Endoscopic resection for T1a-MM and T1b-SM1 squamous cell carcinoma of the esophagus

In Japan, the first paper on endoscopic resection (ER) for squamous cell carcinoma (SCC) of the esophagus confined to the mucosa was reported as endoscopic mucosal resection (EMR) in 1988. Since publication of that article, ER has been recommended as the standard treatment for squamous and mucosal cancer of the esophagus. T1a-EP and T1a-LPM esophageal cancer seldom involves lymph node metastasis. However, in cases of T1a-MM and T1b-SM1 esophageal cancer with lymph node metastasis (10% to 30%), the indication of ER is limited. The risk factors for lymph node metastasis in T1a-MM and T1b-SM1 esophageal cancer were cleared by clinical and pathological studies. Endoscopic findings such as type 0–I or type 0–III, size of 50 mm or more, and pathological findings such as lymphatic permeation, venous permeation, poorly differentiated SCC and INFb or INFc were suggestive of high risk for lymph node metastasis. In addition, histopathological findings of small cancer nests, defined as “budding” or “droplet infiltration,” suggest frequent lymph node metastasis. In cases of T1a-MM and T1b-SM1 esophageal cancer with high risk of lymph node metastasis, adjuvant therapy including chemoradiotherapy and radical esophagectomy are recommended after ER. A recent advance in ER for esophageal cancer is the establishment of endoscopic submucosal dissection (ESD). It has allowed us to perform an en-block resection of a large mucosal lesion of the esophagus and detailed histopathological examination. However, ESD requires more difficult manipulation than EMR. The indication of EMR or ESD is sought.     

Recurrence after endoscopic mucosal resection of esophageal squamous cell carcinoma invading the muscularis mucosae or upper submucosa

Background: Endoscopic mucosal resection (EMR) is recommended for cases of squamous cell carcinoma of the esophagus in which the tumor is confined to the lamina propria mucosa. However, EMR is often performed in patients whose tumors invade the muscularis mucosae (m3) or upper submucosa (sm1) to minimize surgical invasion, despite the increased risk of lymph node metastasis. We evaluated patients who were found to have distant or lymph node metastasis after EMR for such lesions. Methods: Thirty‐four consecutive patients with esophageal carcinoma invading m3 or sm1 who underwent EMR during the period from June 1992 through March 2001 (extended EMR group) were studied. Results: Five of these patients were found to have distant or lymph node metastasis on follow up. Patient 1 died of lung metastasis 34 months after EMR. Patient 2 underwent chemotherapy because of an abnormally high value of squamous cell carcinoma (SCC) antigen. Patient 3 died of upper mediastinal lymph node metastasis 62 months after EMR. Patient 4 underwent total gastrectomy because of gastric wall metastasis 41 months after EMR and underwent chemoradiotherapy because of upper mediastinal lymph node metastasis 87 months after EMR. Patient 5 was found to have cardiac lymph node metastasis by follow‐up endoscopic ultrasonography examination 42 months after EMR and underwent curative lymph node dissection. Conclusion: It is unlikely that patient 1 and patient 2, both with probable distant metastasis, received inadequate treatment. Surgery with lymph node dissection usually cannot prevent distant metastasis. The patients with lymph node recurrence (patient 3 and patient 4) should have been followed up more carefully. We believe that patients with early lymph node metastasis, such as patient 5 in this study, should undergo curative surgical resection. Patients undergoing extended EMR should be carefully followed up for a long period to enable early detection and treatment of lymph node metastasis.     

Clinical outcome of endoscopic mucosal resection for esophageal squamous cell cancer invading muscularis mucosa and submucosal layer

