Celiac Lymph Node Metastasis Research Articles

Solitary Celiac Lymph Node Metastasis Has a Better Long-Term Survival Compared With Solitary Mediastinal Lymph Node Metastasis in Esophagectomy of Esophageal Squamous Cell Cancer: A Propensity Score Matching Analysis.

BackgroundThe prognostic benefit of extensive lymphadenectomy remains controversial in esophageal squamous cell carcinoma (ESCC). The purpose of this retrospective study was to investigate the potential effect of solitary mediastinal (SM) lymph node metastasis and solitary celiac (SC) lymph node metastasis on the short- and long-term outcomes for patients who underwent minimally invasive McKeown esophagectomy.MethodsFrom September 2009 to December 2020, a total of 934 cases were diagnosed with ESCC and underwent minimally invasive McKeown esophagectomy in our department; 223 cases met the inclusion and exclusion criteria. Propensity score matching (PSM) was utilized to contrast the postoperative results and long-term survival of Group 1 (SM) and Group 2 (SC). Univariate and multivariate Cox proportional hazards regression analyses were used on possible predictors of survival.ResultsOne hundred forty-seven patients were available for outcome comparison after PSM. The postoperative results were not significantly different between the two groups. In terms of long-term survival, the 5-year disease-free survival (DFS) was 37.6% and 57.3% (p = 0.191) and 5-year disease-specific survival (DSS) was 39.7% and 68.4% (p = 0.028) for Group 1 (SM) and Group 2 (SC), respectively. Univariate and multivariate Cox proportional hazards regression analyses showed that body mass index (BMI), pathologic stage (pStage), and SC/SM grouping had significant hazard ratios (HRs), which suggested that SC is associated with better DSS.ConclusionThis cohort study showed that SC lymph node metastasis has a better long-term survival compared with SM lymph node metastasis in esophagectomy of ESCC. The results challenge the current understanding and need confirmation in further research.

Should the clinical significance of supraclavicular and celiac lymph node metastasis in thoracic esophageal cancer be reevaluated?

BackgroundLower thoracic esophageal cancer (LTEC) with celiac node metastasis and upper thoracic esophageal cancer (UTEC) with supraclavicular node metastasis were previously categorized as M1a diseases. Our study aimed to investigate whether the clinical significance of supraclavicular and celiac lymph node metastasis should be reevaluated in thoracic esophageal cancer.MethodsA total of 6178 patients with thoracic esophageal cancer were identified from the Surveillance, Epidemiology, and End Results (SEER) database during 2004–2015. Treatment strategies and outcomes (OS, overall survival; CSS, cancer‐specific survival) of patients with different nodal status were reviewed. The Cox proportional hazards regression model was applied to evaluate the prognostic factors. Statistical analyses were performed in all subgroups.ResultsMultivariate analysis identified supraclavicular node metastasis but not celiac node metastasis as an independent predictor of both OS and CSS in LTEC. However, metastasis to supraclavicular or celiac nodes was not an independent predictor of OS and CSS in UTEC. Surgery was not associated with increased OS and CSS for UTEC with celiac or supraclavicular node metastasis but was favored as a predictor of better OS and CSS for LTEC with celiac or supraclavicular node metastasis. Radiotherapy benefited OS and CSS in LTEC involving celiac or supraclavicular nodes and in UTEC involving celiac nodes, while only OS benefited from radiotherapy in UTEC involving supraclavicular nodes.ConclusionsThese results provide preliminary evidence that the clinical significance of supraclavicular and celiac lymph node metastasis should be reevaluated in thoracic esophageal cancer with different prognostic information according to the primary sites.

Different prognosis of patients with esophageal carcinoma with M1a and regional node involvement

