Fibrosing mediastinitis: Successful stenting of the pulmonary artery

Fibrosing mediastinitis is a rare benign condition, which can cause compression of the pulmonary or systemic vessels, tracheobronchial tree, coronary arteries or esophagus, leading to disabling clinical symptoms and even death. The case of a 26-year-old woman who presented with dyspnea is described. She was found to have 80% stenosis of the right pulmonary artery secondary to fibrosing mediastinitis. The stenosis was managed successfully with an endovascular Palmaz-Schatz stent, and the patient remains symptom-free 10 years later.     

Current status of esophageal cancer treatment in Asia

Esophageal cancer is becoming a different disease in Asian and Western countries. The rapidly rising incidence of adenocarcinoma of the lower esophagus and cardia has replaced squamous cell cancers as the predominant cell type in the west. The different cell type and tumor location to some extent influence how the disease is treated; other factors are cultural and the way health care is financed. The goals of treatment, however, are the same; to provide long-term cure with minimal morbidity and mortality and to preserve patients quality of life. Surgical resection has remained the mainstay treatment in Asia. Improvement in surgical outcome has taken place in many centers throughout Asia in the past two decades. Emphasis has been centered on epidemiology of the disease, reducing morbidity and mortality of esophagectomy, and identifying effective surgical or nonsurgical methods of treatments. Randomized controlled trials are also increasingly employed to test many unresolved problems. The Asian contributions are elaborated with specific examples from Japan, Hong Kong, and China.This lecture was presented during the international session at the 58th Annual Meeting of the Japan Esophageal Society.     

Successful esophagectomy in a patient with combined esophageal cancer and hemophilia B

Patients with esophageal cancer often require esophagectomy with esophagogastrostomy. However, the incidence of complications, such as hemorrhage, during operations for esophageal cancer is high, even with minimally invasive surgery. Without the appropriate interventions, the risk of major intraoperative and postoperative hemorrhage is very high in patients with esophageal cancer and hemophilia. We report the case of a 45-year-old man with esophageal cancer and hemophilia B who underwent a successful hybrid, minimally invasive Ivor-Lewis esophagectomy with appropriate perioperative management.     

Esophageal intramural pseudodiverticulosis of the residual esophagus after esophagectomy for esophageal cancer

A 91-year-old man was referred to our hospital with intermittent dysphagia. He had undergone esophagectomy for esophageal cancer(T3N2M0 Stage Ⅲ) 11 years earlier. Endoscopic examination revealed an anastomotic stricture; signs of inflammation,including redness,erosion,edema,bleeding,friability,and exudate with white plaques; and multiple depressions in the residual esophagus. Radiographical examination revealed numerous fine,gastrografinfilled projections and an anastomotic stricture. Biopsy specimens from the area of the anastomotic stricture revealed inflammatory changes without signs of malignancy. Candida glabrata was detected with a culture test of the biopsy specimens. The stricture was diagnosed as a benign stricture that was caused by esophageal intramural pseudodiverticulosis. Accordingly,endoscopic balloon dilatation was performed and antifungal therapy was started in the hospital. Seven weeks later,endoscopic examination revealed improvement in the mucosal inflammation; only the pseudodiverticulosis remained. Consequently,the patient was discharged. At the latest follow-up,the patient was symptomfree and the pseudodiverticulosis remained in the residual esophagus without any signs of stricture or inflammation.     

Strategies to improve surgical results in the treatment of esophageal cancer

Despite advances made in the treatment of esophageal cancer in recent years, it remains a lethal disease. Esophagectomy is, among general surgical procedures, an operation with the highest morbidity and mortality rates. A death rate of 10% is still reported frequently. Reduction of complication and mortality rate should be made by appropriate patient selection, meticulous execution of a well-chosen surgical method, and by high-quality perioperative care. Surgical experience bears a direct relationship to outcome. This review serves to discuss some of the pertinent issues that are related to immediate surgical outcome after esophagectomy.     

Aspergillus mediastinitis following orthotopic heart transplantation: case report and review of the literature

Bacterial mediastinitis after orthotopic heart transplantation (OHT) is well described in the literature. However, little information has been published on fungal mediastinitis in this population. We describe a man with Aspergillus fumigatus mediastinitis diagnosed 10 weeks after OHT. The patient was treated with voriconazole. The literature on Aspergillus mediastinitis is also reviewed.     

