Subtotal Esophagectomy Research Articles

小細胞癌成分を含む食道癌肉腫の１切除例

We experienced a case of esophageal carcinosarcoma with a component of small cell carcinoma. The patient was a 73-year-old man. We administered chemotherapy of CDDP+VP-16, and performed an operation after 2 courses of this chemotherapy. Subtotal esophagectomy and reconstruction with the small intestine was performed. More than three years after resection, he remains alive and recurrence-free. There are few cases of esophageal carcinosarcoma and small cell carcinoma. We report this rare case herein.

Neck Dissection for Thoracic Esophageal Squamous Cell Carcinoma

Subtotal esophagectomy with extended lymph node dissection is a standard procedure for thoracic esophageal squamous cell carcinoma. Three-field lymphadenectomy, including neck dissection, is a standard type of lymph node dissection for complete clearance of tumor cells. Based on various series of analyses for lymph node metastases, the appropriate indication for neck dissection has been clarified. Herein, we describe the established techniques of neck dissection and review recent topics of three-field lymph node dissection for thoracic esophageal squamous cell carcinoma.

A case of esophageal cancer with mesojejunal lymph node metastasis after total gastrectomy

A 56-year-old man was diagnosed with esophageal cancer by upper gastrointestinal endoscopy for examination of dysphagia. The patient had undergone total gastrectomy and jejunal interposition 4 years previously for a gastric cancer at the pT1N0M0 stage according to the UICC-TNM classification. Enhanced CT findings revealed a 3-cm-diameter mass located near the superior mesenteric artery. We conducted subtotal esophagectomy associated with partial jejunectomy including mesojejunectomy. The mass was histologically diagnosed to be mesojejunal lymph node metastasis from esophageal cancer. Mesojejunal lymph node metastasis from esophageal cancer developing after total gastrectomy has been reported in only three cases including ours. The present lymph node metastases may have occurred via the newly developed lymphatic drainage route through the esophagojejunostomy, and this metastatic lymph node can be considered the regional lymph node. Therefore, resection of the interposed jejunal limb with mesojejunectomy may be rational in surgery on esophageal cancer developing after total gastrectomy.

Granulocyte colony-stimulating factor and IL-6 producing carcinosarcoma of the esophagus manifesting as leukocytosis and pyrexia: a case report

Some patients with nonhematopoietic tumors show leukocytosis and pyrexia without overt inflammation. This report describes the case of a 47-year-old Japanese man who complained of persistent fever. Hematological examination showed marked leukocytosis with neutrophilia and elevation of C-reactive protein (CRP). Esophagogastroduodenoscopy demonstrated a polypoid tumor (5 cm in length) in the thoracic esophagus, which was suggested to cause high fever. After subtotal esophagectomy, leukocyte count and CRP level rapidly decreased and the high fever disappeared. Histological examination revealed a carcinosarcoma with four components: squamous cell carcinoma (SCC), basaloid carcinoma, spindle/pleomorphic cell sarcoma, and osteosarcoma. Immunohistochemically, the spindle/pleomorphic cells were positive for granulocyte colony-stimulating factor (G-CSF) and interleukin-6 (IL-6). The patient was alive without recurrence 16 months after surgery.

A rare case of esophageal cancer (T2N0) with a solitary cerebellar metastasis.

A 72-year-old man with a history of distal gastrectomy was diagnosed with esophageal cancer (EC). A subtotal esophagectomy and the residual total gastrectomy were performed via a right-sided thoracotomy and laparotomy with D2 lymph node dissection followed by reconstruction with a retrosternal right colonic interposition. The pathological diagnosis was Mt, 65mm, moderately differentiated squamous cell carcinoma, pT2, ly0, v2, pN0, sM0, pStage II. The patient suddenly developed neurological symptoms 10days after the operation, and brain magnetic resonance imaging detected a single solid left cerebellar tumor. This tumor was completely excised, and pathological diagnosis confirmed the tumor as an EC metastasis. He received adjuvant chemotherapy with cisplatin+5-fluorouracil. Seven months later, he developed multiple brain metastases; however, no evidence of local recurrence or other metastatic sites was found. He died 8months after the surgery. Solitary cerebellar metastasis from EC in which the primary tumor is T2N0 is rare, and the mechanism of this metastatic pattern is of particular interest. Our case study suggests that even if the primary tumor is in the limited stage and other metastatic sites are not identified at presentation, it seems reasonable to perform preoperative imaging of the brain for all patients with EC.