Background and purposeBased on the 6th edition of the American Joint Commission on Cancer (AJCC) staging system for esophageal squamous cell carcinoma (ESCC), M1a node involvement was classified as regional node involvement in the revised 7th/8th edition. However, the clinical significance of M1a node involvement is unclear. Thus, we analyzed the prognostic value of M1a node involvement in patients with ESCC after definitive concurrent chemoradiotherapy (CCRT). Materials and methodsIn total, 188 patients with ESCC had M0 disease according to the 7th/8th edition AJCC. We reclassified 31 (16.5%) of these patients as having M1a disease according to the 6th edition. After definitive CCRT, we compared baseline characteristics between the two groups and analyzed the rates of responders and recurrence. Finally, we compared prognoses according to overall survival (OS), disease-specific OS, and disease-free survival (DFS). ResultsAmong 31 patients reclassified to have M1a disease, 21 (67.7%) had supraclavicular lymph node metastasis and 10 (32.3%) had celiac lymph node metastasis. The number of responders was significantly lower for M1a disease based on univariate (p = 0.004) and multivariate (p = 0.011) analyses. Significantly lower survival rates were observed in individuals with M1a disease (median OS, 16.4 vs. 42.7 months; 5-year OS, 10.8% vs. 41.2%). ConclusionsM1a node involvement should be differentiated from regional node involvement.

The prognostic significance of celiac lymph node metastasis in patients with locally advanced esophageal squamous cell carcinoma receiving curative concurrent chemoradiotherapy.

BackgroundTo evaluate the clinical outcomes of celiac lymph node (LN) metastasis in patients with locally advanced esophageal squamous cell carcinoma (ESCC) receiving curative concurrent chemoradiotherapy (CCRT).Materials and MethodsA total of 375 stage III ESCC patients were identified, including 51 patients with celiac LN metastasis and 324 patients without celiac LN metastasis. Among these 324 patients without celiac LN metastasis, 51 were matched with the 51 patients with celiac LN metastasis using the propensity score matching method.ResultsOverall, the celiac LN metastasis group had worse progression-free survival (PFS) and overall survival (OS) than the non-celiac LN metastasis group and the matched non-celiac LN metastasis group. For the ESCC patients with celiac LN metastasis, lower third ESCC was significantly associated with superior PFS and OS. For patients with upper/middle third ESCC, the celiac LN metastasis group had worse PFS and OS than the non-celiac LN metastasis group and the matched non-celiac LN metastasis group. For patients with lower third ESCC, there were no significant differences in PFS and OS between these groups.ConclusionsOur study suggests celiac LN metastasis is a poor prognostic factor for locally advanced ESCC patients receiving curative CCRT. Among these ESCC patients with celiac LN metastasis, tumor location is a strongly prognostic factor, indicating patients with lower third ESCC have better PFS and OS than those with upper/middle third ESCC. The 6th American Joint Committee on Cancer staging system seems more favorable than 7th edition in the definition of celiac LNs for those patients.

Effect of Extending the Original Eligibility Criteria for the CROSS Neoadjuvant Chemoradiotherapy on Toxicity and Survival in Esophageal Cancer

BackgroundPatients with curable esophageal cancer (EC) who proceed beyond the original Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) eligibility criteria are also treated with neoadjuvant chemoradiotherapy (nCRT). This study assessed the effect that extending the CROSS eligibility criteria for nCRT has on treatment-related toxicity and overall survival (OS) in EC.MethodsThe study enrolled 161 patients with locally advanced EC (T1N1-3/T2-4aN0-3/M0) treated with the CROSS schedule followed by esophagectomy. Group 1 consisted of 89 patients who met the CROSS criteria, and group 2 consisted of 72 patients who met the extended eligibility criteria, i.e. a tumor length greater than 8 cm (n = 24), more than 10% weight loss (n = 35), more than 2–4 cm extension in the stomach (n = 21), celiac lymph node metastasis (n = 13), and/or age over 75 years (n = 2). The study assessed the differences in nCRT-associated toxicity [National Cancer Institute’s Common Terminology Criteria for Adverse Events (CTCAE) grade ≥ 3] and 90-day postoperative mortality. Moreover, the prognostic value for OS was assessed with multivariate Cox regression analysis.ResultsNo difference was found in nCRT-associated toxicity (P = 0.117), postoperative complications (P = 0.783), and 90-day mortality (P = 0.492). The OS differed significantly (P = 0.004), with a median of 37.3 months [95% confidence interval (CI), 10.4–64.2 months] for group 1 and 17.2 months (95% CI 13.8–20.7 months) for group 2. Pathologic N stage (P = 0.023), pathologic T stage (P = 0.043), and group 2 (P = 0.008) were independent prognostic factors for OS.ConclusionsExtension of the CROSS study eligibility criteria for nCRT did not affect nCRT-associated toxicity, postoperative complications, and postoperative mortality, but was prognostic for OS.

Effect of extending the original eligibility criteria for the “CROSS” neoadjuvant chemoradiotherapy on toxicity and survival in esophageal cancer.