A tiny esophageal cancer diagnosed accurately by magnifying endoscopy and endocytoscopy: report of a case

An 82-year-old woman presented for a periodic endoscopic examination after radiotherapy and endoscopic mucosal resection (EMR) of a cancer in the esophagus. Conventional endoscopy demonstrated a tiny, flat, reddish lesion about 1 mm in diameter proximal to the scar of the previous esophageal EMR. Observation after iodine staining showed an apparent unstained area in the lesion. Magnifying observation using a Q240Z (Olympus, Tokyo, Japan) revealed a clearly demarcated aggregation of dilated intrapapillary capillary loops in this part of the lesion. Endocytoscopic observation (XEC120U prototype; Olympus) showed increased cellular density and irregularity of the epithelial nuclei. Endoscopic mucosal resection of the lesion was performed. Pathological studies of the resected specimen revealed a squamous cell carcinoma, maximal diameter 920 μm, confined to the epithelium. We believe that the Endocytoscope has the potential to reduce biopsy histology in cases of esophageal squamous cell carcinoma.     

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

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

食管结核合并结核性腹膜炎1例

食管结核是结核杆菌侵及食管壁导致的一种少见的炎性肉芽肿性病变,其发病率低,易误诊.最容易混淆的疾病是食管癌和食管平滑肌瘤.食管结核常见症状为吞咽困难,胸骨后疼痛,消瘦和发热等,这些症状与食管平滑肌瘤、食管癌比较无特异性,术前诊断较困难.尤其是食管结核合并结合性腹膜炎更是少见.本文报道1例食管结核合并结核性腹膜炎,并结合文献,就诊断及治疗进行复习.     

Nonrecurrent inferior laryngeal nerve in patients with esophageal cancer: report of two cases

The preservation of the recurrent laryngeal nerve is a fundamental skill in cervical procedure such as thyroid, parathyroid or esophagus surgery. Any damage to this nerve could lead to permanent ipsilateral vocal cord paralysis. Therefore this iatrogenic complication must be absolutely avoided by surgeons. However, surgeons rarely encounter the nonrecurrent inferior laryngeal nerve. The aim of this report is to describe this nerve anomaly and its causes based on our recent experience obtained during two esophageal operations.     

Surgical treatment of superficial esophageal cancer, its result and perspective

Background  Our objective was to review the results of surgical treatment for superficial esophageal cancer to obtain the proper indications for the recently proposed esophagus-preserving strategies. Methods  The clinicopathological data of 290 consecutive patients with superficial thoracic or abdominal esophageal cancer who underwent esophagectomy with radical lymph node dissection without preoperative adjuvant treatment from 1984 to 2005 were examined in terms of tumor depth (ep, lpm, mm, sm1, sm2, sm3) and TNM pStage. The category sm1 was subclassified into sm1(0–200): lesions with 200 μm or less vertical tumor invasion depth in the submucosal layer, and sm1(200-): deeper sm1, to make our results referable to endoscopically resected lesions. Results  About 8% of the patients with mm or deeper tumors were classified as TNM pStage IV. Around 20% of mm and sm1(0–200) tumors were associated with lymph node involvement. The 5-year survival rate of the 211sm cancers was 74.8% ± 3.3%; the mean survival time was 11.47 ± 0.68 years. The survival of TNM pStage IV patients was no worse than that of pStage IIB patients. Conclusions  Endoscopic mucosal resection/endoscopic submucosal dissection (EMR/ESD) is definitely indicated for ep or lpm lesions. Any tumors with deeper invasion including mm and sm1(0–200) should be regarded as potentially lymph node positive, and the most reliable treatment is still radical esophagectomy. Recent attempts to treat superficial esophageal cancer while preserving the esophagus should be performed with caution and with informed consent. A randomized controlled trial is necessary to compare the results of the recent esophagus-preserving strategies to the results of radical esophagectomy. Review articles on this topic also appeared in the previous issue (Volume 4 Number 3). An editorial related to this article is available at .     

Cervical cellulitis and mediastinitis following esophageal perforation：A case report

Chicken bone is one of the most frequent foreign bodies （FB） associated with upper esophageal perforation. Upper digestive tract penetrating FB may lead to life threatening complications and requires prompt management. We present the case of a 52-year-old man who sustained an upper esophageal perforation associated with cervical cellulitis and mediastinitis. Following CT-scan evidence of FB penetrating the esophagus, the impacted FB was successfully extracted under rigid esophagoscopy. Direct suture was required to close the esophageal perforation. Cervical and mediastinal drainage were made immediately. Nasogastric tube decompression, broad-spectrum intravenous antibiotics, and parenteral hyperalimentation were administered for 10 d postoperatively. An esophagogram at d 10 revealed no leak at the repair site, and oral alimentation was successfully reinstituted. Conclusion： Rigid endoscope management of FB esophageal penetration is a simple, safe and effective procedure. Primary esophageal repair with drainage of all affected compartments are necessary to avoid life-threatening complications.     