When a tumor invades the muscularis mucosa and submucosal layer (T1a‐MM and T1b in Japan), esophageal squamous cell cancer poses 10–50% risk of lymph node metastasis. By this stage of esophageal cancer, surgery, although very invasive, is the standard radical therapy for the patients. Endoscopic mucosal resection (EMR) is the absolutely curable treatment for cancer in the superficial mucosal layer. Because of its minimal invasiveness, the indications of EMR may be expanded to include the treatment of T1a‐MM and T1b esophageal carcinoma. To date, the clinical outcomes of EMR for T1a‐MM and T1b patients have not been fully elucidated. Here, the retrospective analysis of the clinical outcomes is reported. Between January 1994 and December 2007, 247 patients underwent EMR at Kanagawa Cancer Center. Of these individuals, 44 patients with 44 lesions fulfilled the following criteria: (i) extended EMR treatment for clinical T1a‐MM and T1b tumor; (ii) diagnosis of clinical N0M0; and (iii) follow up for at least 1 year, and negative vertical margin. These patients were reviewed for their clinical features and outcomes. Statistical analyses were performed by the Kaplan–Meier methods, the Chi‐square test, and the Cox proportional hazard model. P‐value of <0.05 was considered statistically significant. The data were analyzed in February 2009. Based on the informed consent and their general health conditions, 44 patients decided the following treatments immediately after the EMR: 2 underwent surgery, 1 underwent adjuvant chemotherapy, and 41 selected follow up without any additional therapy. Of the 41 patients, 20 selected this course by choice, 12 because of severe concurrent diseases, 2 because of poor performance status, and 7 because of other multiple primary cancers. Twelve patients died; two were cause specific (4.5%), eight from multiple primary cancers, one from severe concurrent diseases, and one from unknown causes. No critical complications were noted. Median follow‐up time was 51 months (12–126). Five patients ultimately developed lymph node metastasis. One patient with adjuvant chemotherapy required surgery, and another was treated with chemotherapy whose subsequent death was cause specific. The other three patients received chemoradiotherapy and have not shown cause‐specific death. Overall and cause‐specific survival rates at 5 years were 67.3% and 91.8%, respectively. Among 41 patients treated by EMR alone, only one died from primary esophageal cancer (2.4%), and overall and cause‐specific survival rates at 5 years were 75.6% and 97.6%, respectively. Multivariate analysis revealed that severe concurrent diseases including multiple primary cancers and the administration of 5‐fluorouracil‐based chemotherapy for multiple primary cancers significantly influenced survival (P= 0.025, hazard ratio [HR] 13.1 [95% confidence interval 1.5–114]) and (P= 0.037, HR 0.213 [95% confidence interval 0.05–0.914]), respectively. Eight and six patients developed metachronous esophageal squamous cell cancer and local recurrence, respectively. With the exception of one patient, they could be retreated endoscopically. EMR is a reasonable option for the patients with T1a‐MM and T1b esophageal carcinoma without clinical metastasis, especially for the individuals with severe concurrent diseases. The prognostic factors for the benefit of EMR in such cases should be further examined.     

Predictive factors for lymph node metastasis in esophageal squamous cell carcinomas contacting or penetrating the muscularis mucosae: the utility of droplet infiltration

Background Tissue features to predict the presence or absence of lymph node metastasis (pN) in cases of esophageal squamous cell carcinoma found to contact or penetrate the muscularis mucosae (m3) on endoscopic mucosal resection (EMR) have yet to be clarified in detail. This study was conducted to determine the utility of droplet infiltration (DI) as a candidate. Methods In 27 m3 esophageal squamous cell carcinoma cases who underwent esophagectomy, DI parameters (longitudinal diameter, DIs; number of constituent cells, DIn; distance from the primary focus, DId) for droplet infiltration were examined to allow comparison with vessel permeation (VP) as a predictive factor for lymph node metastasis. Results DIs ≤ 20 μm, DIn ≤ 4, and DId ≥ 200 μm all demonstrated relations with pN (P = 0.001, 0.006, and 0.03, respectively). As predictive factors for lymph node metastasis, DIs ≤ 20 μm and DIn ≤ 4 had sensitivity and likelihood ratios (LR) equal to or higher than VP. Conclusions Tissue features of DI (DIs ≤ 20 μm and DIn ≤ 4) can be applied as predictive factors for lymph node metastasis in m3 esophageal cancers after EMR. This is the English version of a research paper reported in Gastroenterol Endosc 2004;46:2086–94.     