187 Background: Patients with curable esophageal cancer (EC) which proceed beyond the original CROSS eligibility criteria are also treated with neoadjuvant chemoradiotherapy (nCRT). This study assessed the effect of extending the CROSS eligibility criteria for nCRT on treatment related toxicity and overall survival (OS) in EC. Methods: Included were 161 patients with locally advanced EC (T1N1-3/T2-4aN0-3/M0), treated with the CROSS schedule followed by esophagectomy. Group 1 (N = 90) consisted of patients which met the CROSS criteria and patients in group 2 (N = 71) met the extended eligibility criteria, i.e. including a tumor length of > 8 cm (N = 23), > 10% weight loss (N = 35), > 2 – 4 cm extension in the stomach (N = 21), celiac lymph node metastasis (N = 13), and/or age > 75 years (N = 2). We assessed the differences in hematologic toxicity (≥ grade 3) and 90-day postoperative mortality. Moreover, we assessed the prognostic value on OS with multivariate Cox regression analysis. Results: No difference was found in hematologic toxicity and 90-day mortality. The OS differed significantly (P = 0.003), with a median of 37.3 (95% CI 10.56 – 64.0) and 17.2 (95% CI 13.8 – 20.6) months in group I and II, respectively. Pathological N-stage (P = 0.024), ypT-stage (P = 0.044), and group II (P = 0.006) were independent prognostic factors for OS. Conclusions: Extension of the CROSS study eligibility criteria for nCRT did not affect hematologic toxicity and postoperative mortality, but was prognostic for OS.

Supraclavicular and/or celiac lymph node metastases from thoracic esophageal squamous cell carcinoma did not compromise survival following neoadjuvant chemoradiotherapy and surgery.

This study is to evaluate the prognostic significance of supraclavicular and/or celiac lymph node (LN) metastases in locally advanced thoracic esophageal squamous cell carcinoma (ESCC) patients treated with neoadjuvant chemoradiotherapy (NACRT) and surgery. Among the total 199 patients, 75 (37.7%) had supraclavicular and/or celiac LN metastasis. Surgery was performed following NACRT in 168 patients (84.4%). After the median 18.7 (1.0-147.2) months’ follow-up, 2-year rates of progression-free survival (PFS) and overall survival (OS) in all patients were 48.1% and 65.7%, respectively. In multivariate analyses, negative surgical margin (p < 0.001), ypT0 stage (p = 0.004), and ypN0 stage (p = 0.020) were significantly favorable factors for PFS, and negative surgical margin (p < 0.001) was the only significantly favorable factor for OS. Metastasis to the supraclavicular and/or celiac LNs was significant factor neither for PFS (p = 0.311) nor OS (p = 0.515). Supraclavicular and/or celiac LN metastasis did not compromise the clinical outcomes following NACRT and surgery.

Imaging in thoracic oncology: case studies from Multidisciplinary Thoracic Tumor Board (part 2 of 2 part series)

Multidisciplinary tumor board conferences foster collaboration among health care providers from a variety of specialties and help to facilitate optimal patient care. Generally, the clinical questions revolve around the best options for establishing a diagnosis, staging the disease and directing treatment. This article describes and illustrates the clinical scenarios of three patients who were presented at our thoracic Tumor Board, focusing on management issues and the role of imaging. These patients had invasive thymoma; concurrent small cell lung cancer and non-small cell lung cancer; and esophageal cancer with celiac lymph node metastases, respectively.

Accurate Preoperative Staging of Gastric Cancer with Combined Endoscopic Ultrasonography and PET-CT

Accurate staging of gastric cancer is helpful to determine the most appropriate therapy, but no staging modality has been accepted as the standard. Objective is to evaluate the usefulness of endoscopic ultrasonograph (EUS) combined with position emission tomography and computed tomograph (PET-CT) in gastric cancer staging. A total of 124 patients confirmed with gastric cancer were subjected to staging with EUS and PET-CT scanning. The detection rate of primary tumor was 99.2% by combination use of two modalities and 97.6% by EUS alone (p = 0.6219), but the detection rate was 90.3% (112 of 124) by PET-CT alone (compared with the combination, p = 0.0027; compared with EUS alone, p = 0.0299). The locoregional lymph node invasion was identified in 84/124 (67.7%) by combined PET-CT and EUS, which was obviously higher than that with EUS (52.4%) or PET-CT (43.5%) alone (p = 0.0194 and p = 0.0002, respectively). There was no statistical difference in identification of celiac axis lymph node metastasis among three methods, but the combined examination or PET-CT alone was more effective than EUS alone in the detection of distant metastases (all p < 0.01). Furthermore, the combined EUS and PET-CT was more optimal than using EUS or PET-CT alone in the accurate T and N staging and the effect on change of treatment. The present study indicates that the combination of EUS and PET-CT is an ideal modality in the preoperative staging of gastric cancer and it provides beneficial guidance for the treatment of gastric cancer.

