Advanced gastric carcinoma combined with extra-adrenal pheochromocytoma resected after three courses of S-1 and cisplatin as neoadjuvant chemotherapy: Report of a case

We herein describe the case of a patient with advanced gastric carcinoma combined with extra-adrenal pheochromocytoma who received a radical operation after undergoing neoadjuvant chemotherapy. A 48-year-old woman was referred to our hospital for gastric carcinoma. Computed tomography revealed an enlargement of the regional lymph nodes and a para-aortic lymph node. A diagnosis of advanced gastric carcinoma was made (cT3, cN3, cM0, cStage IV according to the Japanese Classification of Gastric Carcinoma, 2nd English edition). A reduction in size was observed in both the gastric tumor and the lymph nodes around the stomach after neoadjuvant chemotherapy. However, the paraaortic lymph node showed no remarkable change. We thus suspected this para-aortic tumor not to be a lymph node, but instead to be an extra-adrenal pheochromocytoma, because of the different response from the other regional lymph nodes. An endocrinological examination confirmed the diagnosis of extra-adrenal pheochromocytoma. A gastrectomy and a resection of the pheochromocytoma were thus performed.     

Sentinel lymph node procedure followed by laparoscopic pelvic and paraaortic lymphadenectomy in women with <Emphasis Type="Underline">IB2-II</Emphasis> cervical cancer

Objective To evaluate the contribution of the sentinel node (SN) procedure followed by pelvic and paraaortic lymphadenectomy to determine lymph node status in women with locally advanced cervical cancer. Patients and methods A total of 21 women with locally advanced cervical cancer underwent a first laparoscopic SN procedure and pelvic and paraaortic lymphadenectomy followed by concurrent chemoradiotherapy (CCR). Laparoscopic radical hysterectomy was performed after CCR when the pelvic and paraaortic nodes were not involved. Results SNs were detected by means of lymphoscintigraphy in 10 women (47.6%) and intra-operatively in 14 women (66.6%). Of the latter 14 patients, 9 (64%) had an involved SN and 1 of the remaining 5 had pelvic non-SN metastases. The SN false-negative rate was 10%. At final histology, 13 of the 21 women (62%) had lymph node metastases. The total number of recovered pelvic non-SNs was 262, and 10 nodes in 8 women were involved. The total number of paraaortic non-SNs was 255, and 2 nodes in 2 women were involved. Conclusion This study shows the poor correlation between pre-operative lymphoscintigraphy and surgical SN mapping in women with locally advanced cervical cancer. A high proportion of women had SN metastases, underlining the importance of multiple sectioning and immunohistochemical staining of SNs.     

Survival benefits of and indications for extended surgery for advanced gastric cancer]

The surgical management of locally advanced gastric cancer remains controversial. It is also unclear whether the postoperative survival rate could be improved by extended lymph node dissection. The aim of this paper is to determine the survival benefit of and the indications for extended surgery. Lymph node metastasis in the paraaortic area frequently occurs in locally advanced cardiac cancer. In our previous studies, the paraaortic lymph nodes above and below the left renal vein were confirmed to be the terminal destination of lymphatic flow in the upper abdominal cavity. Paraaortic lymph node dissection is essential for curarive resection in some cases of advanced gastric cancer. The 5-year survival rate in patients who undergo paraaortic lymph node dissection is nearly 15% according to the literature. Patients with metastasis of the paraaortic lymph nodes on only one side and with fewer than four involved nodes clearly benefit from paraaortic lymph node dissection. It is indicated in cases with metastasis or suspected metastasis of the left or right cardiac lymph node or N2 lymph node station. There is little survival benefit from combined resection of involved organs (T4 disease) and it should only be performed in a select group of patients. Extended surgery for locally advanced gastric cancer, however, is feasible and has acceptable operative morbidity and mortality rates.     

