Additional radical surgery after colonoscopic snare polypectomy for T1 colorectal cancer: use of the minilaparotomy approach

An additional resection is indicated when colorectal polyps resected by colonoscopy reveal T1 carcinoma with unfavorable histology (no free margin or having risk factors for lymph node metastasis). We describe our experience with this type of surgery with the minilaparotomy approach (< or = 7 cm). This prospective study included 19 consecutive patients between 1997 and 2001. Specimens resected by colonoscopy revealed T1 carcinomas with one of the following histological types: inadequate excision (no free margin), lymph-vascular invasion, histologic grade III, or sm2/sm3 (submucosal invasion greater than 200-300 microm from the muscularis mucosa). The minilaparotomy approach included 15 colectomies and 4 anterior resections. Median length of minilaparotomy was 7 cm (range, 4-7 cm). Median number of lymph nodes removed was 11 (range, 7-21 lymph nodes). Median proximal and distal margins were 9.0 (range, 5.2-17.5 cm) and 8.5 cm (range, 2.0-11.5 cm), respectively. The patients quickly returned to normal function without morbidity and mortality. Five (26.3%) had a residual carcinoma within the bowel wall, and one (5.3%) had lymph node metastasis. At a median follow-up of 33.6 months, one patient (5.3%) developed local recurrence and subsequent distant metastasis. The minilaparotomy approach is suitable for an additional operation following colonoscopic polypectomy for T1 carcinoma, thus providing a minimally invasive alternative to conventional laparotomy.     

早期结直肠癌淋巴结转移的基础和临床研究

目的探索早期结直肠癌淋巴结转移的规律和相关因素,探讨其治疗方法以及“高级别上皮内瘤变”这一新概念在临床应用中的一些注意事项。方法对复旦大学附属肿瘤医院1985年1月至2000年12月手术治疗的61例黏膜肌层浸润和黏膜下层浸润的早期结直肠癌病例的临床资料进行回顾性分析,并对其中48例行根治性手术的病例选用细胞角蛋白(CK)的单抗、经免疫组化法进行淋巴结微转移的检测。结果黏膜肌层癌变时25%(4/16)的病例可出现区域淋巴结微转移,黏膜下层癌变时则有31.3%(10/32)的病例可出现淋巴结微转移和转移。在黏膜肌层和黏膜下层浸润的早期结直肠癌中,淋巴结微转移的发生和肿瘤大小相关,当肿瘤最大径≥3cm时微转移多见(P=0.031)。黏膜下层浸润时,淋巴结微转移的发生还和癌变的腺瘤类型(绒毛状腺瘤)、浸润深度(sm3)密切相关(P值分别为0.039和0.018)。随访发现11.5%(3/26)的黏膜肌层癌变病例,有局部复发、血道转移等恶性生物学行为表现。结论黏膜肌层浸润的早期结直肠癌病例中已可以出现区域淋巴结的微转移,当癌变浸润至黏膜下层时淋巴结微转移和转移的发生率更高。在早期结直肠癌的治疗中,选择局部切除手术需要慎重。当肿瘤最大径≥3cm、癌变腺瘤为绒毛状腺瘤或有证据提示黏膜下层浸润已达sm3时,建议选择根治性     