Retrospective Analysis of Adjuvant Intraperitoneal Chemotherapy Effect Prognosis of Resectable Gastric Cancer

Objective: This study evaluated the efficacy and safety of adjuvant intraperitoneal perfusion chemotherapy (IPC) in resectable gastric cancer through retrospective analysis. Methods: Three hundred and sixty T2–4bN0–3M0 resectable gastric cancer patients were included in this study. One hundred and eighty-four patients used systemic chemotherapy combined with IPC (IP+ group) and 176 systemic chemotherapy only (IP– group). Results: With a median of 49.9 months of follow-up, the 5-year overall survival in IP+ patients was significantly better than in IP– patients (60.4 vs. 42.9%; p = 0.001), and the average progression-free survival in IP+ patients was significantly longer than in IP– patients (60.5 vs. 46.2 months; p = 0.001). Relapse rates of peritoneal carcinomatosis, celiac lymph node and hepatic metastasis in the IP+ patients were significantly lower than in the IP– patients. Patients with curative resection, a histological type other than mucinous adenocarcinoma and signet ring cell carcinoma, low and undifferentiated tumor grade, lymph node metastasis, and T3 and T4a benefited from adjuvant IPC. The toxicities were the same except for more patients with leukopenia in the IP+ group (p = 0.001). The number of cycles of IPC and the time of IPC start after surgery had an impact on overall and disease-free survival. Conclusion: Adjuvant IPC for resectable gastric cancer gave encouraging results and large multicenter prospective randomized controlled studies are warranted.

Signet ring cell carcinoma of gallbladder with celiac lymph node metastasis in a young man

Gall bladder cancer is uncommon and histologically most of these are adenocarcinomas. Signet ring cell carcinoma is a rare malignancy of gallbladder. Only few cases of this histologic type have been published and detailed knowledge of this disease is not available. Here, signet ring cell carcinoma of the gallbladder in a 32-year-old man is being reported. The patient had metastasis in the celiac group of lymph nodes at the time of diagnosis. The patient underwent radical surgery, followed by chemotherapy but succumbed to the illness two months post-operatively. Newer treatment modalities and advanced information may improve the prognosis of the disease.

Effect of allogenic hematopoietic stem cell transplantation on tumor recurrence and metastasis of hepato-cellular carcinoma after radical hepatectomy

Objective To evaluate the effect of alIoHCT on recurrence and metastasis of HCC after hepatic radical resection. Methods Umbilical cord blood were collected after labor. The efficacy of separa-tion by 6% hydroxyethyl starch (6% HES) and NH4CL lysing solution were examined. Twenty-two SCID mice were randomized into the scheduled transplantation group (n=8), the single transplantation group (n =8) and the normal saline group (n=6). Human nucleated cells (NC)at a amount of 5×107 were transfused through the tail vein into the 2 groups of transplantation. All the mice in the 3 groups received cyclophospha-mide (CTX) as conditioning regimen before tansplantation and Methylprednisolone (MP) for 1 week continu-ously after trasplantation. Hematopoietic and immune recovery, graft versus host disease (GVHD), engraft-ment and survival rate were observed after transplantation. Six weeks after alloHST, the orthotopic tumor model in SCID mice was established by implanting histologically intact tissue under the embrane of liver. Ten days later, the mice received radical resection of lobe bearing tumor. The condition of recurrence and metas-tasis was observed 4 weeks after operation. Results A murine model of umbilical cord blood transplantation using CTX and MP as conditioning regimen could be successfully established in SCID mice. The percentage CD34+ cells of peripheral blood NC in scheduled transplantation group and single transplantation group was 1.66%±0.47% and 0.68% + 0.56%, respectively. There was significant statistical significance (P<0.01). The intrahepatic recurrence rate after operation was 100% in all the 3 groups. However, the recur-rent tumor volume was (367.18±31.86) mm3 , (648.26±155.22) mm3, (811.38±127.36) mm3, re-spectively in the 3 groups. There was marked difference among the 3 groups (P<0.01). The inhibitory rate of group A and B was 54.7% and 20.1%. The incidence of lung metastasis was 14.3 (1/7), 6.7% (4/6) and 100% (5/5), respectively in the 3 groups and there was remarkable difference (P<0.01). The inci-dence of celiac lymph node metastasis was 14.3 (1/7), 33.4% (2/6) and 40% (2/5), respectively in the 3groups and there was no significant difference (P=0.58). Conclusion AlloHSCT is a useful method for de-creasing metastasis and recurrence of liver cancer after radical resection in early stage. Key words: Carcinoma hepatocellular; Hematopoietic stem cell transplantation; Neoplasm recurrence; Neoplasm metastasis