Common single nucleotide polymorphism of hypoxia‐inducible factor‐1α and its impact on the clinicopathological features of esophageal squamous cell carcinoma

OBJECTIVE: Angiogenesis is one of the most important molecular events in solid tumor development and growth, in which hypoxia‐inducible factor (HIF)‐1α is a key regulator and plays an important role. Studies have shown that a single nucleotide polymorphism (C1772T) in the HIF‐1α gene exerts a large effect on the phenotype of human head and neck squamous cell carcinoma and renal cell carcinoma. But the impact of the C1772T polymorphism on the clinicopathological features of human esophageal squamous cell carcinoma (ESCC) remains unknown, and thus it is the main focus of our study. METHODS: The C1772T genotype of 95 ESCC patients and 104 healthy controls were studied by using the polymerase chain reaction and restriction fragment length polymorphism. Mutations were confirmed by direct DNA sequencing. The impact of C1772T on tumor size, invasive depth, lymph node metastasis, distant metastasis, histological grade and TNM stage was also studied. RESULTS: The genotype frequency observed in the patients and controls was 11.58% versus 10.58%, respectively, for genotype C/T (P > 0.05). Genotype T/T was not found in our study. Larger tumors and a higher rate of lymph node metastasis was found for the C/T group. CONCLUSIONS: Although there is no significant difference of genotype distribution between ESCC patients and healthy controls, genotype C/T is associated with larger tumor and higher rate of lymph node metastasis.     

Long-term outcome after endoscopic mucosal resection in patients with esophageal squamous cell carcinoma invading the muscularis mucosae or deeper

BACKGROUND: Endoscopic mucosal resection is recommended for squamous cell carcinoma of the esophagus confined to the lamina propria. However, endoscopic mucosal resection is often performed in patients with tumors that invade the muscularis mucosa or upper submucosa to minimize surgical invasiveness, despite the increased risk of lymph node metastasis. This study prospectively evaluated long-term outcome in such patients. METHODS: Twenty-six consecutive patients with squamous cell esophageal carcinoma invading the muscularis mucosa or submucosa who underwent endoscopic mucosal resection from June 1992 through March 2000 (extended endoscopic mucosal resection group) were studied. As control group, 44 consecutive patients with esophageal carcinoma invading the muscularis mucosae or upper third of the submucosa and no preoperative evidence of lymph node metastasis who underwent esophagectomy during the same period (surgical resection group) were studied. RESULTS: Overall survival rates at 5 years in the extended endoscopic mucosal resection group and surgical resection group were, respectively, 77.4% and 84.5%. There was no significant difference between survival distributions. Cause-specific survival rates at 5 years in extended endoscopic mucosal resection and surgical resection groups were, respectively, 95.0% and 93.5%. Survival curves for the groups were similar. CONCLUSION: Although patients were not randomized to extended endoscopic mucosal resection or surgical resection in this study, the results suggest that endoscopic mucosal resection may be safe and effective for management of squamous cell esophageal carcinoma invading the muscularis mucosae or upper submucosa.     

Tumor cell dissociation score highly correlates with lymph node metastasis in superficial esophageal carcinoma

BACKGROUND: It is still not clear which parameters are important for predicting the metastatic potential of superficial esophageal squamous cell carcinoma (SESCC). The purpose of the present paper was thus to investigate tumor cell dissociation (TCD) in SESCC as a predictive factor of lymph node metastasis. METHODS: Thirty-three SESCC were classified into four groups based on the depth of tumor invasion. Carcinomas not invading as far as the muscularis mucosa were classified as group A; carcinomas invading to the muscularis mucosa or less than one-third of the upper submucosa were classified as group B; those invading to the middle layer of the submucosa were classified as group C; and those invading one-third of the lower submucosa were classified as group D. The TCD score was calculated by dividing the length of the TCD region by the maximal longitudinal length of the area of invasion into or beyond the lamina propria, and multiplying by 100. E-cadherin expression of the carcinomas was investigated in the TCD area and the successive area of mucosal invasive carcinoma (SAM). RESULTS: The incidence of lymph node metastasis was 0% in group A, 10% in group B, 36.4% in group C and 57.1% in group D. The mean TCD scores (+/-SEM) of SESCC with lymph node metastasis were higher than that without (85.3 +/- 5.7, 16.3 +/- 3.9, respectively; P < 0.001). In group C, the TCD score of cases with lymph node metastases was higher than in those without lymph node metastasis (P < 0.001). E-cadherin expression was significantly reduced in the area of TCD compared with the SAM located over the TCD area (P < 0.001). CONCLUSIONS: The TCD score is an important predictive marker for lymph node metastasis in SESCC. Clinical evaluation of TCD scores in endoscopic mucosal resection (EMR) specimens would enable accurate prediction of lymph node metastasis and extend the indication of EMR treatment for SESCC.     