Skeletal muscle metastasis from esophageal cancer: a report of two cases and a review of the literature

Skeletal muscle metastases from carcinoma are very rare. This report describes two cases of skeletal muscle metastasis from esophageal cancer as the first distant metastasis. Case 1, a 58-year-old man with stage IVa upper thoracic esophageal squamous cell carcinoma (SqCC), underwent chemoradiotherapy (CRT) and a subtotal esophagectomy with a three-field lymph node dissection. After the operation, he complained of a painful mass in his forearm, which was diagnosed to be metastatic SqCC by a biopsy. Local radiation therapy and systemic chemotherapy were performed, but he died 7 months after the first CRT. Case 2, a 61-year-old woman with stage IVa middle thoracic SqCC, underwent CRT. ¹⁸F-Fluorodeoxyglucose positron emission tomography (FDG-PET) after the CRT showed a hot spot in the right gluteus maximus muscle, and it was diagnosed to be metastatic SqCC by a biopsy. Although additional treatment was performed, she died 6 months after the first visit. A short review of the literature concerning skeletal muscle metastasis from esophageal cancer was conducted.     

Pulmonary hypertension associated with combined fibrosing mediastinitis and bronchial anthracofibrosis: A retrospective analysis in a single Chinese hospital

Introduction

Both fibrosing mediastinitis (FM) and bronchial anthracofibrosis (BAF) are unique diseases. The combined appearance of FM and BAF is extremely rare.

Objectives

The aim of this study was to investigate the clinical features of patients with coexisting FM and BAF.

Method

Between January 2003 and December 2015, a total of eight patients were diagnosed at the Peking Union Medical College Hospital as having combined FM and BAF. The clinical presentations, radiographic features and bronchoscopic findings of the eight patients were reviewed.

Results

The patients were five women and three men with a median age of 64 years (range 56‐86 years). Symptoms included dyspnea (eight patients), cough (seven patients), chest pain (two patients), hemoptysis (two patients) and so on. Chest CT of all eight patients showed mediastinal soft‐tissue lesions, with multiple narrowed or obliterated lobar or segmental bronchi and arteries. Bronchoscopy showed that all of the patients had multiple stenoses of lobar or segmental bronchi with anthracotic pigmentation on the mucosa. Echocardiography showed that all of the patients had elevated pulmonary arterial systolic pressure (median 81 mm Hg, range 51‐107 mm Hg). Each of the eight patients had a history of exposure to, or infection with, tuberculosis, although there was no evidence of active disease. All of the eight patients had long‐term exposure to indoor coal or biomass fuel smoke.

Conclusions

FM can coexist with BAF, characterized by prominent pulmonary hypertension. The possible etiological factors are tuberculosis and coal or biomass fuel exposure.     

Gastric cancer occurring in a patient with Plummer-Vinson syndrome： A case report

Plummer-Vinson syndrome (sideropenic dysphagia) is characterized by dysphagia due to an upper esophageal or hypopharyngeal web in patients with chronic iron deficiency anemia. The main cause of dysphagia is the presence of the web in the cervical esophagus, and abnormal motility of the pharynx or esophagus is also found to play a significant role in this condition. This syndrome is thought to be precancerous because squamous cell carcinoma of hypopharynx, oral cavity or esophagus takes place in 10% of those patients suffering from this malady, but it is even more unusual that Plummer-Vinson syndrome should be accompanied by gastric cancer. We have reported here a case of a 43-year-old woman with Plummer-Vinson syndrome who developed stomach cancer and recovered after a radical total gastrectomy with D2 nodal dissection.     

Concordance of studies for nodal staging is prognostic for worse survival in esophageal cancer

Pretreatment clinical staging in esophageal cancer influences prognosis and treatment strategy. Current staging strategies utilize multiple imaging modalities, and often the results are contradictory. No studies have examined the implications of concordance of computed tomography (CT), positron emission tomography (PET), and endoscopic ultrasound (EUS) when used for the evaluation of nodal disease. The objective of this study was to determine if concordance of CT, PET, or EUS for nodal disease predicts worse overall survival. We reviewed 615 esophageal cancer patients with pretreatment CT, PET, and EUS that underwent esophagectomy for survival outcomes based on concordance of studies for nodal disease. Concordant N+ is defined as two or three studies positive for nodal disease; non‐concordant N+ is defined as only one positive study. Node‐positive disease by any study predicted shorter survival than node‐negative disease (42% vs. 73% 5‐year survival; P < 0.001). Additionally, non‐concordant N+ patients had shorter survival than N? patients (52% vs. 73% 5‐year survival; P < 0.001). Concordant N+ patients had shorter survival than non‐concordant N+ patients (38‐ vs. 61‐month median survival; P = 0.017). There were no statistically significant differences in survival based on specific combinations of studies. When PET was disregarded, patients with both CT+ and EUS+ had shorter survival than patients with either CT+ or EUS+ (39‐ vs. 58‐month median survival; P = 0.029). Pretreatment CT, PET, or EUS concordance for node‐positive disease predicts shorter overall survival in patients that undergo esophagectomy for esophageal cancer. Predicting survival in esophageal cancer should consider the synergistic capabilities of CT, PET, and EUS in evaluating nodal status.