Lymphadenectomy via a cervical approach for upper mediastinal lymph node recurrence of esophageal cancer: Report of a case

Although there have been several reports about salvage esophagectomy after definitive chemoradiotherapy (CRT), the effectiveness of lymphadenectomy for lymph node recurrence after CRT has not been fully evaluated. Radiation-induced tissue injury and fibrosis make lymphadenectomy after CRT difficult, therefore the choice of surgical approach should be considered carefully. We performed lymphadenectomy via a cervical approach in a 76-year-old man with upper mediastinal lymph node recurrence. He had previously undergone subtotal esophagectomy for squamous cell carcinoma of the upper thoracic esophagus. At 33 months after the operation, left upper mediastinal lymph node recurrence occurred. After localized CRT with docetaxel plus 60 Gy radiation, the tumor disappeared. However, at 1 year after CRT a lymph node recurrence, measuring 10 mm in size, was found in the same position on a computed tomography (CT) scan and (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) without other recurrences. Lymphadenectomy was performed via a left cervical approach using a Kent retractor to extend the surgical view of the cervicothoracic region. The patient was discharged without complications, and a postoperative CT scan and FDG-PET revealed complete resection of the tumor. In conclusion, our surgical procedure provides a good surgical view, and decreases surgical stress and the incidence of postoperative complications.

Successful Therapy of Brachiocephalic Arteriogastric Fistula After Esophagectomy

We report the case of an 86-year-old man, who had undergone subtotal esophagectomy and reconstruction with a gastric tube through the retrosternal route 7 years ago, who was referred for treatment of a brachiocephalic arteriogastric fistula. An emergency stent-graft placement was performed to prevent massive bleeding from the fistula. After 2 weeks, a follow-up esophagogastroscopy revealed that the gastric tube ulcer had been penetrated, and the stent graft was exposed. Therefore, surgical treatment was indicated. After a carotid-carotid arterial bypass graft was made, the brachiocephalic artery was resected with the stent graft and the gastric wall. The defect between the cervical esophagus and the remnant gastric tube was replaced by a free jejunal graft. The patient tolerated these procedures well and was transferred to the referral hospital 3 months after surgery. Therefore, both an early diagnosis and the administration of multidisciplinary treatment are essential to save patients presenting with an arterioenteric fistula.

Outcomes of endoscopic and surgical resection for a second primary cancer in the residual cervical esophagus after thoracic esophagectomy

Patients who have received subtotal esophagectomy for thoracic esophageal cancer must be closely monitored for second primary malignancies. The purpose of this study is to review and assess patients who developed a second primary esophageal cancer in the residual cervical esophagus. Between 1996 and 2010, 10 patients were diagnosed in our hospital with esophageal squamous cell cancer in the residual cervical esophagus after undergoing thoracic esophagectomy and were treated with endoscopic or surgical resection. Data from these patients were reviewed retrospectively. Seven of the 10 patients (70%) had multiple primary carcinoma lesions at the time of their esophagectomy. A second primary cancer in the residual cervical esophagus was detected in eight patients during follow-up endoscopic examinations while the patients were still asymptomatic. Seven of the patients underwent endoscopic resection for a superficial cancer. None of those patients experienced any complications, and all are currently alive and cancer-free. The remaining three patients underwent resection of the cervical esophagus with regional lymph node dissection. Two of those patients experienced severe complications; one subsequently died (hospital death) from pneumonia, 12 months after surgery, while the other died from recurrence of his cancer. The third patient is alive and cancer-free. Early detection of a second primary malignancy in the residual cervical esophagus followed by endoscopic resection is the best treatment strategy for patients who previously received subtotal esophagectomy for thoracic esophageal cancer. Surgical resection puts patients at high risk of mortality or morbidity.