Clinicopathological features associated with lymph node metastasis in early gastric cancer: Analysis of a single-institution experience in China

BACKGROUND:

An accurate assessment of potential lymph node metastasis is an important issue for the appropriate treatment of early gastric cancer. Minimizing the number of invasive procedures used in cancer therapy is critical for improving the patient’s quality of life.

OBJECTIVE:

To evaluate the clinicopathological features associated with lymph node metastasis of early gastric cancer in patients from a single institution in China.

METHODS:

A retrospective review of data from 410 patients surgically treated for early gastric cancer at the First Affiliated Hospital (Nanjing, China) between 1998 and 2007, was conducted. The clinicopathological variables associated with lymph node metastasis were evaluated.

RESULTS:

Lymph node metastasis was observed in 12.20% of patients. The macroscopic type, tumour size, location in the stomach, depth of gastric carcinoma infiltration, and presence of vascular or lymphatic invasion showed a positive correlation with the incidence of lymph node metastasis by univariate analysis. Multivariate analyses revealed histological classification, macroscopic type, tumour size, depth of gastric carcinoma infiltration, and the presence of vascular or lymphatic invasion to be significantly and independently related to lymph node metastasis. The depth of gastric carcinoma infiltration was the strongest predictive factor for lymph node metastasis. For intramucosal cancer, tumour size was the unique risk factor for lymph node metastasis. For submucosal cancer, histological classification and tumour size were independent risk factors for lymph node metastasis.

CONCLUSIONS:

Histological classification, macroscopic type, tumour size, depth of gastric carcinoma infiltration, and the presence of vascular or lymphatic invasion are independent risk factors for lymph node metastasis in patients with early gastric cancer in China. Minimal invasive treatment, such as endoscopic mucosal resection, may be possible for highly selected cancers.     

Esophageal squamous cell carcinoma with special reference to its early stage

The term ‘early squamous cell carcinoma of the oesophagus’, which was previously restricted to superficial carcinoma with no lymph node metastasis, now encompasses intramucosal carcinoma regardless of the nodal status. Such lesions are rare in Western countries, where the experience is limited. In recent years, the development and greater use of chromoendoscopy and narrow band imaging (NBI), both of which facilitate the evaluation of mucosal morphology, have played an important role in the detection of early esophageal squamous cell carcinoma. In addition, the techniques and indications of endoscopic resection (mucosal resection [EMR] and mucosal dissection [ESD]) are still being refined. In the present article, we will discuss the clinical and pathologic features of esophageal early squamous cell carcinoma, as well as the epidemiology and aetiology of esophageal cancer in general. In addition, we will provide a therapeutic decision tree taking into account endoscopic and surgical modalities as they apply to early esophageal squamous cell carcinoma.     

Predictive factors for lymph node metastasis and endoscopic treatment strategies for undifferentiated early gastric cancer

Background and Aim: Although more than 80% of undifferentiated early gastric cancers (EGC) are not associated with lymph node metastasis, endoscopic mucosal resection is not generally accepted as a means of curative treatment because of an abundance of conflicting data concerning clinicopathological characteristics and prognoses. The aim of this study was to define a subgroup of undifferentiated EGC that could be cured by endoscopic treatment without the risk of lymph node metastasis. Method: A total of 591 patients surgically resected for undifferentiated EGC between January 1999 and March 2005 were reviewed. Associations between various clinicopathological factors and the presence of lymph node metastasis were analyzed to identify the risk factors of lymph node metastasis. Results: Lymph node metastasis was found in 79 patients (13.4%). By multivariate logistic regression analysis, a tumor diameter 2.5 cm or larger, invasion into the middle third of the submucosal layer or deeper, and lymphatic involvement were identified as independent risk factors of lymph node metastasis (P < 0.001, respectively). Lymph node metastasis was not found in any patient with undifferentiated EGC smaller than 2.5 cm confined to the mucosa or upper third of the submucosal layer without lymphatic involvement. Conclusions: Undifferentiated intramucosal EGC smaller than 2.5 cm without lymphatic involvement was not associated with lymph node metastasis. Thus, we propose in this circumstance that endoscopic mucosal resection could be considered a definitive treatment without compromising the possibility of cure.     