Celiac and Perigastric Lymph Node Metastasis of Prostate Cancer Diagnosed with Endoscopic Ultrasound-Guided Fine-Needle Aspiration

Endoscopic ultrasound has been used to diagnose and stage gastrointestinal and nongastrointestinal tumours. To our knowledge, the present report describes the first case of celiac and perigastric lymph node metastasis of prostate cancer diagnosed with endoscopic ultrasound-guided fine-needle aspiration.

Detection of lymph node metastases with ultrasmall superparamagnetic iron oxide (USPIO)-enhanced magnetic resonance imaging in oesophageal cancer: a feasibility study

Aim: In this feasibility study we investigated whether magnetic resonance imaging (MRI) with ultrasmall superparamagnetic iron oxide (USPIO) can be used to identify regional and distant lymph nodes, including mediastinal and celiac lymph node metastases in patients with oesophageal cancer.Patients and methods: Ten patients with a potentially curative resectable cancer of the oesophagus were eligible for this study. All patients included in the study had positive lymph nodes on conventional staging (including endoscopic ultrasound, computed tomography and fluorodeoxyglucose-positron emission tomography). Nine patients underwent MRI + USPIO before surgery. Results were restricted to those patients who had both MRI + USPIO and histological examination. Results were compared with conventional staging and histopathologic findings.Results: One patient was excluded due to expired study time. Five out of 9 patients underwent an exploration; in 1 patient prior to surgery MRI + USPIO diagnosed liver metastases and in 3 patients an oesophageal resection was performed. USPIO uptake in mediastinal lymph nodes was seen in 6 out of 9 patients; in 3 patients non-malignant nodes were not visible. In total, 9 lymph node stations (of 6 patients) were separately analysed; 7 lymph node stations were assessed as positive (N1) on MRI+USPIO compared with 9 by conventional staging. According to histology findings, there was one false-positive and one false-negative result in MRI + USPIO. Also, conventional staging modalities had one false-positive and one false-negative result. MRI + USPIO had surplus value in one patient. Not all lymph node stations could be compared due to unforeseen explorations. No adverse effects occurred after USPIO infusion.Conclusion: MRI+USPIO identified the majority of mediastinal and celiac (suspect) lymph nodes in 9 patients with oesophageal cancer. MRI+USPIO could have an additional value in loco-regional staging; however, more supplementary research is needed.

Accuracy of Endoscopic Ultrasound in the Diagnosis of Distal and Celiac Axis Lymph Node Metastasis in Esophageal Cancer: A Meta-Analysis and Systematic Review

Published data on the accuracy of endoscopic ultrasound (EUS) for staging distant and celiac axis lymph node (CLN) metastasis in patients with esophageal cancer (ECA) has varied. To evaluate the accuracy of EUS in diagnosing distal and CLN metastasis in ECA patients. EUS studies confirmed by surgery were selected. Pooling was conducted by both fixed and random-effects models. Data were extracted from 25 studies (N = 2029) which met the inclusion criteria. In ECA patients, pooled sensitivity of EUS was 67.2% (95% CI: 62.6-71.6) in diagnosis of distal metastasis and 66.6% (95% CI: 61.9-71.1) in diagnosis of CLN metastasis. EUS had a pooled specificity of 97.9% (95% CI: 97.1-98.6) for distal metastasis and 98.1% (95% CI: 97.3-98.7) for CLN metastasis. Although EUS has excellent specificity in accurately diagnosing distal and CLN metastasis in patients with ECA, the sensitivity is low.

