Operative management of adrenal metastases from lung carcinoma

Most surgeons consider patients with solitary adrenal metastasis from a primary lung carcinoma incurable and avoid excision of both the adrenal and primary lung tumors. However, several cases of successful surgical management of these patients recently have been reported. We reviewed 12 surgically treated patients with isolated adrenal and lung disease and identified 2 survivors of greater than fifteen years (17%) and 4 additional patients who are still alive following combined resection (34%). This survival rate, albeit in a selected population, represents an improvement over the natural history of nine months' survival. We suggest that if after six to twelve months of following patients with lung cancer and isolated adrenal metastasis no other evidence of spread of disease is evident, the tumor biology may be favorable and resection of both adrenal and lung lesions is reasonable.     

Long-term survival after three-field lymph-adenectomy for an adenocarcinoma in Barrett’s esophagus with metastasis to Virchow’s node

Here, we report a case of long-term survival after resection of an adenocarcinoma in Barrett’s esophagus with metastasis to Virchow’s node. A 71-year-old women was referred to our hospital with a tumor in the lower third of the thoracic esophagus, located just beneath the tracheal bifurcation because of an hiatal hernia. On admission, she had a palpable lymph node in Virchow’s node. The esophageal tumor and this lymph node were biopsied. They were pathologically found to be an adenocarcinoma in the esophagus which had metastasised to the lymph node. She underwent transthoracic esophagectomy with three-field lymph node dissection. The pathological diagnosis was adenocarcinoma in Barrett’s esophagus with the UICC stage classification of pT1, pN1, pM1-LYM, Stage IVB. She received postoperative chemotherapy of cisplatin combined with 5-fluorouracil. The patient is well without recurrence at 14 years to date after surgery. We recommend thoracoabdominal esophagectomy with three-field lymphadenectomy for an advanced carcinoma in the upper and middle thoracic esophagus regardless of histological types.     

Patterns of lymph node metastasis in 3-field dissection for carcinoma in the thoracic esophagus

Lymph node metastasis is well-known as the most important prognostic indicator for esophageal carcinomas, and an accurate assessment of positive metastasis can only be made after total lymphadenectomy around the esophagus. However, prior to the development of 3-field lymph node dissection in Japan, no such operation existed for ascertaining the full positivity distribution. We report herein the results of a restrospective study conducted on 70 patients who underwent subtotal esophagectomy with 3-field dissection to discover the patterns of lymph node metastasis from carcinoma in the thoracic esophagus. Lymph node metastases tended to have an orderly spreading pattern in relation to the tumor location, even though the lymph node metastasis varied widely from the lower neck to the upper abdomen. The nodes along the right recurrent nerve and the paracardiac nodes were most frequently found to be positive for metastasis. In contrast, no metastasis was found in the internal jugular nodes, the pretracheal nodes, the common hepatic nodes, or the splenic nodes. Patients with carcinoma in the upper thoracic esophagus rarely had metastasis in the abdominal nodes, while those with carcinoma in the lower thoracic esophagus rarely had metastasis in the cervical nodes. Thus, surgical extirpation of the lymph nodes during 3-field dissection is effective not only to determine the correct tumor staging for the planning of adequate adjuvant therapies postoperatively, but also to produce a guideline for prospective lymphadenectomy for esophageal carcinomas.     

Results of simultaneous resection and plastic surgery of the esophagus with extra-cavitary cervical esophagostomy in esophageal cancer in its thoracic part

The work analyses the results of one-stage resection and plastics of the esophagus with a tube formed from the greater curvature of the stomach and creation of an ++extra-cavitary anastomosis on the neck in combined and surgical treatment of carcinoma of the thoracic esophagus in 279 patients. Various complications occurred in 181 (64.8%) patients. The mortality was 19.3% (16.8% among patients who underwent radical operation and 25.6% among those treated by a palliative operation). The number of complications in the groups of surgical and combined treatment was approximately equal. The results of 5-year survival were better in the group with combined treatment. Postponed + extra-cavitary anastomosis was formed in 65.2% of cases. One-stage resection and plastics of the esophagus with ++extra-cavitary anastomosis is an adequate operation from the oncological standpoint in the treatment of carcinoma of the thoracic esophagus. Its further perfection is necessary for improvement of the immediate and late-term results of treatment.     