Prediction of Lymph Node Status in Superficial Esophageal Carcinoma

Background  Esophageal carcinoma is among the cancers with the worst prognosis. Real chances for cure depend on both early recognition and early treatment. The ability to predict lymph node involvement allows early curative treatment with less invasive approaches. Aims  To determine clinicohistopathological criteria correlated with lymph node involvement in patients with early esophageal cancer (T1) and to identify the best candidate patients for local endoscopic or less invasive surgical treatments. Methods  A total of 98 patients with pT1 esophageal cancer [67 with squamous cell carcinomas (SCC) and 31 with adenocarcinomas (ADK)] underwent Ivor–Lewis or McKeown esophagectomy in the period between 1980 and 2006 at our institution. Based on the depth of invasion, lesions were classified as m1, m2, or m3 if mucosal, and sm1, sm2, or sm3 if submucosal. Results  The rates of lymph node metastasis were 0% for the 27 mucosal carcinomas (T1m) and 28% for the 71 submucosal (T1sm) carcinomas (P < 0.001). Sm1 carcinomas were associated with a lower rate of lymph-node metastasis (8.3% versus 49 % sm2/3, P  = 0.003). As for histotype, the rates of lymph node metastasis for sm1 were 0% for ADK and 12.5% for SCC; for sm2/3 there were no significant differences. On multivariate analysis, depth of infiltration, lymphocytic infiltrate, angiolymphatic and neural invasion were significantly associated with lymph node involvement. Neural invasion was the single parameter with the greatest accuracy (82%); depth of infiltration and angiolymphatic invasion had 75% accuracy. Altogether these three parameters had an accuracy of 97%. Five-year survival rate was 56.7% overall: 77.7% for T1m and 53.3% for T1sm (P  = 0.048). Conclusions  The most important factors for predicting lymph node metastasis in early esophageal cancer are depth of tumor infiltration, angiolymphatic invasion, neural invasion and grade of lymphocytic infiltration. The best candidates for endoscopic therapy are tumors with high-grade lymphocytic infiltration, no angiolymphatic or neural invasion, mucosal infiltration or sm1 (only for ADK), and tumor <1 cm in size. For sm SCC and sm2/3 ADK the treatment of choice remains esophagectomy with standard lymphadenectomy.     

Can depth of tumour invasion predict lymph node positivity in patients undergoing resection for early rectal cancer? A comparative study between T1 and T2 cancers

Objective The present study investigated the risk of lymph node metastasis according to the depth of tumour invasion in patients undergoing resection for rectal cancer. Method The histology of patients undergoing oncological resection with regional lymphadenectomy for rectal cancer at St Marks Hospital from 1971 to 1996 was reviewed. Of the total number of 1549 patients, 303 patients with T₁ or T₂ rectal cancers were selected. The tumour type, grade, evidence of vascular invasion, depth of submucosal invasion (classed into ‘sm1‐3’) were evaluated as potential predictors of lymph node positivity using univariate and multi‐level logistic regression analysis. Results Tumour stage was classified as T₁ in 55 (18.2%) and T₂ in 248 (81.2%) patients. The incidence of lymph node metastasis in the T₁ group was 12.7% (7/55), compared to 19% (47/247) in the T₂ group. The node positive and negative groups were similar with regard to patient demographics, although the former contained a significantly higher number of poorly differentiated (P = 0.001) and extramural vascular invasion tumours (P = 0.002). There was no significant difference in the number of patients with sm1‐3, or T₂ tumour depths within the lymph node positive and negative groups. On multivariate analysis the presence of extramural vascular invasion (odds ratio = 10.0) and tumour grade (odds ratio for poorly vs well‐differentiated = 11.7) were independent predictors of lymph node metastasis. Conclusion Whilst the degree of vascular invasion and poor differentiation of rectal tumours were significant risk factors for lymph node metastasis, depth of submucosal invasion was not. This has important implications for patients with superficial early rectal cancers in whom local excision is being considered.     

Is Total Mesorectal Excision Always Necessary for T1–T2 Lower Rectal Cancer?

Background

The goal of this multicenter study was to clarify the determinants of local excision for patients with T1–T2 lower rectal cancer.

Methods

Data from 567 consecutive patients who underwent radical resection for T1–T2 lower rectal cancer at 12 institutions between 1991 and 1998 were reviewed. Rates of lymph node metastasis were investigated using a tree analysis, which was hierarchized using independent risk factors for nodal involvement.

