High rate of lymph-node metastasis in submucosal esophageal squamous-cell carcinomas and adenocarcinomas

BACKGROUND AND STUDY AIMS: The application of endoscopic mucosectomy in early esophageal cancer is limited by the presence of lymph-node metastasis. The aim of this prospective study was to analyze the rate of lymph-node involvement relative to the depth of mucosal or submucosal tumor penetration, comparing squamous-cell carcinomas and adenocarcinomas. PATIENTS AND METHODS: A total of 60 patients with pT1 esophageal cancer--24 with squamous-cell carcinomas (SCCs) and 36 with adenocarcinomas--were treated with transthoracic en-bloc esophagectomy with two-field lymphadenectomy (n = 50) or transhiatal esophageal resection (n = 10). An average of 30 lymph nodes were examined, and the following characteristics were evaluated: histology, mucosal infiltration, depth of submucosal wall infiltration in three thirds (sm1, sm2, sm3), grading, resection category, ratio of metastatic to resected lymph nodes, and locations of metastatic nodes. RESULTS: The rates of lymph-node metastasis were 0% for the 16 mucosal carcinomas and 45% for the 44 submucosal carcinomas (P < 0.01). There were no significant differences in the extent of lymph-node involvement between submucosal adenocarcinomas (41%) and submucosal SCCs (50%). Sm1 carcinomas were associated with a lower rate of lymph-node metastasis (SCCs 33%, adenocarcinomas 22%) than sm3 carcinomas (SCCs 69%, adenocarcinomas 78%). Two patients (9%) with submucosal SCCs and five patients (23%) with submucosal adenocarcinomas were classified as having stage pM1 lymph. The average lymph-node ratio in patients with pN1 was 0.13 for adenocarcinomas and 0.1 for SCCs (difference not significant). In the multivariate analysis, the parameters mucosal vs. submucosal (P < 0.01) and G1/G2 vs. G3 (P < 0.05) showed a significant impact in relation to metastatic lymph nodes. CONCLUSIONS: The most important factor for predicting lymph-node metastasis in early esophageal cancer is the presence of submucosal infiltration. Early adenocarcinomas and SCCs do not differ with regard to their rate of lymphatic involvement. The rate of lymph-node metastasis increases with the depth of submucosal infiltration, but metastases can already occur in sm1 lesions. Submucosal infiltration is a contraindication for endoscopic mucosectomy. Limited surgical procedures without adequate lymphadenectomy do not appear to be appropriate in the treatment of patients with submucosal esophageal carcinomas.     

Endoscopic mucosal resection for squamous premalignant and early malignant lesions of the esophagus

BACK AND STUDY AIMS: Endoscopic mucosal resection (EMR) is used to treat premalignant and malignant digestive tract lesions. This report presents the efficacy and safety of EMR for squamous superficial neoplastic esophageal lesions. PATIENTS AND METHODS: A retrospective cohort study presented data from 51 patients with 54 lesions over an 8-year period, between November 1997 and September 2005. Dysplasas or mucosal (m) T1 carcinomas were treated with repeated EMR until there was a complete local remission. Patients with submucosal (sm) T1 carcinomas were treated with repeated EMR until there was a complete local remission. Patients with submucosal (sm) T1 carcinomas or more advanced stage were offered surgery or chemoradiotherapy. RESULTS: There was no mortality, perforation, or major hemorrhage, and there were three easily dilated stenoses. Of the patients, 16 had lesions graded as T1sm or more advanced and one patient was found to have normal tissue post EMR. Complete local remission was achieved in 31 of the 34 patients with dysplasia or T1 m cancers (91%). There was no distant relapse and there was local disease recurrence in eight of the 31 patients (26%). The 5-year survival rate was 95%. CONCLUSIONS: EMR for squamous superficial neoplastic lesions of the esophagus is safe and provides satisfactory survival results.     