Brain metastasis from stage I esophageal squamous cell carcinoma after surgery: a case report

Esophageal cancer rarely metastasizes to the brain. The authors experienced a case of esophageal carcinoma which metastasized to the cerebellum as the first presentation. A 61-year-old man was identified as having esophageal carcinoma by esophagogastroduodenoscopy during a medical checkup. Subtotal esophagectomy with dissection of 3 regional lymph nodes was performed. The tumor was 30 × 20 mm2 in size, and was revealed to be a moderately differentiated squamous cell carcinoma. The pathological finding was T1b(SM)N0M0 stage I. Fourteen months after the surgery, the patient complained of nausea. Brain magnetic resonance imaging (MRI) showed a cystic tumor of 42 × 28 × 28 mm3 in size in the central cerebellum. No other metastasis was pointed out. A craniotomy for brain tumor resection was performed, and the histopathological examination revealed that it was a metastatic carcinoma from the esophagus. Gamma knife therapy was added. The patient died of cerebellar metastasis recurrence 24 months after the first surgery.

Long-term survival following radical surgery after chemotherapy for esophagogastric adenocarcinoma with extensive lymph node metastases: Report of a case

A 46-year-old man was referred to us after he presented to his local physician complaining of difficulty eating. Upper gastrointestinal endoscopy revealed a tumor at the esophagogastric junction (EGJ), and moderately differentiated adenocarcinoma was diagnosed from the biopsy findings. Computed tomography (CT) showed apparent enlargement of the pretracheal lymph nodes, the lymph nodes around the bilateral recurrent laryngeal nerves, and the lower thoracic paraesophageal lymph nodes, confirming metastasis. Since the disease was far advanced esophagogastric cancer with marked lymph node metastases throughout the mediastinum, curative resection would have been unlikely. Thus, he was commenced on systemic chemotherapy with cisplatin (90 mg/body, day 8) + S-1 (120 mg/body/day, given for 3 weeks, followed by a 2-week withdrawal). Even after six cycles of chemotherapy over 8 months, a complete response could not be achieved. Finally, we performed transthoracic subtotal esophagectomy with extensive lymph node dissection reconstructed using a gastric tube through a retrosternal route. The patient remains recurrence-free 7 years later.

Intrathoracic hernia of a retrosternal colonic graft after esophagectomy: Report of a case

We report a case of intrathoracic herniation of the colonic interposition pulled up through the retrosternal space after subtotal esophagectomy for esophageal cancer. The patient, a 68-year-old man, presented with progressive dysphagia about 1 year after this operation. We performed left thoracotomy and laparotomy, which revealed the reconstructed colon herniating into the left thoracic cavity through a large defect in the left mediastinal pleura. The redundant colon was resected, and the colonic graft was shortened and straightened. We concluded that the defect in the mediastinal pleura and colonic redundancy had permitted the colonic graft to herniate into the left thoracic cavity.

Long-term survival after resection of paraaortic lymph node metastasis that developed 6 years after the esophagectomy

A 62-year-old man underwent subtotal esophagectomy with an extended three-field lymph node dissection for squamous cell carcinoma of the lower thoracic esophagus (histological stage pT3N1M0, pStage III). Computed tomography showed a swollen paraaortic lymph node about 6 years later. Positron emission tomography also indicated lymph node metastasis. The patient was treated with surgery, and the lymph node was diagnosed to be metastasis of esophageal cancer. Surgery was followed by chemotherapy with nedaplatin and 5-fluorouracil. The patient has remained alive more than 5 years after surgery without any evidence of recurrence. Although the optimal treatment for the recurrence region of esophageal cancer remains controversial, the current case suggests the possibility of performing a salvage resection for a lymph node recurrence of esophageal cancer in selected patients.

Effects of acetylcholine on sling and clasp fibers of the human lower esophageal sphincter

Manometric studies on the human lower esophageal sphincter (LES) have shown radial asymmetry of the high-pressure zone (HPZ). The aim of this study was to compare the functional properties of human LES clasp and sling muscles, and to look at their relationship with the expression of muscarinic receptors and intracellular Ca(2+) concentration. Muscle strips of sling and clasp fibers from the LES were obtained from patients undergoing subtotal esophagectomy. Isometric tension responses of the strips to acetylcholine were studied. Western blotting and reverse transcription-polymerase chain reaction (RT-PCR) were used to determine the expression of five subtypes of muscarinic receptors. Intracellular Ca(2+) ([Ca(2+) ]i) was measured using laser scanning confocal microscopy. Acetylcholine caused a concentration-dependent increase in the tension of sling and clasp strips, the sling strip being stronger than clasp (P=0.00). Messenger RNA and protein for the five muscarinic acetylcholine receptor (mAChRs) expressed in the sling and clasp muscles were highest for M2, and then in decreasing levels: M(3)>M(1)>M(4)>M(5) . Acetylcholine caused significant elevation of [Ca(2+) ]i in sling and clasp muscle cells in the presence of extracellular Ca2+ (1.5mmol/L), and Ach-induced [Ca(2+) ]i elevation was 1.6 times greater in sling cells than in clasp cells. Variation of intracellular concentrations of Ca(2+) may be the reason for differential responses to acetylcholine for sling versus clasp fibers. However, these differences are not associated with the distribution and the level of expression of the five mAChRs between the two muscle types. Further study should focus on the ligand affinity and signal transduction pathway.