A case of mucosal esophageal carcinoma with a large intramural metastasis in the stomach

The prognosis of mucosal carcinoma of the esophagus is extremely good because of low frequency of lymphatic invasion compared with submucosal carcinoma. A 64-year-old male was admitted presented with dysphagia and weight loss. Roentgenogram and esophagoscopy revealed erosive lesions in the lower portion of the esophagus and a huge submucosal tumor that looked like the myosarcoma in the cardial portion. After total resection of thoracic esophagus and partial gastrectomy, esophagogastrostomy was done through the anterior thoracic route. During the operation, we found a few disseminative foci in the thoracic cavity (pl1) and direct invasion of cardial tumor to the celiac portion. Therefore, the operation was absolute by palliative. Histological examination of the resected specimen showed that the IIc-like lesion of the lower portion of the esophagus was a moderately differentiated squamous cell carcinoma invading the mucosa (mm), which was 2.0 x 1.6 cm in size, with marked lymphatic invasion, and intra-mural metastatic foci (7.0 x 5.0 cm) at the cardial portion. The patient died 3 months after the operation with mediastinal lymph node metastasis. In our 19 cases of resected mucosal carcinoma of the esophagus, lymphatic invasion was positive in 16%, and lymph node metastasis was positive in 16%, and intramural metastasis was in only one case. Frequency of intramural metastasis in esophageal carcinoma is about 10% in sm -a3 lesion, 5% in mm. In our experience, the prognosis of curatively resected mucosal carcinoma of the esophagus is generally good. We get long survivals, when curative operation is undergone, even if the lymphatic invasion is positive.     

Spontaneous regression in small cell esophageal carcinoma

Spontaneous regression or remission of cancers has been defined as the disappearance of the malignancies without any treatment or with obviously inadequate treatment. Spontaneous regression is rare, while any case with a small cell carcinoma in the esophagus was not found in the literature. We experienced a 73-year-old man with small-cell carcinoma in the thoracic esophagus whom underwent esophagectomy with lymphadenectomy. A pathological examination of the resected specimens found metastasis from the small cell carcinoma in the mediastinal lymph nodes, but no malignant cells in the esophageal lesion—an ulcer scar from which the biopsy specimen was taken to be a small-cell carcinoma. This may be the first case report that spontaneous regression in a small-cell carcinoma in the esophagus was found by esophagectomy and pathological examination.     

Laparoscopic adrenalectomy for solitary metachronous adrenal metastasis from lung cancer: Report of a case

We report herein the case of a 69-year-old man who underwent laparoscopic adrenalectomy for a solitary adrenal metastasis 10 months after a left lower lobectomy for T2N1M0 lung cancer. A 30×20 mm tumor was found in the left adrenal gland, and dissected using an ultrasonically activated scalpel. Histological examination revealed metastatic squamous cell carcinoma. The patient recovered uneventfully and his condition is now stable 18 months after the second operation, with no evidence of local recurrence or metastatic disease. Although laparoscopic resection for malignant adrenal tumors is still controversial, we consider that laparoscopic adrenalectomy may be an optional treatment for metastatic adrenal tumors, provided the tumor is solitary, small in size, and well-localized. To our knowledge, only 14 cases of laparoscopic adrenalectomy for malignant tumors have been reported to date; however, this is the first case of successful laparoscopic adrenalectomy for a metastasis from lung cancer.     

Synchronous laparoscopic resection of colorectal and renal/adrenal neoplasms

Synchronous laparoscopic resections of coexisting abdominal diseases are shown to be feasible without additional postoperative morbidity. We report our experience with synchronous laparoscopic resection of colorectal carcinoma and renal/adrenal neoplasms with an emphasis on surgical and oncologic outcomes. Five patients diagnosed to have synchronous colorectal carcinoma and renal/adrenal neoplasms (renal cell carcinoma in 2 patients, adrenal cortical adenoma in 2 patients, and adrenal metastasis in 1 patient) underwent synchronous laparoscopic resection. The median operative time was 420 minutes and the median operative blood loss was 1000 mL. Three patients developed minor complications, including wound infection in 2 patients and retention of urine in 1 patient. There was no operative mortality. The median duration of hospital stay was 11 days. At a median follow-up of 17.6 months, no patient developed recurrence of disease. Synchronous laparoscopic resection of colorectal and renal/adrenal neoplasms is technically feasible and safe.     