Magnifying endoscopy, stereoscopic microscopy, and the microvascular architecture of superficial esophageal carcinoma

BACKGROUND AND STUDY AIMS: In this study we clarify the microvascular architecture of superficial esophageal carcinoma as observed by ultra-high magnification endoscopy and stereoscopic microscopy with Microfil injection. PATIENTS AND METHODS: We observed two surgically resected specimens of superficial esophageal cancer under stereoscopic microscopy with Microfil injection. In addition, in the histological investigation, we measured the caliber of the vessels at the surface of the tumor. We carried out ultra-high magnification before treatment in 82 patients with superficial esophageal neoplasms. We classified the depth of tumor penetration of superficial esophageal carcinoma into four categories: m1 to m3 (mucosal cancer) and sm (submucosal cancer). RESULTS: By observing the normal esophageal mucosa under a stereoscopic microscope and an ultra-high magnification endoscope, we were able to visualize the intrapapillary capillary loops (IPCL). In cancer lesions, we observed characteristic changes in the superficial microvascular architecture according to the depth of tumor invasion. In m1 invasion, there was dilatation of the IPCL; in m2 invasion, there was dilatation and elongation of the IPCL; in m3, there was a mixed appearance of the IPCL and tumor vessels; and in sm invasion, complete replacement by tumor vessels. On the basis of the above criteria, ultra-high magnification endoscopic observation before treatment showed a rate of agreement between histological depth of invasion and magnified appearance of 60/72 cases (83.3 %) for which satisfactory pictures were obtained. The histological investigation showed the caliber of the IPCL of the m1 cancer lesions (12.9 +/- 3.9 microm) to be significantly greater than that of the normal esophageal mucosa (6.9 +/- 1.5 microm) (P < 0.0001). CONCLUSIONS: Observation of the microvascular architecture of superficial esophageal carcinoma is useful in the diagnosis of the depth of invasion.     

Clinical pathological analysis of surgically resected superficial esophageal carcinoma to determine criteria for deciding on treatment strategy

We performed a clinical pathological study of conventionally resected superficial esophageal carcinomas since this type of lesion has been increasing, in order to develop criteria of determination for therapeutic strategies. Pathological studies were performed on specimens obtained by radical surgical resection in 133 cases of superficial esophageal cancer. Evaluation was performed in terms of the gross classification of the lesion type, depth of invasion, lymph node metastasis, vascular invasion, size of the lesion, outcome, etc. In 0-I, 0-IIc+0-IIa, and 0-III type submucosal cancer lesions the rate of metastasis to lymph nodes was more than 40%, but in 0-IIa and 0-IIb mucosal cancer cases no lymph node metastasis was observed. 0-IIc type lesions showed a wide range of invasiveness, ranging from m1 to sm3. In cases with m1 or m2 invasion, no lymph node or lymph-vessel invasion was recognized, but in m3, sm1, sm2, and sm3 cases lymph node metastasis was recognized in 12.5%, 22.2%, 44.0% and 47.4%, respectively. In 47% of lesions with a greatest dimension of less than 30 mm invasion was limited to the mucosa. Seventy-two percent of m1 and m2 cases were 30 mm in size or less. Lymph node metastasis was recognized in only 16.7% of cases less than 30 mm in size, but in cases of lesions 30 mm or more the rate of lymph node metastasis was 35.8%. 0-IIb and 0-IIa type lesions are indications for endoscopic esophageal mucosal resection (EEMR), while 0-I, 0-IIc+0-IIa, and 0-III lesions should be candidates for radical surgical resection. In the 0-IIc category, lesions in which the depression is relatively flat and with a finely granular surface are indications for EEMR, but those cases in which the surface of depression shows granules of varying sizes should be treated with radical surgical resection. Cases of 0-IIa type 30 mm or larger in greatest dimension which have a gently sloping protruding margin shoulder or reddening should be treated with caution, but EEMR can be performed first and subsequent therapeutic strategy decided on, based on the pathological findings of the specimen.     