进展期胃癌腹主动脉旁淋巴结微小转移与患者预后的关系

目的研究进展期胃癌腹主动脉旁淋巴结的微小转移对于评价预防性淋巴结清除的意义。方法采用细胞角蛋白抗体,对47例进展期胃癌患者根治性手术清除的2339枚淋巴结(其中包括390枚腹主动旁淋巴结),进行免疫组织化学染色研究。结果常规HE染色发现390枚腹主动脉旁淋巴结中,95枚从14例患者中清除的淋巴结为转移阳性。剩余的295枚淋巴结中,有45枚从另15例患者中清除的淋巴结经免疫组化染色发现有微小转移。术后5年生存率在腹主动脉旁淋巴结转移阴性组为56．0％,微小转移组为25．2％,常规染色淋巴结转移组为9．0％。结论进展期胃癌存在较高的腹主动脉旁淋巴结微小转移率,预防性淋巴结清除对此类患者有效。     

Cancer of the cardia. Prognostic factors and treatment]

Pronostic of carcinoma of the esogastric junction is worsened by the potential two-way route of spread in case of lymph node metastasis: mediastinum and abdomen. During the last 10 years the authors observed 71 cases of adenocarcinoma of the gastric cardia, including 7 cases of linitis plastica. Histopathologic and clinical follow-up data are presented. The aims of the study were to evaluate prognostic factors and to define the best surgical treatment. There were mainly elderly patients with a poor physical status. Ten patients did not undergo surgery (14%). Among 57 patients undergoing radial resection (80.3%), total gastrectomy and upper polar esogastrectomy were performed in respectively 29 and 28 cases. The carcinomas were truly located to the gastric cardia in only 37 cases (65%). Operative mortality was 12.3%, not depending of the surgical technique. All patients five-year survival rate was 10.2%, improving to 15% in case of curative resection. The value of lymph node metastasis (80.7% of the patients) as a prognostic factor depended of the proximal or distal localization of the nodes. A positive surgical margin (15.7% of the patients) was a poor prognostic factor with a 6.9 months mean survival. The authors conclude that an aggressive surgical approach is worthwhile, because of the carcinoma invasion (nodes, margin), but not always possible (poor physical status).     

Risk factors for morbidity and mortality in resection of cancer of the cardia

Operations were performed on 166 patients for adenocarcinoma of the cardia, between 1970 and 1986, with resections being applied to 102 of them (6.1 per cent), including 87 curative approaches with complete removal of tumours and no macroscopic evidence of metastases. Total gastrectomy with oesophagectomy was performed on 36 patients and proximal oesophagogastrectomy on 66, in 43 of these via left thoracic incision. Regional lymph nodes were free of tumour in 29 patients (28 per cent). The other approaches to proximal resection were thoracoabdominal in eight cases, abdominal in 13, and transmediastinal in two. Leakage of oesophageal anastomosis occurred in 19 cases and was followed by septicaemia and death in 13. Overall mortality during hospitalisation amounted to 22.5 per cent, including two patients who died on the 30th postoperative day as a result of dehiscence and septicaemia. Mortality figures were 17 per cent following total gastrectomy and 19 per cent in the wake of proximal gastrectomy by thoracic incision. Mortality amounted to 48 per cent in the 23 cases on which abdominal, thoraco-abdominal, and transmediastinal operations had been performed. Multiple logistic regression was used to determine age, ECG, spread of lymph nodes, and surgical techniques as potential risk factors. Emphasis in the context of surgical techniques was laid on proximal versus total gastrectomy, incision on both sides of the diaphragm, palliative resection, and anastomotic suturing (using one-layer or two-layer techniques or mechanical staples). Tumour spread to lymph nodes and proximal resection were the only independent variables associated with dehiscence. Electrocardiogram (ECG), lymph node involvement, and palliative resection proved to be of relevance to prognostication of lethality. No statistical correlations were found to exist between lethality, on the one hand, and surgical approach, age of patient, incision on either side of the diaphragm or suturing, on the other. The conclusion was drawn that in cases of cardia carcinoma total gastrectomy does not aggravate the risk of lethality, as compared to cardia resection.     

Nodal involvement as an indicator of postoperative liver metastasis in carcinoma of the papilla of Vater

