided, after obtaining informed consent, that surgical resection of the esophagus would be performed. Subtotal esophagectomy with lymph node dissection and colonic interposition was carried out. During surgery, the patient was diagnosed as having liver cirrhosis. Histopathologic examination of the surgically resected specimen revealed a 10 cm‐long narrowing of the middle and lower thoracic esophagus with thick walls, particularly in the inner circular muscle layer, without malignancy. Unfortunately, the patient’s postoperative course was followed by cervical leakage. He subsequently died of multiple organ failure on the sixteenth postoperative day. It is worth keeping in mind that esophageal benign stricture with longitudinal ulceration can be induced by esophageal submucosal dissection, as seen in the present case.     

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.     

Basaloid squamous carcinoma of the esophagus developed from achalasia: report of a case

A 57-year-old man, who had been diagnosed as having flask type, grade II achalasia of the esophagus at the age of 26, underwent Heller’s esophagomyectomy in a nearby hospital in 1971. A type 0-Is lesion measuring 2 cm in size was found on the middle thoracic esophagus in September 2002. A protruding tumor with a central depression, not stained with iodine, was detected by endoscopic examination. Standard subtotal esophagectomy with three-field lymph node dissection was performed. By histopathological examination, the esophageal lesion was classified as basaloid squamous carcinoma, extending to the middle part of the submucosa (T1b; sm2), without lymph node metastasis. The majority of the invasive carcinoma was composed of basaloid carcinoma, while a part showed as squamous cell carcinoma at the mucosal site. Achalasia of the esophagus is considered as a risk factor for squamous cell carcinoma by persistent mucosal inflammation caused by chronic stasis and food retention. Most of the reported carcinomas developing from esophageal achalasia are squamous cell carcinoma histologically. An extremely rare case of superficial basaloid squamous carcinoma with achalasia is presented.     

Validity of intraoperative pathological diagnosis of paratracheal lymph node as a strategy for selection of patients for cervical lymph node dissection during esophagectomy

The aim of this paper is to examine whether intraoperative examination of paratracheal nodes can indicate cervical node dissection and whether this approach is valid. From 1988 to 1997, 76 patients with thoracic esophageal squamous cell carcinoma received esophagectomies with and without cervical lymph node (LN) dissection based on the results of intraoperative pathological diagnosis from selective checking of paratracheal LN. We retrospectively examined the outcomes for the patients and the micro metastasis in the dissected lymph node using cytokeratin staining. Three of the seven patients with cervical LN dissection were detected as having cervical LN metastasis by postoperative hematoxylin-eosin or cytokeratin staining. Five (7%) of the 69 patients without cervical LN dissection had cervical LN recurrence after the operation. Four of the seven patients who were diagnosed as having metastasis or micro metastasis in paratracheal LN by postoperative examination had cervical LN recurrence after the operation. In conclusion, the esophagectomy with and without cervical LN dissection for thoracic esophageal squamous cell carcinoma based on the results of intraoperative pathological diagnosis from selective checking of paratracheal LN was not fully acceptable. The reliability of intraoperative pathological diagnosis of selective checking may improve by increasing the number of checked LN and the detection of micro metastasis.     

Effective treatment with chemotherapy and surgical resection for small cell carcinoma of the esophagus: report of a case.

We report on a patient with small cell carcinoma of the esophagus treated with effective combination chemotherapy followed by surgical resection. A 69 year-old male had an ulcerated tumor in the middle part of the esophagus, which was microscopically diagnosed as small cell carcinoma of the esophagus. After combination chemotherapy, endoscopy showed that the esophageal tumor had changed into a shallow ulcer. No cancer cell was found in the biopsy specimen of the ulcer. A subtotal esophagectomy with regional lymph node dissection was performed. Histological examination showed that a few cancer cells remained in a microvessel of the submucosal layer in the removed esophagus and no cancerous lesion was found in regional lymph nodes. The patient was well and was able to remain at home. However, he eventually died 21 months after first detection of the carcinoma due to progression of multiple lung and mediastinal lymph node metastases. After complete or partial remission is achieved by the combination chemotherapy, surgical resection may be recommended as the second therapy that occasionally produces long-term remission and possibly long-term survival for patients with small cell carcinoma of the esophagus, such as the present case.     