Multimodality treatments for nodal relapse after endoscopic mucosal resection of a superficial esophageal squamous cell carcinoma

Patients with esophageal intraepithelial carcinoma (m1) and carcinoma invading the lamina propria (m2) are generally considered good candidates for endoscopic mucosal resection (EMR) in Japan, as hardly any of them show lymph node metastasis. Although a few cases of esophageal carcinoma invading the lamina propria have been reported to show nodal involvement, lymph node metastasis and subsequent death due to carcinoma after EMR of m1 or m2 esophageal carcinoma has never been reported in the English literature. Here we describe a patient who suffered relapse of lymph node metastasis after EMR of an esophageal carcinoma invading the lamina propria without any of the reported risk factors associated with lymph node metastasis, including vascular invasion. Unfortunately, the patient died due to disease recurrence, despite receiving multimodality treatments including chemoradiotherapy and salvage surgery.     

Lifting of lesions during endoscopic mucosal resection (EMR) of early colorectal cancer: implications for the assessment of resectability

BACKGROUND AND STUDY AIMS: This study assessed the indications for and limitations of endoscopic mucosal resection (EMR) for early colorectal cancer, focusing on the way in which the lesion lifts after submucosal injection. PATIENTS AND METHODS: The study included 94 patients with early colorectal cancer who received EMR treatment. The lifting of the lesion after submucosal injection was analyzed (classified as completely lifted/soft; completely lifted/hard; incompletely lifted; and non-lifted) along with the endoscopic findings, pathological findings, and clinical course. RESULTS: Almost all completely lifted/soft lesions were mucosal cancers. Some of the completely lifted/hard lesions were staged as sm2. The incompletely lifted lesions included stages sm1 to sm3. Non-lifting lesions were almost always deeper than sm3. The lifting condition was significantly associated with the depth of invasion, and the lesion type was related to the extent of lifting but not to tumor size or recurrent disease. Recurrent disease was noted in three patients who underwent piecemeal EMR. CONCLUSIONS: The indication for EMR is easily assessed on the basis of the lifting characteristics of the tumor after submucosal injection, which was found to be significantly related to the depth of invasion. The factor limiting the indication for EMR is not the size of a tumor, but its lifting condition.     

食管早癌内镜下黏膜剥离术后追加手术及放疗的握判

目的初步探讨食管早癌内镜下黏膜剥离术(ESD)后追加手术及放疗的评判依据。方法回顾性分析2009年7月-2015年10月,该院消化科112例行ESD治疗的食管早癌患者临床资料、术后病理结果及术后随访结果。结果随访期内共有7例患者进一步治疗,其中追加食管癌根治手术3例;贲门癌根治术1例,术后淋巴结阳性再次追加化疗;追加ESD术1例;放疗2例。7例患者肿瘤浸润至上皮内层(m1)和黏膜下层上1/3(sm1)各3例,浸润至黏膜肌层(m3)者1例。1例患者病理提示脉管内转移,随访13个月胃镜检查局部无复发,但CT提示腹腔淋巴结转移,随访16个月后死亡。另有1例浸润深度达m1的高级别上皮内瘤变(HGIN)患者,垂直及水平切缘均为阴性,随访7个月局部无复发,但CT提示肝及腹膜后淋巴结转移。结论术前准确判断癌灶浸润深度及有无淋巴结转移是决定患者治疗方式的重要依据;术后评估病灶是否达到了治愈性切除,随访有无局部复发及淋巴结、远处转移则决定是否需要追加手术及放疗。     

Indication for endoscopic resection of submucosal colorectal carcinoma: special reference to lymph node metastasis

We investigated the relationship between histological factors and lymph node metastasis in 77 lesions with submucosally invasive colorectal carcinomas to establish useful criteria for lesions in which endoscopic treatment alone results in cure of malignancy. There were positive correlations between histological factors, including the level of invasion, the histologic grade, presence or absence of lymphatic invasion, presence or absence of budding, and lymph node metastasis (p < 0.05, p < 0.05, p < 0.005, p < 0.01). The presence or absence of venous invasion did not influence lymph node metastasis. Laparoscopic surgery involving lymph node dissection should be indicated for sm1 carcinoma lesions with unfavorable histological factors. In lesions diagnosed as sm2 or sm3 prior to resection, intestinal resection involving lymph node dissection by laparoscopic surgery should be directly performed without endoscopic resection.In treating submucosally invasive colorectal carcinomas, the level of invasion can be clinically diagnosed, consequently endoscopic resection should be initially performed when lesions are evaluated as sm1 prior to resection. When histological investigation reveals sm1 carcinoma with histologic grade I (well-differentiated) or II (moderately-differentiated), and the absence of lymphatic invasion and budding, endoscopic treatment alone is sufficient.     