BACKGROUND/PURPOSE: Although lymph node metastatic involvement is one of the most important prognostic factors for carcinoma of the papilla of Vater, a detailed analysis of this factor in relation to prognosis has not been conducted. METHODS: From 1985 to 2003, 29 patients with carcinoma of the papilla of Vater underwent pancreaticoduodenectomy and dissection of regional lymph nodes at Yamagata University Hospital. We analyzed clinicopathologic variables in relation to prognosis and precisely evaluated nodal involvement in each patient to determine lymphatic flow. Furthermore, the relationship between recurrent site and nodal involvement was investigated. RESULTS: The overall survival rate was 55% at 5 years. The significant prognostic factors were morphological ulcer formation (P = 0.04), histological type (P = 0.03), nodal involvement (P = 0.002), and lymphatic invasion (P = 0.03). Multivariate analysis indicated no independent factor, but nodal involvement may be the strongest prognostic factor. The overall rate of nodal involvement was 41.4% (12 of 29 patients). The metastatic rates in the superior posterior pancreaticoduodenal lymph nodes, the inferior posterior pancreaticoduodenal lymph nodes, the superior mesenteric lymph nodes, and paraaortic lymph nodes were high (31.0%, 20.7%, 17.2%, and 13.8%, respectively). Patients with nodal involvement had a significantly higher rate of liver metastasis after surgery than those without it (P = 0.02). Ulcer formation and histological type were significantly correlated with nodal involvement (P = 0.05 and P = 0.002, respectively). CONCLUSIONS: Nodal involvement is the most important prognostic factor in patients with carcinoma of the papilla of Vater. Patients with nodal involvement are at high risk of liver metastasis; therefore, adjuvant therapy may be necessary for the control of liver metastasis. Preoperative ulcer formation and histological type in the biopsy specimen are good indicators for extended lymph node dissection and adjuvant therapy, because these variables are correlated with nodal involvement. However, our data revealed only the sites of the positive nodes, without addressing the effect of extended lymph node dissection and adjuvant chemotherapy. To date, there has been reporting of extended lymph node dissection and adjuvant chemotherapy in patients with carcinoma of the papilla of Vater. Further studies will be necessary to resolve these problems.     

Impact of Splenectomy in Patients with Gastric Adenocarcinoma of the Cardia

Previous reports have suggested that splenectomy treatment of gastric carcinoma of the cardia results in poor patient outcome, but the reason for this is unclear. This study aimed to clarify the impact of splenectomy for gastric carcinoma patients. A total of 118 patients with gastric carcinoma of the cardia were enrolled in this study. The characteristics of patients with lymph node metastasis at the splenic hilum were determined, and the effects of lymph node dissection or splenectomy on postoperative morbidity, mortality, and pattern of recurrence were evaluated. Advanced tumors were common in patients with lymph node metastasis at the splenic hilum, Siewert type III, greater curvature sites, larger and deeper tumors, multiple metastatic lymph nodes, and high incidences of para-aortic lymph node metastasis frequently observed. The effectiveness of lymph node dissection of the splenic hilum was low and equal to that of dissection of the para-aortic lymph nodes. Postoperative morbidity, as represented by pancreatic fistula, was high following splenectomy or pancreaticosplenectomy, but patient mortality did not occur. Hematogenous metastasis was common, as well as peritoneal metastasis after curative gastrectomy. Splenectomy should be limited in those patients with gastric cardia tumors invading the spleen or with metastatic bulky lymph nodes extending to the spleen.     

Lymphatic flow of the remnant stomach

Aiming at establishing an appropriate lymph node dissection for carcinoma of the remnant stomach and of the lower esophageal carcinoma in the status post-gastrectomy, lymphatic flow was investigated clinically as well as experimentally. Nineteen cases of carcinoma of the remnant stomach and 8 cases of esophageal carcinoma after partial gastrectomy were studied. Lymph node metastasis of the remnant stomach carcinoma were more frequently seen at perigastrium, splenic hilum, and along splenic artery. Those further extended to para-aortic and diaphragmatic nodes. Three cases of lower esophageal carcinoma after gastrectomy had massive nodal involvement at perigastrium, as well as intra-thoracic lymph nodes. Experimentally 5-Fu emulsion was injected submucosally under endoscope in 25 dogs and subserosally in 6 rabbits. 5-Fu contents in lymph nodes were measured 30 minutes after injection. The most prominent difference in lymphatic flow from the remnant stomach was increase in ascending flow into intrathoracic lymph nodes through para-aorta. This increment was seen irrespective of Billroth I or II anastomosis. On the contrary, descending lymphatic flow from the lower esophagus into the intra-abdominal lymph nodes was not disturbed by gastrectomy. Cardiac lymph node dissection in rabbits accelerated ascending flow. Those results would indicate the necessity of complete block of ascending flow in cases of the remnant stomach carcinoma and of intra-abdominal lymph node dissection in those of the lower esophageal carcinoma after gastrectomy.     