Combined robotic lobectomy and adrenalectomy for lung cancer and solitary adrenal metastasis

Background and Objectives:

Surgical resection of isolated adrenal metastasis in primary lung cancer is associated with improved survival. We report a combined robotic lobectomy and adrenalectomy for resection of a primary lung cancer and metastasis to the adrenal gland.

Methods:

A 69-year-old male with a significant smoking history and shortness of breath was found to have a 3-cm left upper lobe mass with an enlarged left adrenal gland measuring 1.5cm. The adrenal gland was biopsied confirming metastatic poorly differentiated carcinoma, likely lung cancer. Computed tomography, positron emission tomography, and mediastinoscopy revealed no evidence of disease outside the adrenal gland.

Results:

Following induction chemotherapy, the patient underwent combination robotic lobectomy, lymphadenectomy, and adrenalectomy while in the same lateral decubitus position. Thoracic and urologic oncology teams performed their respective portions of the operation. Overall operative time was 4 hours, and length of hospital stay was 3 days. Estimated blood loss was 150mL with no narcotic requirements beyond the first postoperative day. Final pathology revealed large cell carcinoma of the lung with metastasis to the adrenal. All surgical margins were negative.

Conclusions:

Combination robotic lobectomy and adrenalectomy is feasible and can be associated with a short convalescence, minimal pain, and an oncologically sound approach.     

Adenosquamous carcinoma arising in Barrett''s esophagus

Primary adenocarcinoma of the esophagus is rare in Japan and, in most cases, arises from Barrett's esophagus epithelium. A 72-year-old man reporting heartburn and dysphagia and preoperatively diagnosed with adenosquamous carcinoma arising from Barrett's esophagus underwent thoracic esophagectomy and lymph node dissection in curative resection. Pathological diagnosis of the resected specimen showed adenosquamous carcinoma (coexistent adenocarcinoma and squamous cell carcinoma) invasive to the submucosal layer; metastasis was found in regional lymph nodes. Pathological staging was pT1bN1M0, stage II. Unfortunately, the man died of liver and lung metastasis 17 months postoperatively. To our knowledge, this rare case is only the fifth reported in the English literature on adenosquamous carcinoma arising from Barrett's esophagus.     

胃癌浸润食管的外科治疗及预后分析

目的探讨胃癌侵犯食管病例手术入路的合理选择和淋巴结清扫范围以及影响预后的因素。方法回顾1994年8月至2004年2月外科治疗693例胃癌患者发生食管侵犯63例的临床资料。分析淋巴结转移范围及各站淋巴结转移率;比较经上腹部正中切口和经左侧胸腹联合切口两组患者的5年生存率;分析影响术后生存率的各种因素。结果全组根治性切除率85.7%,联合脏器切除25例(39.7%)。总的淋巴结转移率为73.0%,其中腹腔内转移率为73.0%;胸腔内转移率为12.7%。经上腹部正中切口手术者35例,左侧胸腹联合切口手术者28例;前者5年累计生存率为18%,后者为38%,差异有统计学意义(P<0.05)。联合脏器切除组5年累计生存率16%。Logistic分析:年龄、组织学分类,肿瘤直径、Borrmann分型、淋巴结转移、胸腔淋巴结转移及手术入路的选择是影响预后的因素。结论胃癌侵犯食管应在腹腔淋巴结彻底清扫基础上清扫胸腔和膈肌上、下淋巴结;选择左侧胸腹联合切口可以提高根治率和5年生存率。     

Adenosquamous carcinoma arising in Barrett's esophagus

Primary adenocarcinoma of the esophagus is rare in Japan and, in most cases, arises from Barrett's esophagus epithelium. A 72-year-old man reporting heartburn and dysphagia and preoperatively diagnosed with adenosquamous carcinoma arising from Barrett's esophagus underwent thoracic esophagectomy and lymph node dissection in curative resection. Pathological diagnosis of the resected specimen showed adenosquamous carcinoma (coexistent adenocarcinoma and squamous cell carcinoma) invasive to the submucosal layer; metastasis was found in regional lymph nodes. Pathological staging was pT1bN1M0, stage II. Unfortunately, the man died of liver and lung metastasis 17 months postoperatively. To our knowledge, this rare case is only the fifth reported in the English literature on adenosquamous carcinoma arising from Barrett's esophagus.     