Vimentin expression of esophageal squamous cell carcinoma and its aggressive potential for lymph node metastasis.

e14566 Background: Esophageal squamous cell carcinoma (ESCC) has been generally considered as one of the most aggressive cancers with poor prognosis. Vimentin has been regarded as a marker of epithelial-mesenchymal transition (EMT). However, little is known about ESCC with vimentin expression as a marker of EMT. In this study, we analyzed vimentin expression of ESCC and its aggressive behavior. Methods: One hundred and twenty-nine ESCC were surgically resected at Hirosaki University Hospital from 1996 to 2008. All the patients underwent operations including subtotal esophagectomy and dissection of lymph nodes. No patients received radiotherapy or chemotherapy before operation. In each patient, one representative histological specimen at the deepest invaded area of an esophageal cancer lesion was selected, and immunohistochemical examination of Vimentin and α-smooth muscle actine (α-SMA) was performed. In addition, in cases of lymph node metastasis, the largest metastatic carcinoma specimen was selected, and the same immunohistochemical examination of vimentin was performed. Results: Vimentin expression was identified in 96 of the 129 cases (74.4%). The cases with vimentin-positive carcinoma cells showed a significantly higher incidence of lymph node metastasis (P=0.001). Carcinomas with vimentin expression were more advanced in terms of tumor status and lymphatic invasion (P=0.001, P=0.009, respectively), and associated with stronger stromal α-SMA expression (P<0.001). Vimentin expression was also associated with distant metastasis, including distant node metastasis (P=0.014). Vimentin expression in both primary and metastatic carcinomas was found in 68.6% (48/70) of the cases, while no vimentin expression in both primary and metastatic carcinomas comprised 92.3% of the cases (12/13) (P<0.001). Finally, Vimentin expression in ESCC is an independent predictor of lymph node metastasis (multivariate analysis, P=0.014, odds ratio: 3.314, 95% confidence interval: 1.276-8.605). Conclusions: Vimentin expression in ESCC is an independent predictor of lymph node metastasis. In addition, vimentin expression was frequently retained in metastatic carcinoma of the lymph node.

Gastropericardial fistula resulting from ulcerative perforation of the reconstructed gastric tube after surgery for esophageal cancer

Gastropericardial fistulae are rare and may cause fatal complications such as acute purulent carditis and cardiac tamponade. The present report describes a case of a gastropericardial fistula caused by a peptic ulcer perforating a retrosternal reconstructed gastric tube 2 years after subtotal esophagectomy for esophageal cancer. Surgical intervention involved left thoracotomy, pericardium fenestration, and drainage of the pericardium and left thoracic cavity. The patient suffered postoperative complications including septic shock, acute respiratory distress syndrome, and cardiac insufficiency; however, he recovered after successful surgical intervention. In this case, the withdrawal of proton pump inhibitors and the patient’s sustained drinking habit after esophageal replacement surgery may have caused peptic ulcers in the gastric tube. Early diagnosis and surgical treatment of gastropericardial fistulae are essential to avoid fatal complications.

What influences the acidity in the gastric conduit in patients who underwent cervical esophagogastrostomy for cancer?