Is There Improvement over Years in the Diagnostic Accuracy of Endoscopic Ultrasound in Evaluating Celiac Axis Lymph Nodes Metastasis in Esophageal Cancers? A Meta-Analysis & Systematic Review

Purpose: To evaluate if technology over years affected the diagnostic accuracy of Endoscopic Ultrasound (EUS) in evaluating celiac axis lymph node (CLN) metastasis in esophageal cancers. This analysis was done by grouping EUS studies into three time periods to standardize the change in EUS technology and also to standardize the change in EUS criteria for lymph node involvement. These time periods were 1989 to 1995, 1996 to 1999, and 2000 to 2006. Methods: Study Selection Criteria: Only EUS studies confirmed by surgery or appropriate prolonged follow-up were selected. Data collection & extraction: Articles were searched in Medline, Pubmed, Ovid journals, CINAH, Medline nonindexed citations, and Cochrane control trial registry. Statistical Method: Meta-analysis for the accuracy of EUS was found by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. Pooling of likelihood ratios and diagnostic odds ratios was conducted by the fixed and random effects models. The heterogeneity of was tested using Cochran's Q test based upon inverse variance weights. Results: Initial search identified 3980 reference articles, of these, 362 relevant articles were selected and reviewed. Data was extracted from 23 studies (N = 1966) which met the inclusion criteria. There were 8 studies for the time period 1989 to 1995. During the time period of 1996 to 1999, there were 10 studies that met the inclusion criteria. Five studies met the inclusion criteria for the time period between 2000 to 2006. All the pooled estimates during the three time periods are given in table 1. The P for chi-squared heterogeneity for all the pooled accuracy estimates was >0.05. Conclusion: EUS-FNA is highly specific in diagnosing celiac axis lymph nodes metastasis in esophageal cancers. Over years, the specificity remained very high, while the sensitivity did not improve.[figure1]Figure

ENDOSONOGRAPHY OF OBSTRUCTIVE ESOPHAGEAL CANCER

Purpose: Endoscopic ultrasound (EUS) is the most accurate method for T-and N-staging of primary esophageal tumors. Malignant esophageal strictures may hinder passage of the echoendoscope during EUS staging which will require stricture dilation. We determined how complete EUS staging after esophageal stricture balloon dilatation impacted the management of esophageal carcinoma in terms of resectability and neoadjuvant therapy. A secondary aim was to provide safety data of esophageal balloon dilation of malignant strictures. Methods: We reviewed 137 consecutive procedures from a 6 year period (4/1/98-3/19/04) who were referred for staging EUS for esophageal carcinoma. We recorded the percentage of patients requiring esophageal malignant stricture dilation prior to EUS, size of balloon dilatation required, and complications. Tumor characteristics recorded included tumor/stricture length, TNM staging by EUS and record of any change in management (T4 or M1) after complete staging. All patients dilated underwent through-the-scope balloon dilation. Results: Among 137 consecutive EGD/EUS examinations, 41 (30%) patients required dilation for symptomatic dysphagia and to advance the echoendoscope beyond the stricture. All patients were dilated to >12 mm, with maximum diameter of 20 mm, and an average dilation increment of 5.4 mm. Average tumor/stricture length requiring dilation was 4.9 cm. No complications requiring hospitalization occurred as a direct result of any of the dilations performed. Tumor staging by EUS after dilation was T1 (2.4%), T2 (7.3%), T3 (61.0%), and T4 (29.3%). Nodal staging was N0 (4.9%), N1 (87.8%), and N2 (7.3%). 19.5% of patients had evidence of M1 disease with liver metastasis, celiac node metastasis, or invasion into local vasculature. 16 patients (39.0%) were found to be unresectable (T4 or M1), which had not previously been identified, thereby changing management. Conclusions: Staging is essential in management of esophageal carcinoma and can change treatment outcome if complete EUS staging is performed. More than 1/3 of patients had a change in management by discovering T4 or M1 disease, which would not have been identified if stricture dilation had not been performed. Although the traditional “rule of three” was not employed, gradual, serial dilatation using through-the-scope esophageal balloon dilators to at least 12 mm to allow the echoendoscope to pass though malignant strictures is safe and effective, prior to TNM staging by EUS.