A case of a superficial carcinoma of the esophagus with isolated lymph node metastasis around the abdominal aorta

Superficial carcinoma of the esophagus with isolated para-aortic lymph node metastasis is quite rare. A 56-year-old female demonstrated a type 0-IIa+IIb lesion in the middle thoracic esophagus on endoscopic examination. Enhanced computed tomography and positron emission tomography demonstrated two swollen lymph nodes on the right side of the inferior vena cava, but did not demonstrate either a primary lesion or regional lymph node metastasis. A retroperitoneal videoscopic lymph node biopsy was thus performed, and the histopathological diagnosis was metastasis of squamous cell carcinoma. Induction chemotherapy was administered with cisplatin/5-FU, and followed by definitive chemoradiotherapy with cisplatin/5-FU plus 60 Gy radiation. The patient showed satisfactory responses in both the primary and metastatic lesions. This is the first case report describing superficial carcinoma of the esophagus with isolated lymph node metastasis around the abdominal aorta. A precise histological diagnosis of the lymph node is quite important in such cases, and an adequate curative effect can be expected.     

Cutaneous metastasis from esophageal basaloid squamous cell carcinoma: A case report

Introduction and importanceBasaloid squamous cell carcinoma (BSCC) of the esophagus is a relatively rare histologic variant of squamous cell carcinoma. Here, we reported a case of solitary cutaneous metastasis as the first symptom of esophageal BSCC and was successfully treated with multidisciplinary treatment.Case presentationA 67-year-old man visited a local hospital with symptoms of dysphagia and cutaneous nodules on his left shoulder. Fluorine-18 fluorodeoxyglucose positron emission tomography revealed hypermetabolic accumulations in the middle thoracic esophagus, right recurrent laryngeal nerve lymph node, and epidermis of the left shoulder. Esophagogastroscopy revealed an ulcerative and infiltrating type tumor in the middle thoracic esophagus. Based on histopathologic examination of the endoscopic biopsy and the resected cutaneous tumor, the patient was diagnosed as esophageal BSCC with cutaneous metastasis. The patient was treated with chemotherapy followed by chemoradiotherapy. The therapeutic effect was a complete response, which was sustained for 39 months.Clinical discussionReview of previous literature in the PubMed database revealed only been two case reports on cutaneous metastasis of BSCC. Advanced BSCC of the esophagus with distant metastasis has a poor prognosis. Therefore, in our case, future careful follow-up is required.ConclusionEsophageal BSCC with cutaneous metastasis can be successfully managed by multidisciplinary treatment, including local resection of the cutaneous metastasis, systemic chemotherapy, and chemoradiotherapy.     

Long-term Survival After Gastric Cancer and Liver and Paraaortic Lymph Node Metastases: Report of a Case

We report the case of a 46-year-old man in whom successful resection of carcinoma of the stomach with liver and paraaortic lymph node metastases was carried out. The carcinoma was removed completely with combined resection of the lower esophagus, total stomach, distal pancreas, spleen, two metastatic liver nodes, and groups 1 and 2 and abdominal paraaortic lymph nodes. Adjuvant chemotherapy was admin-istered postoperatively. The patient is currently well with a grade 1 performance status and no signs of recurrence 12 years after his operation. This experience suggests that even the presence of metastatic paraaortic lymph nodes and liver metastases is not necessarily a contraindication to surgery when the carcinoma can be resected curatively and safely. Received: January 31, 2000 / Accepted: July 25, 2000     