Superextended lymphadenectomy (D4) in the treatment of gastric adenocarcinoma

BACKGROUND: The incidence of paraaortic lymph node metastasis (N4) in relation with the site of the tumour, and survival in patients with gastric cancer who underwent gastric resection and superextended lymphadenectomy (D4), have been analyzed. METHODS: The frequency of paraaortic lymph node metastasis was studied in 132 patients who underwent gastrectomy with D4 lymphadenectomy during the period June 1988 - December 2000. Six patients with plastic linitis and 3 with carcinoma of the gastric stump were excluded from the analysis. RESULTS: In personal experience the most frequent postoperative morbidity were respiratory complication (7.6%) and pancreatic fistula (6.8%). Among the 132 patients the total number of dissected nodes was 6362 and the mean number of dissected nodes per case was 48.2. The total number of retrieved lymph nodes from the paraaortic station was 755 with a mean number 5.7 per patients. N4 nodal involvement was found in 25 (19%) of 132 patients: 14 (36%) patients with carcinoma located in the proximal third, 5 (13%) with tumour located in the middle third and 6 (11%) with carcinoma of the distal third of the stomach. The median survival time and the overall cumulative 5-year survival rate for curatively (R0) resected patients were 74 months and 52% respectively. CONCLUSIONS: The presence of metastasis in paraaortic lymph nodes in 19% of our patients, the low morbidity and mortality, the good survival after superextended lymphadenectomy, suggest that this lymphadenectomy should be considered in the curative surgical treatment of advanced gastric cancer, especially if located in the proximal third of the stomach (N4 in 36% of cases).     

Lymph node metastasis from hilar cholangiocarcinoma: audit of 110 patients who underwent regional and paraaortic node dissection

OBJECTIVE: To assess the status of the regional and paraaortic lymph nodes in hilar cholangiocarcinoma and to clarify the efficacy of systematic extended lymphadenectomy. SUMMARY BACKGROUND DATA: There have been no studies in which regional and paraaortic lymphadenectomies for hilar cholangiocarcinoma have been routinely performed. Therefore, the metastasis rates to the regional and paraaortic nodes, the mode of lymphatic spread, and the effect of extended lymph node dissection on survival remain unknown. METHODS: This study involved 110 patients who underwent surgical resection for hilar cholangiocarcinoma with lymph node dissection including both the regional and paraaortic nodes. A total of 2,652 nodes retrieved from the surgical specimens were examined microscopically. RESULTS: Of the 110 patients, 52 (47.3%) had no involved nodes, 39 (35.5%) had regional lymph node metastases, and 19 (17.3%) had regional and paraaortic node metastases. The incidence of positive nodes was significantly higher in the patients with pT3 disease than in those with pT2 disease. The pericholedochal nodes were most commonly involved (42.7%), followed by the periportal nodes (30.9%), the common hepatic nodes (27.3%), and the posterior pancreaticoduodenal nodes (14.5%). The celiac and superior mesenteric nodes were rarely involved. The 3-year and 5-year survival rates were 55.4% and 30.5% for the 52 patients without involved nodes, 31.8% and 14.7% for the 39 patients with regional node metastases, and 12.3% and 12.3% for the 19 patients with paraaortic node metastases, respectively. Of the 19 patients with positive paraaortic nodes, 7 had no macroscopic evidence of paraaortic disease on intraoperative inspection. The survival in this group was significantly better than in the remaining 12 patients. CONCLUSION: The paraaortic nodes and the regional nodes are frequently involved in advanced hilar cholangiocarcinoma. Whether extended lymph node dissection provides a survival benefit requires further study. However, the fact that long-term survival is possible despite pN2 or pM1 disease encourages the authors to perform an aggressive surgical procedure with extended lymph node dissection in selected patients with hilar cholangiocarcinoma.     

Difference in main lymphatic pathways from the lower esophagus and gastric cardia

Lymphatic pathways draining the lower esophago-cardiac region were studied in 17 patients with carcinoma of the lower esophagus or gastric cardia, by measuring radioisotope uptakes in the regional lymph nodes. The uptakes were most remarkable in lower mediastinal and upper gastric lymph nodes, when the radioactive colloid was injected at the lower esophagus. A lesser degree of uptakes were observed both in other mediastinal and abdominal lymph nodes. On the contrary, a high degree of uptakes were detected only in abdominal lymph nodes, when the colloid was injected at the gastric cardia. The results indicated that main lymphatic pathways originating from the lower esophagus advance both upward and downward, and that those from the gastric cardia make their way downward to upper gastric, para-celiac and para-aortic lymph nodes. The actual incidences of lymph node metastases were also studied in 108 patients with carcinoma of the lower esophagus and 93 patients with carcinoma of the gastric cardia. In the former group, very high incidences were observed in lower esophageal and upper gastric lymph nodes. In the latter group, the incidence was most remarkable in upper gastric lymph nodes and far less significant in lower mediastinal lymph nodes. The results confirmed those of the radioisotope study. The importance of dissection of para-aortic lymph nodes near the left renal vein was also stressed.     