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.     

Clinical significance of preoperative and postoperative cytokeratin 19 messenger RNA level in peripheral blood of esophageal cancer patients

The purpose of this study is to analyze the correlation between preoperative/postoperative Cytokeratin 19 (CK19) messenger RNA (mRNA) level in peripheral blood (PB) and the clinical significance in esophageal cancer patients with different clinicopathological factors. We detected the preoperative and postoperative CK19 mRNA level in the PB of 139 esophageal cancer patients who underwent complete resection and evaluated its clinical significance. We found that both the preoperative and postoperative CK19 mRNA level increased in the esophageal cancer patients with lymph node metastasis, relapse or distant metastasis compared with that in cancers without lymph node metastasis, relapse or distant metastasis. High postoperative CK19 mRNA levels indicate a short disease‐free survival (DFS) for the whole cohort esophageal cancer patients, whereas the high preoperative CK19 mRNA levels only indicate a short DFS for the esophageal cancer patients with squamous cell carcinoma, TNM III stage, and lymph node metastasis. The dynamic change of CK19 mRNA levels could indicate the prognosis of esophageal cancer patients. The patients with decreasing CK19 mRNA level after surgery had good prognosis, and the patients with changeless CK19 mRNA level had poor prognosis. Taken together, CK19 mRNA levels could be a promising marker in assessing prognosis or assigning treatment for the esophageal cancer patients according to different clinicopathological factors.     

T1肺癌淋巴结转移特点及临床意义

目的探讨T1肺癌淋巴结转移频度、分布范围及特点,为淋巴结清除术提供依据.方法按Naruke肺癌淋巴结分布图对215例T1肺癌施行了手术及广泛肺内、叶间、纵隔淋巴结清除术并对其进行统计分析.结果清除淋巴结1 674组.N1转移率11%,N2转移率6%.肿瘤最大直径≤1.5 cm㎝和1.6～3.0 cm者的淋巴结转移率分别为5%和8%.肿瘤最大直径≤1.5 cm的鳞癌N1、N2均无转移.N2转移在鳞癌、腺癌、小细胞癌分别为5%、23%和3/9,差异有极显著性(P＜0.01).N2转移鳞癌为某一组淋巴结转移的为3/4,腺癌≥3组转移占40%,跳跃式转移占N2转移的41%.N2阳性上叶肺癌下纵隔转移占14%,N2阳性下叶肺癌上纵隔转移占60%.结论瘤体增大,淋巴结转移频度增加,腺癌比鳞癌转移活跃,小细胞癌最活跃,肺癌可跨区域纵隔转移.除肿瘤最大直径≤1.5 cm的鳞癌不进行淋巴结清除亦有可能达到根治外,其余类型T1肺癌均应广泛清除肺内及纵隔淋巴结.     

Lymph node dissection in esophageal carcinoma: Minimally invasive esophagectomy vs open surgery