Adrenal Metastasis from Rectal Cancer: Report of a Case

We report a case of heterochronic adrenal metastasis from colorectal carcinoma in a 51-year-old woman. A left adrenal metastasis was found by computed tomography and magnetic resonance imaging 8 months after an anterior resection for advanced rectal carcinoma, and a left hepatectomy for a solitary liver metastasis. The level of serum carcinoembryonic antigen was still within the normal range. A left adrenalectomy was performed, and histopathological examination revealed adenocarcinoma, compatible with the rectal carcinoma resected 8 months earlier. The patient died of lung metastases 6 months after the adrenalectomy. A review of autopsy series in the world literature revealed that adrenal metastasis from colorectal cancer is not rare. Therefore, the possibility of adrenal metastasis should be considered in the follow-up of patients after primary surgery for colorectal cancer, even though the liver and lung are the main metastatic sites. Received: March 7, 2002 / Accepted: July 2, 2002 Reprint requests to: S. Murakami     

The assessment of operability of esophageal carcinoma.

The extremely poor outlook for patients with esophageal cancer necessitates careful definition of the extent of disease prior to the selection of treatment. Evaluation of regional lymph node involvement may avoid excessive morbidity and identify favorable candidates for aggressive excisional therapy. The role of combined mediastinoscopy and celiotomy in assessing the operability of epidermoid carcinoma of the thoracic esophagus was examined in 30 consecutive candidates for esophageal resection at the North Carolina Memorial Hospital. The prognostic value of combined mediastinoscopy and celiotomy in assessing the operability of epidermoid value in assessing mediastinal extension of carcinoma of the upper thoracic and midthoracic esophagus.     

A case of basaloid carcinoma of the esophagus with a solitary lung metastasis for which thoracoscopic partial lung resection was performed

We experienced a case of basaloid carcinoma of the esophagus with a solitary lung metastasis for which thoracoscopic partial lung resection was performed. To the best of our knowledge, this is the first reported case of basaloid carcinoma of the esophagus with lung metastasis for which surgery was performed. There are no evidence-based treatment strategies for postoperative recurrence of basaloid carcinoma of the esophagus. Treatment strategies such as adjuvant therapy centered on chemotherapy and surgical indications should be established.     

Combined resection of the thoracic esophagus and thoracic descending aorta.

We conducted combined resection of the thoracic esophagus and thoracic descending aorta in 2 patients, one with advanced esophageal cancer with aortic invasion and the other aortoesophageal fistula caused by a false aortic aneurysm. Combined resection of esophageal tumor and adjacent involved organs was conducted in 14 patients with A3:T4 esophageal cancer but none survived 3 years and resecting tumor-invaded organs did not improve patient survival. One major problem of combined resection of the esophagus and aorta is contamination of the posterior mediastinum. In 1 patient, 2-stage surgery for the esophagus and in situ aortic replacement was conducted to reduce operative risk and avoiding infection of the prosthetic vascular graft. With thoracic descending aortic aneurysm adjacent to the esophagus on the increase, cardiovascular surgeons should prepared to undertake combined resection of both the aorta and esophagus.     

Successful management of aorto esophageal fistula due to rupture thoracic aortic aneurysm in an elderly patient

Aorto-esophageal fistula due to ruptured thoracic aortic aneurysm is very rare but is associated with extremely high mortality. An 81-year-old woman was admitted due to repeated hematemesis. Endoscopic examination revealed ulceration with blood clot on the mid-esophagus and compression of an extra-esophageal mass. The thoracic CT scan revealed an aortoesophageal fistula due to a ruptured descending thoracic aortic aneurysm. Surgery was performed on April 3, 1996. We report an aorto-esophageal fistula managed successfully in one stage by resection and replacement of the aortic aneurysm with a prosthetic graft and total esophageal resection. The esophagus was reconstructed using orthotopic gastric interposition with omentopexy around the prosthetic aortic graft. The postoperative course was uneventful and theere have been no signs of mediastinal sepsis, graft infection or pyothorax 12 months postoperatively. We suggest that the resection of both the aneurysm and the esophagus as well as the immediate reconstruction of the esophagus by orthotopic gastric interposition to obliterate the retrosternal space are important technique in the management of intrathoracic infections.