Lymph node metastasis with adenocarcinoma of the gastric cardia: clinicopathological analysis and indication for D1 dissection.

PURPOSE: To establish the indications for proximal resection with dissection of perigastric lymph nodes in order to treat adenocarcinoma of the gastric cardia. METHODS: We analyzed the clinicopathological features of 110 resected adenocarcinomas of the gastric cardia with respect to the appropriate operative method and extent of lymphadenectomy for treatment. RESULTS: Of the 110 patients, 93 underwent curative resection. The D2 group (total gastrectomy with dissection of extended regional lymph nodes) revealed higher morbidity and mortality rates compared to the D1 group (proximal resection with dissection of perigastric lymph nodes). The risk of lymph node metastasis was determined by depth of invasion, size of tumors, and gross findings of tumors. CONCLUSION: The appropriate operative method for adenocarcinoma of the gastric cardia requires: (i) tumor size less than 4 cm; and (ii) gross findings indicating a superficial type of lesion, which are recommended for proximal resection with dissection of perigastric lymph nodes.     

Hybrid SPECT-CT: an additional technique for sentinel node detection of patients with invasive bladder cancer

OBJECTIVES: To explore the feasibility of performing lymphoscintigraphy combined with computed tomography (CT) for preoperative detection of sentinel lymph nodes in patients with invasive bladder cancer. MATERIALS: Six consecutive patients scheduled for radical cystectomy underwent lymphoscintigraphy after transurethral injection of Albures-technetium 99m in the detrusor muscle peritumourally both with planar imaging and with single-photon emission computed tomography/CT (SPECT/CT). CT for anatomic fusion was performed directly after the SPECT/CT and both investigations were combined to a fused image. Radical cystectomy started with extended lymphadenectomy and intraoperative detection of sentinel nodes with both Geiger probe and dye marker. The conventional planar lymphoscintigraphies and the fused SPECT/CT were compared with each other and with the outcome of intraoperative sentinel node detection and final histopathologic analyses. RESULTS: The method allowed anatomically detailed preoperative visualisation of 21 sentinel nodes in five of the six patients, whereas planar pictures only visualised two sentinel nodes in two of six patients. Two patients had lymph node metastases and in the other four the nodes were negative. The combined method visualised all metastatic sentinel nodes, whereas planar lymphoscintigraphy detected only one of six node metastases. CONCLUSIONS: The combination of lymphoscintigraphy with CT enhanced preoperative anatomic localisation of sentinel nodes in bladder cancer and aided in the identification of sentinel nodes during surgery. The yield of detected sentinel nodes, both metastatic and nonmetastatic, was markedly increased using the combined method compared to conventional planar lymphoscintigraphy.     

Difference in main lymphatic pathways from the lower esophagus and gastric cardia

Lymphatic pathways draining the lower esophago-cardiac region were studied in 17 patients with carcinoma of the lower esophagus or gastric cardia, by measuring radioisotope uptakes in the regional lymph nodes. The uptakes were most remarkable in lower mediastinal and upper gastric lymph nodes, when the radioactive colloid was injected at the lower esophagus. A lesser degree of uptakes were observed both in other mediastinal and abdominal lymph nodes. On the contrary, a high degree of uptakes were detected only in abdominal lymph nodes, when the colloid was injected at the gastric cardia. The results indicated that main lymphatic pathways originating from the lower esophagus advance both upward and downward, and that those from the gastric cardia make their way downward to upper gastric, para-celiac and para-aortic lymph nodes. The actual incidences of lymph node metastases were also studied in 108 patients with carcinoma of the lower esophagus and 93 patients with carcinoma of the gastric cardia. In the former group, very high incidences were observed in lower esophageal and upper gastric lymph nodes. In the latter group, the incidence was most remarkable in upper gastric lymph nodes and far less significant in lower mediastinal lymph nodes. The results confirmed those of the radioisotope study. The importance of dissection of para-aortic lymph nodes near the left renal vein was also stressed.     