AIM: To compare lymph node dissection results of minimally invasive esophagectomy(MIE) and open surgery for esophageal squamous cell carcinoma.METHODS: We retrospectively reviewed data from patients who underwent MIE or open surgery for esophageal squamous cell carcinoma from January 2011 to September 2014. Number of lymph nodes resected, positive lymph node(p N+) rate, lymph node sampling(LNS) rate and lymph node metastatic(LNM) rate were evaluated. R E S U LT S : A m o n g 4 4 7 p a t i e n t s i n c l u d e d, 1 2 3 underwent MIE and 324 underwent open surgery. The number of lymph nodes resected did not significantly differ between the MIE and open surgery groups(21.1 ± 4.3 vs 20.4 ± 3.8, respectively, P = 0.0944). The p N+ rate of stage T3 esophageal squamous cell carcinoma in the open surgery group was higher than that in the MIE group(16.3% vs 11.4%, P = 0.031), but no differences was observed for stages T1 and T2 esophageal squamous cell carcinoma. The LNS rate at left para-recurrent laryngeal nerve(RLN) site was significantly higher for open surgery than for MIE(80.2% vs 43.9%, P 0.001), but no differences were noted at other sites. The LNM rate at left para-RLN site in the open surgery group was significantly higher than that in the MIE group, regardless of pathologic T stage. CONCLUSION: For stages T1 and T2 esophageal squamous cell carcinoma, the lymph node dissection result after MIE was comparable to that achieved by open surgery. However, the efficacy of MIE in lymphadenectomy for stage T3 esophageal squamous cell carcinoma, particularly at left para-RLN site, remains to be improved.     

Association between positive murine double minute 2 expression and clinicopathological characteristics of esophageal squamous cell carcinoma: a meta‐analysis

The correlations of murine double minute 2 (MDM2) T309G and esophageal cancer were elucidated because the association between MDM2 expression states and clinicopathological parameters of esophageal squamous cell carcinoma (ESCC) is controversial. We conducted a meta‐analysis on studies screened from PubMed, Web of Science, Embase, the Cochrane Library, and the Chinese Biomedical Literature Databases that were published before October 2014. All studies describing the association between MDM2 and ESCC were traced. Meta‐analysis was performed using the STATA software (Stata Corp., College Station, TX, USA). A total of 9 studies with 707 cases and 324 controls were included. MDM2 expression was higher in ESCC than in normal esophageal epithelium (odds ratio [OR] 10.38, 95% confidence interval [CI] 6.42–16.78, P < 0.001). High MDM2 expression was associated with early primary tumor stage (T1/T2 vs. T3/T4, OR 0.59, 95% CI 0.38–0.92, P = 0.018) and increased risk of regional lymph node metastasis (N0 vs. N1, OR 1.66, 95% CI 1.03–2.67, P = 0.039). However, no relationship was observed between MDM2 expression and the risk of distant metastasis (OR = 2.09, 95% CI 1.00–4.36, P = 0.050), and MDM2 was not significantly correlated with TP53 expression (OR 1.22, 95% CI 0.53–2.77, P = 0.643). Our analysis suggests that MDM2 acts as a potent marker of early primary tumor stage but higher risk of regional lymph node metastasis in ESCC. However, because of the limited number of studies included, the result should be further clarified by well‐designed prospective studies.     

Endoscopic versus surgical therapy for Barrett’s esophagus neoplasia

Esophagectomy has been the traditional therapy for high-grade dysplasia and intramucosal cancer. Though surgery can completely resect the cancer and the affected lymph nodes, it carries significant morbidity and mortality (often exceeds 2%). New developments in endoscopy have provided less-invasive therapies that can also be used to stage tissue invasion of cancer; they include esophageal mucosal resection (EMR) and endoscopic submucosal dissection. Additional endoscopic therapies include photodynamic therapy, radiofrequency ablation (RFA) and argon plasma coagulation. Combining EMR that targets the cancer and RFA that targets the surrounding Barrett’s esophagus offers an alternative to the operative approach when there is no lymph node metastasis. Arguments for surgical esophagectomy include concern for missed lymph node metastasis and incomplete endoscopic resection. Based on EMR’s high neoplasia eradication rate and its fewer and more manageable complications, EMR, especially when combined with RFA, appears to be a viable alternative to surgery in early submucosal cancers, that is, sm1.     

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.     