Évolution favorable à long terme des patients traités par résection muqueuse endoscopique pour une dysplasie de haut grade ou un cancer épidermoïde superficiel de l’œsophage

Introduction

Endoscopic mucosal resection (EMR) is a curative treatment of early squamous cell carcinoma (SCC) of the esophagus. The objective was to evaluate the efficacy, safety, long-term outcome, and survival of EMR.

Patients and methods

Forty-four patients were treated by EMR between February 1998 and October 2005 for an early SCC of the esophagus. The technique of EMR was carried out by suction and section with cap or traction and section, or by the combination of both.

Results

Forty-four patients had endoscopic treatment with resection of 49 early SCC. They were all of T1N0 stage as found by standard endoscopic ultrasound (EUS). No major complications occurred. The median endoscopic follow-up was 44 months. A curative resection (T1m1, T1m2) was achieved in 68% of cases without recurrence. Among patients with T2 lesion (16%), 6 had a radio-chemotherapy and only 1 patient died because of the metastatic evolution of esophageal cancer. The remaining 2 left patients had a complementary esophagectomy, among whom 1 died after recurrence. Eight patients had a histologically significant risk of nodes invasion (2 m3, 3 sm1, 2 sm2, and 1 sm3), and 6 had a complementary radio-chemotherapy without recurrence in the follow-up.

Conclusion

SCC of the esophagus shown usT1N0 in EUS can be treated curatively by endoscopic mucosal resection with a high rate of resecability (98%) and an acceptable complication rate. In the subgroup of 12 patients (m3 sm1, sm2, sm3 and T2) that were treated by complementary radiochemotherapy, the 5-year overall survival was 91%.     

Early esophageal carcinoma: endoscopic ultrasonography using the sonoprobe

Background: Almost all cases of superficial esophageal carcinoma are curable by endoscopic mucosal resection (EMR), but a precise diagnosis of the depth of tumor invasion is necessary to assess the indication for EMR. Although endoscopy has a high rate of accuracy for diagnosing the depth of tumor invasion, it depends on the experience of the examiner in interpreting surface information of the lesions. Today, endoscopic ultrasonography (EUS) is one of the most powerful techniques for obtaining objective tomographic images of a tumor. The high-frequency ultrasound probe is appropriate for EUS in cases of superficial esophageal carcinoma because of its excellent near-field resolution that provides precise ultrasound images under direct control of the endoscope. Methods: We performed EUS with the Sonoprobe System in 85 cases of superficial esophageal carcinoma before treatment and evaluated the resected specimens histopathologically. We interpreted the depth of tumor invasion based on our fundamental studies of ultrasonograms taken with a 20-MHz probe. Results: The clinical usefulness of the Sonoprobe with linear and radial scanning modes is due to its capacity to differentiate between mucosal and submucosal carcinoma by means of analyses of the muscularis mucosae. Although a clear assessment of microinvasion and lymphoid hyperplasia surrounding the tumor of interest remains speculative, the diagnostic accuracy rate for 96 lesions of superficial esophageal carcinoma reached 93% in terms of differentiating between mucosal from submucosal carcinoma. Conclusion: EUS with the Sonoprobe can play an important role in the pretreatment diagnosis of superficial esophageal carcinomas.     