Effect of bilateral supraclavicular postoperative radiotherapy in middle and lower thoracic esophageal carcinoma

AIM: To evaluate whether postoperative radiotherapy is an alternative to neck lymph node surgery and if it provides a survival benefit for those receiving two-field, chest and abdomen, lymphadenectomy.METHODS: A total of 530 cases with middle and lower thoracic esophageal carcinoma in our hospital from January 2008 to April 2009 were selected and analyzed, of which 219 cases received right chest, upper abdominal incision Ivor-Lewis surgery and simultaneously underwent mediastinal and abdominal two-field lymphadenectomy. If regional lymph node metastasis occurred within the recurrent laryngeal nerve, the patients would receive bilateral supraclavicular radiotherapy (DT = 5000cGy) to be adopted at postoperative 4-5 wk (Group A) or cervical lymphadenectomy at postoperative 3-4 wk (Group B). If there were no regional lymph node metastases within the recurrent laryngeal nerve, the patients only underwent two-field, chest and abdomen, lymphadenectomy (Group C).RESULTS: In 219 cases who underwent two-field lymphadenectomy, 91 cases were diagnosed with regional lymph node metastasis within the recurrent laryngeal nerve. Of them, 48 cases received cervical radiotherapy, and 43 cases underwent staging lymphadenectomy; 128 patients were not given the follow-up treatment of cervical radiotherapy because there was no regional lymph node metastasis within the recurrent laryngeal nerve. Five-year survival rates in group A and B were 47% and 50%, respectively, with no statistical difference between them, and the rate in group C was 58%.CONCLUSION: For patients with middle and lower thoracic esophageal carcinoma combined with lymph node metastasis within the recurrent laryngeal nerve, cervical radiotherapy can be a substitute for surgery and provide benefit.     

Rapid-growth carcinosarcoma of the esophagus arising from 0-IIc squamous cell carcinoma after definitive chemoradiotherapy: a case report

A case of carcinosarcoma arising from the area of intraepithelial spread of relapsed esophageal squamous cell carcinoma (SCC) after definitive chemoradiotherapy (CRT) is reported herein. A 71-year-old man was referred to our hospital because of a superficial esophageal carcinoma. Definitive CRT was performed because the patient refused surgical treatment. Complete response was recognized after CRT, but tumor relapse was diagnosed 3 months later. The relapsed tumor initially revealed a minimal depression with a small white nodule. This nodule developed to a sessile elevated mass after 1 month and finally to a polypoid tumor 3.2 × 2.3 × 1.5 cm in size within 125 days. A subtotal esophagectomy with two-field lymph node dissection was performed. Histologically, the polypoid tumor was composed mainly of spindle-shaped sarcomatous cells and invaded the muscularis propria of the esophageal wall. An area of intraepithelial spread of SCC was found at the base of its stalk. No lymph node metastases were found. The postoperative course was uneventful, and the patient has remained free of disease for 45 months. To our knowledge, this is the only reported case of esophageal carcinosarcoma arising from an area of intraepithelial spread of relapsed SCC that showed such rapid growth by serial endoscopies.     

Posterior mediastinal lymph node dissection using the pneumomediastinum method for esophageal cancer

Although posterior mediastinal lymph node metastases are often observed in patients with esophageal cancer, their complete resection via a right thoracic approach is difficult and carries a risk of complications. We have developed a novel procedure for en-bloc dissection of the posterior mediastinal lymph nodes using the pneumomediastinum method. The patient was a 48-year-old female with middle thoracic esophageal cancer. A computed tomography scan showed a posterior mediastinal lymph node 1?cm in diameter. After division of the gastrosplenic ligament by hand-assisted laparoscopic surgery, the esophageal hiatus was opened, and carbon dioxide was introduced into the mediastinum. The anterior and left sides of the distal esophagus were separated, and a swollen posterior mediastinal lymph node was detected. Subsequently, the adventitia of the thoracic aorta was exposed, and the posterior side of the lymph node was separated. While lifting these nodes like a membrane, we cut them along the border of the left mediastinal pleura. Histopathological examination revealed a single squamous cell carcinoma metastasis in the resected lymph node. A good surgical view was obtained in our surgical procedure, and en-bloc dissection of the posterior mediastinal lymph nodes was safely performed.     