Results

The independent risk factors for lymph node metastasis were female gender, depth of tumor invasion, histology other than well-differentiated adenocarcinoma, and lymphatic invasion. According to the first three parameters that can be obtained preoperatively, only 0.99% of the patients without risk factors had lymph node metastasis. On the other hand, even if the lower rectal cancer was at stage T1, women with histological types other than well-differentiated adenocarcinoma had an approximately 30% probability of having lymph node metastasis. Lymphatic invasion was most useful to predict nodal involvement among patients with T2 lower rectal cancer. The rates of lymph node metastasis in T2 patients with and without lymphatic invasion were 32.9% and 9.1%, respectively.

Conclusions

Gender is one of the most important predictors for lymph node metastasis in patients with early distal rectal cancer. Three parameters, including depth of tumor invasion, histology, and gender, are useful determinants for local excision. Additional studies are required to establish the minimum optimal treatment for T2 lower rectal cancer.     

结直肠癌根治术后复发转移危险因素分析

目的探讨结直肠癌根治术后复发转移的相关因素。方法应用单因素和多因素Cox分析方法,回顾性分析1990—1999年692例结直肠癌根治术后病例的临床病理因素。结果复发转移率23.4%(162/692),复发转移在术后2年内出现者占74.1%(120/162),3年内出现者占92.0%(149/162)。3、5年生存率:复发转移组分别为33.1%和19.7%,非复发转移组分别为92.8%和86.1%。单因素分析显示,结直肠癌患者的Dukes分期、淋巴结转移、肠壁浸润深度、分化程度、肿瘤部位、大体类型与复发转移有关。多因素分析显示,结直肠癌的淋巴结转移、肿瘤部位、分化程度是复发转移的危险因素,其中淋巴结转移是影响术后复发转移最重要的因素。分别进行局部复发和远处转移多因素分析显示,淋巴结转移、肿瘤部位、分化程度与局部复发有关,而淋巴结转移、肠壁浸润深度与远处转移有关。直肠癌多因素分析显示分化程度是术后复发的预后因素。结论淋巴结转移是影响结直肠癌术后复发转移最重要的危险因素。浸润深度是术后远处转移的重要预后因素,肿瘤位于直肠且分化程度低的患者术后局部复发的风险较大。     

Laparoscopic bowel resection for early colon cancer

Following the successful introduction of laparoscopic cholecystectomy, many reports confirming the feasibility of using laparoscopy for bowel resection and predicting that it would be advantageous in terms of its minimal invasiveness have been published. In the context of cancer treatment, however, the feasibility of lymphadenectomy, the risk of recurrence, and survival have emerged as major concerns. Even though mucosal cancer (Tis) can be treated by endoscopic resection (ER), when this is not possible open surgery (OS) must be performed. In patients with T1 cancer, tumors showing slight submucosal layer invasion (sm 1) can be treated in the same way as Tis (in cancer) cancers. But 5% to 10% of patients with T1 cancer have massive submucosal layer invasion (sm 2-3) with paracolic lymph node metastasis. At least partial bowel resection with paracolic lymphadenectomy is considered necessary for T1 (sm 2-3) cancers in principle. In summary, laparoscopic local excision of Tis cancers that are endoscopically unresectable and laparoscopically assisted partial resection with paracolic lymphadenectomy for T1 cancers have become accepted because local excision and partial resection with paracolic lymphnedectomy are fairly simple to perform laparoscopically. Therefore as a strategy for the treatment of early colorectal cancer (CRC), minimally invasive laparoscopic bowel resection (LBR) has been positioned between endoscopic resection (ER) and open surgery (OS). While the difficulty of performing radical lymphadenectomy is considered one of the greatest obstacles to the introduction of laparoscopic bowel resection (LBR) for the treatment of advanced colorectal cancer (CRC), early colon cancer is a good indication for laparoscopic bowel resection.     