Right gastroepiploic artery occlusion test for resection of recurrent lesion after esophageal reconstruction using a gastric tube

Background Blood supply to a reconstructed gastric tube after esophagectomy is mainly through the right gastroepiploic artery (RGEA); therefore, a recurrent lesion involving the RGEA is thought to be unresectable, or if possible, resectable combined with a whole gastric tube. Methods We developed a new method of right gastroepiploic artery occlusion test for evaluation of the blood circulation of a reconstructed gastric tube in a patient who has a recurrent lesion involving the RGEA. A balloon occlusion catheter is inserted into the RGEA through the celiac trunk through a 7 Fr angiographic catheter, and the balloon is inflated. Celiac angiography and color Doppler endoscopic ultrasonography can evaluate intragastric blood flow from the right gastric artery during occlusion of the RGEA. Results We present a case of successful resection of celiac lymph node metastasis invading the RGEA and the celiac trunk after esophageal reconstruction using a gastric tube. Conclusions When ligation of the right gastroepiploic artery is needed, the test is safe and simple to perform; and findings can be reliably evaluated by angiography and color Doppler endoscopic ultrasonography.

Recurrence pattern of squamous cell carcinoma of the thoracic esophagus after extended radical esophagectomy with three-field lymphadenectomy.

Extended radical esophagectomy with three-field lymphadenectomy for patients with thoracic esophageal cancer has been shown to be effective. But even if this operation is performed, some patients still experience relapse of the disease. The purpose of this study was to clarify the pattern and timing of recurrence after extended radical esophagectomy. Recurrence of esophageal squamous cell carcinoma was examined in 171 of 174 patients who underwent extended radical esophagectomy with three-field lymphadenectomy. Recurrence patterns were classified as locoregional (at the site of the primary tumor, the anastomotic site, or the lymph nodes), hematogenous, and other (pleura or site of gastrostomy). Factors associated with recurrence were identified using univariate and multivariate statistical methods for survival analysis. The overall 5-year survival rate was 55.6%. Recurrence was recognized in 74 patients (43.3%). The median disease-free interval until recurrence was 11 months. Thirty patients (17.5%) developed a locoregional recurrence, and 24 (14.0%) developed a hematogenous recurrence. Five patients (2.9%) developed both recurrences simultaneously and were classified as hematogenous recurrences. Of 30 patients with cervical lymph node metastasis, recurrent disease was recognized in 19 patients (63.3%). In multivariate analysis of 160 patients, the depth of invasion and pM-lym (cervical or celiac lymph node metastasis) were significant factors for locoregional recurrence; the depth of invasion and number of lymph node metastases at operation were significant factors for hematogenous recurrence. Survival time for patients with hematogenous recurrence (median 16 months) was significantly shorter than that of patients with locoregional recurrence (median 25.5 months). Locoregional recurrence is associated mainly with the extent of the local tumor and lymph node metastasis; hematogenous recurrence is not only associated with tumor stage but also with the tumor's oncologic behavior.

Intraoperative Hepatic Lymphatic Mapping in Patients with Liver Metastases from Colorectal Carcinoma

The survival of patients undergoing liver resection for colorectal metastases is poor in the presence of extrahepatic disease. Therefore identification of periportal and celiac lymph node metastases is central to proper patient selection. In this study we examined the technique of intraoperative hepatic lymphatic mapping with isosulfan blue dye in humans. Intrahepatic dye injection was performed in patients undergoing surgical exploration for colorectal liver metastases. The location of all blue-stained lymphatics and lymph nodes was recorded. All stained and unstained lymph nodes were biopsied for pathologic examination. Thirteen intraoperative lymphatic mapping procedures were performed in 11 patients. A blue-stained lymphatic was visualized in 11 of 13 injections (85%). A blue lymph node was visualized in seven of 13 injections (54%). Three of the seven blue nodes (43%) were not detected by the surgeon before the mapping procedure. There were no complications associated with the intrahepatic dye injections. All biopsied lymph nodes were negative for metastatic tumor. We conclude that intraoperative hepatic lymphatic mapping with isosulfan blue dye is a simple, rapid, and safe technique in humans. It may serve as an adjunct to random lymph node biopsy for the identification of periportal and celiac nodal metastases before liver resection in patients with metastatic colorectal carcinoma.