Outcomes of endoscopic and surgical resection for a second primary cancer in the residual cervical esophagus after thoracic esophagectomy

Patients who have received subtotal esophagectomy for thoracic esophageal cancer must be closely monitored for second primary malignancies. The purpose of this study is to review and assess patients who developed a second primary esophageal cancer in the residual cervical esophagus. Between 1996 and 2010, 10 patients were diagnosed in our hospital with esophageal squamous cell cancer in the residual cervical esophagus after undergoing thoracic esophagectomy and were treated with endoscopic or surgical resection. Data from these patients were reviewed retrospectively. Seven of the 10 patients (70%) had multiple primary carcinoma lesions at the time of their esophagectomy. A second primary cancer in the residual cervical esophagus was detected in eight patients during follow-up endoscopic examinations while the patients were still asymptomatic. Seven of the patients underwent endoscopic resection for a superficial cancer. None of those patients experienced any complications, and all are currently alive and cancer-free. The remaining three patients underwent resection of the cervical esophagus with regional lymph node dissection. Two of those patients experienced severe complications; one subsequently died (hospital death) from pneumonia, 12 months after surgery, while the other died from recurrence of his cancer. The third patient is alive and cancer-free. Early detection of a second primary malignancy in the residual cervical esophagus followed by endoscopic resection is the best treatment strategy for patients who previously received subtotal esophagectomy for thoracic esophageal cancer. Surgical resection puts patients at high risk of mortality or morbidity.     

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.     

Thoracoscopic radical esophagectomy combined with left inferior pulmonary ligament lymphadenectomy for esophageal carcinoma via the right thoracic approach: A single-center retrospective study of 30 cases

To evaluate the necessity, safety, and feasibility of left inferior pulmonary ligament lymphadenectomy during video-assisted thoracic surgery (VATS) radical esophagectomy via the right thoracic approach.Thirty patients (20 men, 10 women) with thoracic esophageal squamous cell carcinoma (ESCC) were recruited for this study. The patients’ age ranged from 50 to 80 years, with an average age of 66.17 ± 7.47 years. After the patients underwent VATS radical esophagectomy and left inferior pulmonary ligament lymph node dissection (LIPLND) via the right thoracic approach, the operative outcomes included operative time, length of hospital stay, postoperative complications, number of lymph nodes removed, and postoperative pathologic results were evaluated.There were no massive hemorrhages of the left inferior pulmonary vein during the operation. The operative time of LIPLND was 8.67 ± 2.04 minutes, and the length of postoperative hospital stay was 12.23 ± 2.36 days. The postoperative complications included 2 cases of left pneumothorax, 4 pulmonary infection cases, and no chylothorax. Moreover, 68 LIPLNs were dissected, 5 of which were positive, and the degree of metastasis was 7.4%. The postoperative pathologic results showed that 3 cases of LIPLNs were positive, with a metastasis rate of 10.0%. Among them, 2 cases were SCC of the lower thoracic esophagus, and 1 case was SCC of the middle thoracic esophagus, which involved the lower segment.Thoracoscopic esophagectomy combined with left inferior pulmonary ligament lymphadenectomy for esophageal carcinoma via the right thoracic approach will not increase the difficulty of operation, increase the incidence of postoperative complications or prolong the postoperative hospital stay, and can theoretically reduce tumor recurrence. Therefore, we believe that LIPLND is necessary, safe, and feasible and is worthy of clinical popularization and application.     

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.     

Sentinel node mapping in esophageal squamous cell carcinoma using intra-operative combined blue dye and radiotracer techniques

Background

Extended surgeries such as two- or three-field lymph node dissections are gaining more acceptance for treatment of esophageal cancer. Sentinel node biopsy is an alternative approach in this regard. In the current study we evaluated the accuracy of sentinel node mapping of the squamous cell carcinoma of the esophagus using intra-operative combined blue dye and radiotracer techniques.

Methods

Immediately after thoracotomy and before mobilizing the tumor, 1 mCi/0.4 ml Tc-99 m-antimony sulfide colloid was injected in two sites proximal and distal to the tumor. Concomitantly, 2 ml of 1 % methylene blue was also injected in the same manner. Sentinel nodes were removed and sent for frozen section and H&E staining. A two-field lymphadenectomy was performed for all patients.

Results

Twenty-three patients were included in the study. The detection rate was 100 %. Eleven patients had pathological lymph node involvement and in 10 patients sentinel node was pathologically positive too. Frozen section results showed 100 % concordant with H&E results. One patient with a false negative result had a pT3 tumor.

Conclusions

Sentinel node mapping in SCC of the mid to distal esophagus is feasible and accurate, especially in pT1 and pT2 tumors.