Frühkarzinome des Ösophagus

Squamous cell carcinoma of the esophagus can be treated endoscopically under certain conditions. A carcinoma (T1a) limited to the mucosa with a low infiltration depth (m1–m2) and limited extent (≤2 cm) can be removed by electrical snare with no risk of lymph node metastasis. Due to the increased risk of lymphatic spread, deeply infiltrating submucosal tumours (sm2–sm3) must be treated by surgical resection. Endoscopic resection (mucosectomy) is performed by electric snare and the cap method, additionally with APC coagulation or photodynamic therapy. Multifocal tumour growth and incomplete resection are both risk factors for local recurrence. If the strict conditions for endoscopic resection are fulfilled, the 5-year survival time of these patients with early cancer is no different from that of the population as a whole.     

Risk Factors for Lymph Node Metastasis in Submucosal Invasive Colorectal Cancer

BACKGROUND: Recent studies have shown a 7-15% lymph node (LN) metastasis rate in submucosal invasive colorectal cancer (SICC). Identifying risk factors for LN metastasis is crucial in selecting therapeutic modalities for SICC. We assessed the possibility of and the risk factors for LN metastasis in SICC. METHODS: We performed a retrospective study on 168 SICC patients who underwent curative resection between June 1989 and December 2004 at Asan Medical Center. The level of submucosal invasion was classified into upper third (sm1), middle third (sm2), and lower third (sm3). The following carcinoma-related variables were assessed: tumor size, tumor location, depth of submucosal invasion, cell differentiation, lymphovascular invasion, neural invasion, and tumor cell dissociation (TCD). RESULTS: The overall LN metastasis rate was 14.3%. Significant predictors of LN metastasis both univariately and multivariately were sm3 (p = 0.039), poorly differentiated cancer (p = 0.028), and TCD (p = 0.045). Lymphovascular invasion was a risk factor for LN metastasis in univariate analysis (p = 0.019); however, in multivariate analysis, lymphovascular invasion could not predict LN metastasis. No statistical difference was observed in the risk of LN metastasis with regard to tumor location, size, and neural invasion. CONCLUSION: The depth of submucosal invasion, cell differentiation, and tumor cell dissociation were significant pathologic predictors of LN metastasis in SICC. Because SICC is associated with a considerable risk of LN metastasis, local excision may be performed carefully in SICC without adverse features.     

Management of T1 carcinoma of the lower third rectum

The earliest invasive carcinoma of colon and rectum is an invasion into the submucosa. For the TNM classification, these lesions are T1 Nx Mx. They present as an adenoma with invasive carcinoma, or a frank carcinoma. Local excision for T1 carcinoma of the rectum can be curative if the lesion is accessible for an adequate excision and if the lesion has not spread to the lymph nodes or distant metastasis. The key to success in local excision is selecting the lesions that have low risk of metastasis.     

Controversy in the treatment of superficial esophageal carcinoma--indications and problems of the procedures]

In our institution, 152 cases have been treated, which are 24.3% of total 626 cases with esophageal carcinomas. Analysis of these 152 cases revealed that neither intraepithelial cancer (ep), nor mm2 cancer, in which the lesion is limited within the upper two-thirds of the proper mucosal layer, had any vessels invasion and lymph node metastases. In addition, only 25% of the cases with mm3 cancer, limited within the deeper one-third of the proper mucosal layer, had vessels invasion without lymph node metastases. The 5-year survival of the cases less than sm1 was as good as 100%. However, those of sm2 and sm3 patients were 58.9% and 54.2%, respectively. Thus, we made the treatment strategy for superficial esophageal cancer as follows: 1. For ep to mm2 cases, endoscopic mucosal resection could be applied. 2. For the cases whose lesions widely spread in the esophagus, blunt resection would be indicated. 3. For the cases with mm3 to sm3 cancer, thoracotomy and laparotomy with wide lymph node dissection from neck to abdomen should be employed. Since a radical operation for esophageal cancer has high operative risk and poor postoperative quality of life, we should properly pick up and apply more cases with mucosal carcinoma for endoscopic mucosal resection.     