Primary esophageal adenosquamous carcinoma: a retrospective analysis of 24 cases

Primary adenosquamous carcinoma (ASC) of the esophagus is a rare kind of malignancy characterized by mixed glandular and squamous differentiation as well as a propensity for aggressive clinical behavior. Data on the evaluation of the clinicopathological features and the prognosis of patients suffering from this malignancy are few because of the rarity of this disease. We conducted a retrospective review of 24 patients with primary esophageal ASC among 6546 esophageal cancer patients who underwent transthoracic esophagectomy in our hospital. The clinicopathological presentation, diagnosis, treatment, and prognostic factors of the patients were respectively investigated. The Kaplan–Meier method and the log rank test were used to calculate and compare overall survival (OS). The Cox proportional hazards model was employed to identify independent prognostic factors. There were 18 males and 6 females with a median age of 60 years (range: 40–78 years). The clinical symptoms, macroscopic type, as well as the radiological and endoscopic features of esophageal ASC were similar to those of esophageal squamous cell carcinoma. Sixteen (88.9%) of the 18 cases who underwent preoperative esophagoscopic biopsy were misdiagnosed as adenocarcinoma or squamous cell carcinoma. The overall median follow‐up period was 36 months, and the median survival time was 32 months. The 1, 3, 5‐year OS rates were 75.0%, 48.5%, and 19.4%, respectively. Univariate analysis showed that gender (P = 0.047), lymph node metastasis (P = 0.007), and TNM stage (P = 0.037) were important factors associated with OS of the 22 patients who underwent radical resection. Multivariate analysis showed that the pathological N stage was the only independent prognostic factor (P = 0.031, hazard ratio [HR], 5.369, 95% confidence interval [CI], 1.167–24.700). These results suggest that esophageal ASC is an uncommon disease prone to be misdiagnosed by endoscopic biopsy. Surgical resection is the primary treatment, but the prognosis of ASC is usually poorer than conventional squamous cell carcinoma. Lymph node metastasis is an independent prognostic factor after radical resection.     

内镜下黏膜切除术后食管狭窄的危险因素分析

目的 分析食管病变内镜下黏膜切除术后食管狭窄的可能的危险因素.方法 2008年至2009年间,共对219例食管早期癌或癌前病变进行内镜下黏膜切除术治疗,其中9例出现食管狭窄,对这9例患者（狭窄组）的病变性质、范围、治疗情况等进行回顾性分析,并与其它术后无狭窄患者（对照组,n=202,有8例术后病理证实有黏膜下层浸润,转外科手术,未纳入比较）进行比较.结果 两组患者在性别、年龄、病变位置、病变长度及术后病理方面无显著差别,但狭窄组创面范围＞3/4食管周径的比例（8/9,88.9%）明显高于对照组（9/202,4.5%,P＜0.01）.结论 对内镜治疗后范围超过食管周径3/4的早期食管癌或癌前病变,内镜下黏膜切除术后发生食管狭窄的风险明显增加.     

EMR as salvage treatment for patients with locoregional failure of definitive chemoradiotherapy for esophageal cancer

BACKGROUND: Definitive chemoradiotherapy is recognized as a standard treatment for esophageal cancer. Although most failures of this combined modality are locoregional, without distant metastasis, there are few curative treatment options available in such cases except salvage esophagectomy. METHODS: Experience with 16 patients with squamous cell carcinoma of the esophagus who underwent EMR as a salvage treatment after locoregional failure of definitive chemoradiotherapy was reviewed retrospectively. EMR was performed by using the mucosal strip technique. Eight patients had local recurrence at the primary site after a complete response to chemoradiotherapy, 5 had metachronous multiple cancers, and 3 had residual tumor after completing chemoradiotherapy. RESULTS: In all patients, the EMR-treated tumors were histopathologic stage T1 and were clinical stage N0M0 as defined by EUS and CT. No serious complication was observed in any patient. At a median follow-up of 33 months (range 11-73 months) from the initiation of chemoradiotherapy, 3 patients (38%) with local recurrence at the primary site, 3 (40%) with metachronous multiple cancers, and two (67%) with residual cancer were still alive and disease-free after salvage EMR, for periods of 30 to 63 months. The 3-year survival rate from the initiation of salvage EMR for all patients was 56%. CONCLUSIONS: Long-term survival can be achieved with salvage EMR for locoregional failure after definitive chemoradiotherapy for esophageal cancer without serious complications. EMR may be a salvage treatment option when a recurrent or residual tumor is superficial or local.