Risk factors for local recurrence of superficial esophageal cancer after treatment by endoscopic mucosal resection

BACKGROUND AND STUDY AIM: The aim of this study was to elucidate the risk factors for local recurrence after endoscopic mucosal resection (EMR) treatment for superficial esophageal cancer (SEC). PATIENTS AND METHODS: We performed a retrospective analysis of the clinical course of 62 patients with 64 SECs that were treated by EMR between 1993 and 2004. Follow-up examinations by chromoscopy with iodine solution and biopsy were performed 3 months, 6 months, 12 months, and then annually after EMR. Local recurrence was defined as a histologically confirmed finding of cancer cells at the site of the preceding EMR. The contributions of lesion-related and procedure-related factors to local recurrence were analyzed retrospectively. RESULTS: Local recurrence was detected in 14/64 SECs 3-36 months after EMR. Of the lesion-related factors we assessed, local recurrence was found to be more frequent in SECs with a larger diameter (P = 0.01), larger circumferential spread (P = 0.04), or deeper invasion (P = 0.04), although the last two factors failed to demonstrate statistical significance after correction for multiple testing. Piecemeal resection did not increase the risk of local recurrence (P = 0.11), but the need for adjunctive coagulation therapy was found to increase the risk of local recurrence (P = 0.06). CONCLUSIONS: Larger SECs are associated with a higher risk of local recurrence after EMR. In patients with residual lesions, coagulation therapy does not seem to be adequate as additional endoscopic treatment.     

食管癌术后淋巴结转移的CT分析

目的:探讨食管癌术后淋巴结转移的规律及影响因素。资料与方法:分析63例食管癌术后淋巴结转移CT表现及转移淋巴结分布,对手术加放、化疗与单纯手术治疗者,及术前淋巴结转移阳性与阴性患者,术后淋巴结转移时间对比并进行统计学分析。结果:食管癌术后淋巴结转移最常见于2R区、7区及2L区。手术加放、化疗与单纯手术治疗及术前有否淋巴结转移,其术后淋巴结转移时间有明显差异。结论:食管癌术后淋巴结转移受多种因素影响,若能合理的结合放、化疗,可延长食管癌术后淋巴结转移时间,提高生存率。CT是食管癌术后淋巴结转移的有效诊断方法。     

Present state and measures of Barrett's cancer in Japan

Barrett's adenocarcinoma is common esophageal cancer in western countries but very rare in Japan. We reviewed 206 cases of Barrett's cancer in Japanese literature that issued from 2000 to 2004. 80% of them were superficial cancer. There was no mucosal Barrett's cancer with lymph nodes metastasis, therefore EMR (endoscopic mucosal resection) method is an appropriate way for mucosal cancer. Barrett's cancer with submucosal invasion occur lymph nodes metastasis, so surgical operation should be applied for deeper invasion to submucosal cancer.     

Lésions transformées réséquées incomplètement et leur suivi. Comment les craindre macroscopiquement, quand faire le contrôle endoscopique au vu de l’histologie et que faire; seconde mucosectomie ou résection chirurgicale ? Cas de la nappe villeuse ou du polype sessile

In general, the choice of endoscopic therapy lies between mucosal resection and submucosal dissection. These forms of treatment must be restricted to neoplastic lesions not at the risk of lymph-node involvement and entail complete endoscopic resection in a single piece (monobloc) if: 1) the cancer is well or moderately well-differentiated; 2) there is no lymphatic or vascular spread; 3) there is no discontinuity of the invasive margin (“budding”); 4) the margin of healthy tissue is at least 1-mm wide; 5) there is no invasion beyond the mucosa or invasion remains confined within the superficial submucosa to a depth of less than 1 mm. The following observations or test results suggest the presence of deep invasion and, therefore, the possibility of lymph-node involvement: 1) the size and shape (surface contours) of the lesion; 2) appearance of the lesional epithelial pits; 3) endoscopic ultrasound, especially using high-frequency mini-probe; 4) separation after submucosal fluid injection. Mucosal resection is 1) indicated for sessile lesions (Is) with a base diameter greater than 10 mm, or with suspicion of submucosal carcinoma (Kudo class V); 2) indicated for class II flat lesions, which should, under no circumstances, be treated by polypectomy. If a part of the lesion is of Kudo type V, the goal of R0 (microscopically negative margins) mucosal resection is advisable only for colorectal lesions of less than 15-mm diameter; 3) contra-indicated for type III ulcerated lesions, where an alternative approach must be considered, except where there is comorbidity. Submucosal dissection or colorectal ESD is at present: 1) indicated where R0 resection is strictly necessary, i.e. when the lesions are suggestive of submucosal cancer or when the crypts have Kudo classification type V naked eye appearances (such features preclude the use of EMR); 2) contraindicated in the presence of a lesion which is not elevated after submucosal injection, for lesions with Kudo type V naked eye appearances over more than a 3 cm diameter and for ulcerated lesions. Such lesions should be managed by surgical resection, taking account of the patient’s fitness for surgery. However, the chances of relapse after EMR and, therefore, the requirement to carry out repeat endoscopy should be weighed against the risk of perforation and the technical difficulty of ESD (reflected in the time needed to perform the procedure).     