Surgical management of malignant colorectal polyps

The anatomic landmarks of the depth of invasion for pedunculated lesions (Haggitt level) and the Sm system for the sessile lesions give excellent objective information in the management of malignant colorectal polyps. Malignant polyps with low risk of lymph node metastasis include pedunculated lesions with invasion into Haggitt levels 1, 2, and 3. Level 4 pedunculated lesions and sessile lesions in which the invasion is into Sm1 or Sm2 level also have low risk if there are no adverse factors. These lesions can be treated by a complete local excision. Lesions that have high risk of lymph node metastasis are those with invasion into the lower third of the submucosa (Sm3), lesions that contain lymphovascular invasion, and lesions sited in the lower third of the rectum. These lesions require an oncologic colorectal resection. For lesions in the distal third of the rectum, a per anal full-thickness excision followed by an adjuvant chemoradiation may be an alternative. The box below summarizes malignant colorectal polyps requiring oncologic bowel resections:     

Extramammary Paget's disease of scrotum--report of 25 cases and literature review

ObjectivesWe evaluate the clinical manifestations, management, and prognostic characteristics of scrotal extramammary Paget's disease (EMPD).MethodsThe study comprised 25 patients with scrotal EMPD at our institute from January 1982 to February 2005, with all available clinical and pathological data reviewed.ResultsOf these 25 patients, 1 received radiotherapy and 24 received local wide excisions. In 24 operated patients, 7 had local recurrence and/or metastasis of groin lymph node. Five of the 7 with recurrence had a positive surgical margin postoperatively and they received a second local extensive excision. One of the 7 with recurrence and metastasis of the groin lymph node had a second local extensive excision with groin lymphadenectomy, and the last one who only had metastasis of the groin lymph node had a groin lymphadenectomy. Four of 13 patients with dermal invasion by Paget's cell had metastasis. None of the other 12 patients without dermal invasion had metastasis. However, there was no statistical metastasis rate difference (P = 0.096) between the patients with dermal invasion by Paget's cell and without. There was no statistical difference (P = 0.947) in mean delay time from onset of symptoms to diagnosis between the 2 groups either. The follow-up duration varies from 17 to 243 months (mean 119 + 86.2 months). One patient with stage D died of EMPD of the scrotum.ConclusionsWe found that EMPD of the scrotum is usually a slow progressive disease, mainly seen in elderly patients, and has a good prognosis when there is noninvasive disease. The primary treatment for EMPD of the scrotum is wide surgical excision. The key to decreasing tumor recurrence, however, is a precise, preoperative histological examination to define the range of the lesion.     

972例结肠癌患者预后多因素分析

目的 通过对972例结肠癌患者临床病理等因素的分析,探讨影响结肠癌患者术后生存的因素.方法 对972例结肠癌患者的临床资料进行单因素及多因素COX回归分析,生存率采用寿命表法计算,生存率的比较采用Log.rank检验法.结果 单因素分析表明,年龄、围手术期输血、术前血清cEA(癌胚抗原,carcinoembryonie aIltigen)水平、肿瘤大体类型、肿瘤浸润深度、淋巴结转移、肝转移、其他脏器转移、肿瘤局部复发、腹膜种植、病理类型、TNM分期及淋巴结廓清术式均为影响预后的因素.多因素回归分析表明,年龄、术前血清CEA水平、肿瘤大体类型、淋巴结转移、肝转移、其他脏器转移、肿瘤局部复发、腹膜种植、病理类型、淋巴结廓清术式以及TNM分期是影响患者术后生存的独立因素.结论 淋巴结转移是影响结肠癌患者预后最重要的因素.     

Muscle Invasion in Oral Tongue Squamous Cell Carcinoma as a Predictor of Nodal Status and Local Recurrence: Just as Effective as Depth of Invasion?