Significance of aggressive lymph node dissection in advanced gallbladder carcinoma

Although aggressive lymph node dissection has been performed in gallbladder carcinoma as well as in other carcinomas of the alimentary tract, there is no definitive evidence of the efficacy of extended lymph node dissection. However, extensive lymph node metastasis is well known in advanced carcinoma of the gallbladder. From the viewpoint of the balance between radicality and safety in surgery, wider lymph node dissection consisting of the lymph nodes in the hepatoduodenal ligamentum and parapancreatic area is recommended in selected patients who hare no involvement of the paraaortic lymph nodes. Complete dissection of the superior mesenteric lymph nodes with pancreaticoduodenectomy is unlikely to result in cure.     

Proximal subtotal gastrectomy for the treatment of carcinoma of the upper third of the stomach: Its indications based on lymph node metastasis and perigastric lymphatic flow

To clarify the indications for a proximal subtotal gastrectomy in the treatment of carcinoma in the upper third of the stomach based on lymph node metastases, 1055 patients in whom either a D₂ or greater lymph node removal was performed were reviewed. In the patients in which the lesion was confined to the upper stomach and did not invade beyond the muscularis propria of the stomach wall, no metastases to either the lymph nodes above and below the pylorus or the lymph nodes along the greater curvature were observed. A lymphatic flow study revealed a minimal flow to these nodes from the upper stomach in patients without lymph node metastasis, but in cases with lymph node metastases the lymphatic flow changed. The indications for a proximal subtotal gastrectomy for a carcinoma of upper third of the stomach therefore must fulfill the following two conditions: (1) The deepest layer of cancerous invasion does not extend beyond the muscularis propria of the stomach wall, and (2) No macroscopic evidence of lymph node metastasis can be detected during surgery.     

Applicability of lymphoscintigraphy with sentinel node biopsy to eccrine carcinoma of the head and neck

BACKGROUND: Eccrine carcinoma of the head and neck has the propensity to metastasize both to regional and distant sites. When associated with nodal metastasis, there is a high incidence of distant spread of disease, ultimately being associated with the death of the patient. Management of the patient with clinically negative nodes remains controversial. Although elective nodal dissection has been performed, the impact of this intervention remains indeterminate. This case series serves as a feasibility study for use of the technique of lymphoscintigraphy with sentinel node biopsy for eccrine carcinoma arising in the head and neck. METHODS: Two patients with eccrine carcinoma underwent sentinel node biopsy by way of the standard, three-part technique using lymphoscintigraphy, 1% isosulfan blue dye, and intraoperative use of the gamma probe. RESULTS: In each of these cases, the lymphoscintigram successfully identified sentinel lymph nodes. Intraoperative findings were significant for confirmation of sentinel nodes with the presence of blue dye in the lymph node. In one case, frozen section identified a positive sentinel lymph node, and the patient underwent definitive nodal dissection and postoperative radiotherapy. In the second case, immunohistochemistry as part of final pathology identified a single microscopic foci of metastatic eccrine carcinoma, for which the patient elected to receive definitive radiation therapy. CONCLUSIONS: This report documents the efficacy of lymphoscintigraphy with sentinel lymph node biopsy in identifying microscopic metastasis eccrine carcinoma in primary lesions arising in the head and neck.     

Clinical evaluation of the esophageal lymph flow system based on RI uptake of dissected regional lymph nodes following lymphoscintigraphy

For surgical treatment of esophageal cancer, the importance of evaluating lymph node metastasis and the lymph flow of the esophagus can not be overemphasized. In oder to investigate the lymph flow of the esophagus, we preoperatively performed lymphoscintigraphy by endoscopic local injection of 99mTc Rhenium Colloid into the esophageal wall in 42 esophageal cancer cases and 4 gastric cancer cases. Postoperatively, the RI uptake of each dissected regional lymph nodes was examined by a Scintillation Counter. The findings were as follows. From the upper third of the thoracic esophagus, the main lymph flow was ascending to the neck and upper mediastinum. From the middle third, the lymph flow was ascending to the neck and upper mediastinum and descending into the abdomen. From the lower third, the main lymph flow was descending to the abdomen. In some cases, the lymph flow to the tracheal bifurcation nodes or to the lymph nodes around the left renal vein was observed. In 61% of the esophageal cancer cases with a partial bilateral neck dissection, the lymph flow to the bilateral supraclavicular lymph nodes was predominant compared to the upper mediastinum nodes.