胸段食管癌重点清扫淋巴结的临床病理特点及预后分析

目的探讨手术重点清扫淋巴结的临床病理特点及预后,为规范化清扫提供参考。方法对515例胸段食管癌手术患者的临床资料进行分析,重点研究隆突下、食管旁、胃左动脉旁三组重点清扫淋巴结与临床病理因素间的单因素和多因素分析及预后情况。结果单因素和多因素分析显示:隆突下淋巴结转移与肿瘤长度、分化程度和浸润深度有关(P<0.05);食管旁淋巴结转移与肿瘤浸润深度有关(P<0.05);胃左动脉旁淋巴结转移与肿瘤部位、分化程度和浸润深度有关(P<0.05)。生存分析显示:在N1³患者,食管旁、胃左动脉旁淋巴结的清扫组与未清扫组相比,其1、3、5年生存率均有显著差异(P<0.05)。结论胸段食管癌应尽可能对转移率较高的食管旁和胃左动脉旁淋巴结清扫彻底。对病变侵及食管全层或病变长度>3 cm的患者应常规实施隆突下淋巴结的彻底清扫。在N13患者,食管旁、胃左动脉旁淋巴结的清扫组与未清扫组相比,其1、3、5年生存率均有显著差异(P<0.05)。结论胸段食管癌应尽可能对转移率较高的食管旁和胃左动脉旁淋巴结清扫彻底。对病变侵及食管全层或病变长度>3 cm的患者应常规实施隆突下淋巴结的彻底清扫。在N1³患者中,行食管旁、胃左动脉旁淋巴结清扫能提高患者的生存率。     

胃癌神经旁浸润的临床意义

目的 :探讨胃癌神经旁浸润 (perineural invasion,PNI)的临床意义。方法 :对 132例行胃癌根治术病例的胃癌组织的石蜡标本行苏木素 -伊红 (HE)染色。当肿瘤细胞浸润神经束或神经束膜时 ,判断为 PNI阳性 ,并进一步分析PNI与胃癌临床病理特征的关系。结果 :PNI在 5 1.5 %的病例中呈阳性。PNI与 L auren分类 (P<0 .0 1)、肿瘤大小 (P<0 .0 1)、浸润深度 (P<0 .0 0 1)、淋巴结转移 (P<0 .0 0 1)、淋巴管浸润 (P<0 .0 0 1)和 TNM分期 (P<0 .0 0 1)密切相关。但PNI与患者年龄、性别、肿瘤位置和血管浸润均无关。结论 :胃癌神经旁浸润与肿瘤的进展密切相关 ,其可能有助于判断胃癌患者的预后 ,并应在常规病理报告中列出     

D2-40用于大肠癌淋巴管形成及其与转移关系的研究

目的 探讨大肠癌淋巴管形成的临床病理意义.方法 应用新型特异淋巴管标记物D2-40检测96例大肠癌中心区、周边区及相应正常组织中的淋巴管密度(LVD),并结合临床病理参数进行分析.结果 大肠癌中心区LVD(14.5±2.4)个/高倍镜明显高于周边区(6.7±1.2)个/高倍镜及正常组织(5.9±1.1)个/高倍镜(P均<0.01),周边区LVD高于正常组织(P<0.01).周边区LVD与浸润深度和肝转移密切相关(r=0.71,0.78,P均<0.05),而与肿瘤大小、大体类型及淋巴结转移无关(P均>0.05).中心区LVD与肿瘤大小、大体类型、浸润深度、淋巴结转移及肝转移无关(P均>0.05).结论大肠癌周边区淋巴管形成是判断其肝转移和不良预后的依据.     