Tumor depth of invasion (DOI) is a histologic feature that consistently correlates with lymph node metastasis; however, there are many difficulties with accurately assessing DOI. The aim of this study was to identify a simpler and more reproducible method of determining DOI, by using skeletal muscle invasion as a surrogate marker of depth. Oral tongue squamous cell carcinoma American Joint Committee on Cancer (AJCC) stage T1 cases were identified in the Emory University Department of Pathology database. 61 cases, with a minimum of 2 years of follow-up, were included in the study. Cases were examined histologically to assess muscle invasion and DOI. The two methods of measurement were analyzed to determine the positive predictive value (PPV) of DOI or muscle invasion for both nodal disease and local recurrence. Cases with muscle invasion had a 23.3% PPV of occult lymph node metastasis. Cases with DOI of greater than 3 mm had a 29.7% PPV of occult lymph node metastasis. Cases with muscle invasion had a 43.7% PPV of local tumor recurrence. Cases with maximum DOI of greater than 3 mm had a 40.4% PPV of tumor recurrence. Although the PPV of muscle invasion in regards to nodal status was slightly less than DOI, it represents a more easily reproducible parameter which could guide surgeons in determining if the case warrants an elective neck dissection in a cN0 (clinically negative) neck. Interestingly, the PPV of local recurrence was higher with muscle invasion than DOI, and may represent an important indicator for extent of resection.     

Results of curative or non-curative nephrectomy for renal cell carcinoma invading adjacent organs]

We reviewed 12 patients who had undergone curative or non-curative nephrectomy for renal cell carcinoma invading adjacent organs (stage T4). 83 patients with renal cell carcinoma confined within the perirenal fascia (T1-T3) who had undergone nephrectomy served as controls. Of the 12 patients with T4 tumor 6 had undergone simultaneous excision of involved adjacent organs (hemicolectomy in 4, resection of the tail of pancreas in 5, splenectomy in 2). At operation 6 patients with T4 tumor had distant metastasis, 3 had fixed lymph node metastases, and 4 had tumor extension into the main renal vein or vena cava. Although T4 tumor had distant or fixed lymph node metastasis more frequently than T1-T3 tumors, the incidence of gross tumor thrombus showed no such difference between T3 and T4 tumors. Postoperative follow-up of patients with T4 tumor showed that local recurrence developed within 9 months in 3 of 5 patients who had undergone curative excision, new distant metastasis developed within 6 months in 5 patients, 1 patient died of acute renal failure in the early convalescence, 10 patients died of the disease within 12 months and 1 died of the disease in 31 months. Pathological examination showed that T4 tumors tended to be classified as grade 3, to extend in an infiltrating fashion and to have a sarcomatoid structure. Patients who had a tumor where these three histological features were dominant died to tumor within 3 months after nephrectomy. These results indicate that curative excision of T4 renal cell carcinoma is not only difficult, but frequently associated with early local recurrence and new distant metastasis.(ABSTRACT TRUNCATED AT 250 WORDS)     

The treatment of early colorectal cancer

One hundred and eighty-three patients with early colorectal cancer (mucosal or submucosal carcinoma) were treated endoscopically or surgically from 1962 through 1984 at our hospital. Regional lymph node metastasis was recognized in 6 among 98 submucosal cancers. Lymphatic vessel permeation of cancer cells was also found in 31.8% of submucosal cancers. Local recurrence was observed in 3 patients with submucosal cancer. From our experience, the policy of treatment for early cancer was discussed and proposed. If the growth is pedunculated or small sessile polyp endoscopic polypectomy should be performed and bowel resection must be subsequent when histological examination of resected specimen showed massive cancer invasion to the stalk or submucosal layer. If the growth does not have stalk and is diagnosed early cancer, bowel resection with dissection of surrounding tissues should be recommended for high security, because these growth has more frequently submucosal invasion. For early rectal cancer, transanal or trans-sacral local wedge excision for mucosal or submucosal minute invasion cancer and trans-sacral sleeve resection with dissection of mesorectal tissues for submucosal invasive cancer. When histological examination of resected specimen showed unexpectively more massive invasion near to or into propria muscle layer, more wide bowel resection must be subsequent. If sm massive cancer locates near to anal canal, limited Miles' operation must be also in mind, preserving voiding and sexual functions.     

Decision for salvage treatment after transanal endoscopic microsurgery

BACKGROUND: Transanal endoscopic microsurgery (TEM) has emerged as an alternative to classic radical operation for early rectal cancer. Early rectal cancer can be treated by adequate local excision such as TEM. If there are adverse risk factors, especially poor cellular differentiation, close resection margin, or positive lymphovascular invasion or incomplete excision, a radical resection is indicated. This study aimed to clarify the factors related to recurrence for patients required to undergo a salvage operation after TEM. METHODS: This retrospective study analyzed 167 patients who underwent TEM for rectal cancer between 1994 and 2004. Of these patients, 36 with poor differentiation, mucinous carcinoma, proper muscle invasion, lymphovascular invasion, and positive resection margin were included in the analysis. RESULTS: Of the 36 patients, 12 underwent a salvage operation, and the remaining 24 did not because of poor physical condition or refusal of radical surgery. There were a total of 6 (16.7%) recurrences. One (8.3%) of the 12 patients who underwent salvage surgery had systemic recurrence. Five (20.8%) of the 24 patients who did not receive surgery had recurrence (3 local recurrences, 2 distant recurrences). Analysis of the subgroups showed that 2 (28.6%) of 7 patients with lymphovascular invasion had recurrence, and that 1 patient (100%) had a T3 lesion. Three (17.6%) of 17 patients had T2 lesions. CONCLUSIONS: For high-risk patients, TEM followed by radical surgery is the most beneficial in preventing local recurrence. Radical salvage surgery is strongly recommended if pathologic results after TEM show T3 lesion or lymphovascular invasion.     

Stage IA vulvar squamous cell carcinoma: an analysis of tumor invasive characteristics and risk

Early invasive vulvar squamous cell carcinoma (SCC) with less than 1.0 mm of invasion (FIGO stage IA) has been shown to have a minimal risk of lymph node metastasis and is associated with an excellent prognosis. The prognostic significance of other histologic parameters other than depth of invasion, however, remains controversial. Seventy-eight consecutive cases of vulvar SCC having a depth of invasion of 5.0 mm or less were reviewed and the clinical outcome compared with the type of surgical excision, the presence of concurrent lymph node metastases, the depth of tumor invasion, the tumor thickness, the tumor horizontal spread, the estimated tumor volume, tumor histologic subtype, tumor histologic grade, tumor pattern of invasion, tumor multifocality, presence of perineural invasion, presence of angiolymphatic invasion and the presence of precursor lesions, including the type of vulvar intraepithelial neoplasia and presence of lichen sclerosus. The only histologic feature for predicting concurrent lymph node metastasis was tumor depth of invasion. The 3 most important features of stage IA tumors in predicting tumor recurrence were the depth of invasion, presence of SCC at the surgical margins, and the histologic grade.     

Diagnosis and treatment of early esophageal carcinoma

It has become easier to find early esophageal carcinomas, which are localized in the mucosa or submucosal layer, by progress of X-ray technology. The term 'superficial esophageal carcinoma' is applied to tumours in which infiltration is limited to the submucosal layer. If there is no lymph node metastasis, we use the term "early carcinoma". In our hospital, we have resected 88 cases of superficial esophageal carcinoma including 55 early esophageal carcinoma cases. Five year-survival rate of early carcinoma is 61%. In contrast, 5 year-survival rate of superficial esophageal carcinoma with lymph node metastasis is only 13%. Therefore, from a prognostic point of view, it would be valuable to be able to detect the presence of lymph node metastasis in patients with superficial esophageal carcinoma. From X-ray findings, we divide superficial carcinoma into 5 types. In superficial flat type, there is no lymph node metastasis, but in other types there is no correlation between the types and lymph node metastasis. The condition of the surface of superficial esophageal carcinoma (smooth or irregular), however, has a close connection with lymph node metastasis or vascular invasion. To improve the prognosis of resected esophageal carcinoma cases, we should read X-ray films thoroughly before operation so that we can predict lymph node metastasis or vascular invasion and choose the most effective operative method.