影响早期胃癌患者淋巴结转移的相关临床病理因素分析

目的探讨早期胃癌发生转移的规律,为选择合适的治疗方案提供思路。方法收集2006年1月-2012年12月间安康市中心医院收治并确诊的早期胃癌患者118例,对8个可能与早期胃癌淋巴结转移发生有关的因素进行单因素和多因素logistic回归分析。结果有无溃疡、肿瘤大小、浸润深度及有无淋巴管浸润4个因素淋巴结转移率分别比较具有统计学意义（P〈0．05）;进一步多因素logistic回归分析显示,影响淋巴结转移的独立危险因素包括有溃疡、肿瘤大小≥3cm、浸润深度至黏膜下层、有淋巴管浸润（OR值分别为2．872、2．351、3．461、1．784,均P〈0．05）。结论早期胃癌发生淋巴结转移与多因素有关,建议术前严格筛查,排除各危险因素并选择合理的治疗方案。     

Preoperative evaluation of submucosal invasive colorectal cancer using a 15-MHz ultrasound miniprobe

BACKGROUND AND STUDY AIMS: Recently, it was reported that focal submucosal invasive colorectal cancer could be treated by polypectomy or endoscopic mucosal resection (EMR) because of the rarity of lymph-node metastasis. Our objective was to examine the accuracy and efficacy of a 15-MHz ultrasound miniprobe in the preoperative evaluation of the degree of submucosal invasion in colorectal cancer. PATIENTS AND METHODS: A total of 35 patients with submucosal invasive colorectal cancer who underwent ultrasonography with a miniprobe were studied prospectively. The results of this imaging were compared with the histologic findings in resected specimens. RESULTS: Although the accuracy of the miniprobe in categorizing submucosal invasion into three subclasses (SM1, invasion limited to the upper third; SM2, limited to the middle third; SM3, limited to the lower third) was low (37.1%; 13/35), the accuracy in differentiation between < or = SMI (M and SMI) and > or = SM2 (SM2, SM3, MP, and S) was 85.7 % (30/35). CONCLUSIONS: The miniprobe can be useful for therapeutic decision-making in submucosal invasive colorectal cancer.     

Advances in para-aortic nodal dissection in gastric cancer surgery: A review of research progress over the last decade

Approximately 17%-40% of para-aortic lymph node (PAN) metastasis occurs in patients with advanced gastric cancer. As the third tier of lymphatic drainage of the stomach and the final station in front of the systemic circulation, PAN infiltration is defined as distant metastasis and plays a key role in the evaluation of the prognosis of advanced gastric cancer. Many clinical factors including tumor size ≥ 5 cm, pT3 or pT4 depth of tumor invasion, pN2 and pN3 stages, the macroscopic type of Borrmann III/IV, and the diffuse/mixed Lauren classification are indicators of PAN metastasis. Whether PAN dissection (PAND) should be performed on patients with or without the macroscopic PAN invasion remains unascertained, regardless of the numerous retrospective comparative studies reported on the improved prognosis over D2 alone. Another paradoxical result from many other studies showed no significant difference in the overall survival between these two lymphadenectomies. A phase II trial launched by the Japan Clinical Oncology Group indicated that two or three courses of S-1 and cisplatin preoperatively followed by radical surgery with D2 + PAND and postoperative S-1 is the current standard strategy for the treatment of patients with extensive lymph node metastasis, and this regimen could be substituted by a promising strategy with effective combination chemotherapy or suitable chemotherapy duration. This review focuses on the advances in radical gastrectomy plus PAND with or without chemotherapy for patients with advanced gastric cancer.