The aim of this study was to determine the factors influencing acidity in the gastric conduit after esophagectomy for cancer. Acidity and bile reflux in the stomach and in the gastric conduit were examined by 24-h pH monitoring and bilimetry in 40 patients who underwent transthoracic subtotal esophagectomy followed by esophageal reconstruction using a gastric conduit, which was pulled up to the neck through a posterior mediastinal route in 17 patients, through a retrosternal route in 10 patients, and through a subcutaneous route in 13 patients. They were examined at 1 week before surgery, at 1 month after surgery, and at 1 year after surgery. Helicobacter pylori infection was examined pathologically and using the (13) C-urea breath test. The factors influencing acidity of the gastric conduit were analyzed using the stepwise regression model. Gastric acidity assessed by percentage (%) time of pH < 4 was reduced after surgery and was significantly less in patients with H. pylori infection compared with those without H. pylori infection throughout the period from 1 week before surgery to 1 year after surgery. Duodenogastric reflux (DGR) assessed by % time absorbance > 0.14 into the lower portion of the gastric conduit was significantly increased after surgery throughout the period from 1 month after surgery to 1 year after surgery. Multivariate analysis showed that the acidity in the gastric conduit was influenced by H. pylori infection and DGR at 1 month after surgery, and by H. pylori infection and the route for esophageal reconstruction at 1 year after surgery. Acidity in the gastric conduit was significantly decreased after surgery. Acidity in the gastric conduit for esophageal substitutes is influenced by H. pylori infection and surgery. DGR influences the gastric acidity in the short-term after surgery, but not in the long-term after surgery.

Multiple solitary leiomyomas in the esophagus: Report of a case

We herein report our findings for an asymptomatic 65-year-old man presenting with multiple solitary leiomyomas in the esophagus, who was undergoing follow-up for primary aldosteronism with high levels of serum progesterone. Esophageal endoscopy and computed tomography showed multiple submucosal tumors with calcification in the thoracic esophagus. A subtotal esophagectomy was performed because the possibility of malignancy could not be ruled out based on a needle biopsy taken of the specimen. The final resected specimen showed eight solitary, encapsulated nodules between the middle and lower thoracic esophagus. Histopathological examinations showed these nodules to have the typical histological findings of leiomyomas. In addition, staining with antibodies against the progesterone receptor revealed diffuse expression in the nuclei of the leiomyoma cells. Only four cases with more than eight solitary leiomyomas have been reported, including the current case. However, this is the first reported case where primary aldosteronism with elevated serum progesterone levels has been implicated in the pathogenesis of multiple solitary leiomyomas in the esophagus.

Application of laminated anastomosis with absorbable suture in cervical esophagogastrostomy

To observe the clinical results of laminated anastomosis using absorbable suture in cervical esophagogastrostomy, and to reduce the incidence of cervical esophagogastric anastomotic stricture. A retrospective analysis was carried out on 210 patients who underwent cervical esophagogastrostomy after subtotal esophagectomy from January 2008 to June 2010. Among them, 96 cases were treated with traditional full layer interrupted varus suture (varus group) and the remaining 114 cases were treated with seromuscular layer and mucosal layer laminated anastomosis with absorbable suture (laminated group). Esophageal angiography was performed in 1 week, 1 month, and 3 months after the operation. The diameter of anastomatic stoma was measured on the anteroposterior and lateral angiography image respectively. The area of anastomatic stoma was calculated. The degree of stenosis was assessed according to the patients' dysphagia symptom. There was no operative deaths, no serious pulmonary complications and chylothorax, no sever esophageal reflux in all patients. The ratio of cervical esophagogastric anastomotic leakage was 2.1% (2/96) in the varus group. No anastomotic leakage in the laminated group. Compared with the varus group, the area of the anastomatic stoma in the laminated group was significantly increased in all measured time points (P<0.01). The incidence of obstruction in the laminated group was decreased significantly (P<0.01) in 1 month or in 3 months after operation compared with the varus group. Application of the laminated anastomosis with absorbable suture in cervical esophagogastrostomy can significantly reduce the incidence of anastomotic stenosis.

Giant liposarcoma of the esophagus with Li-Fraumeni-like syndrome

Primary esophageal liposarcoma is a rare malignancy, with only 25 cases reported in the English literature. In this report, we present a new case of giant esophageal liposarcoma in a 49-year-old woman with a family history of upper gastrointestinal tract cancer. This was a transmural tumor located in the lower esophagus. Subtotal esophagectomy was successfully performed, and histopathology revealed a well-differentiated liposarcoma. The patient was followed-up for 20 months without recurrence. However, asynchronous ovarian serous adenocarcinoma was found 1 year after the esophageal surgery, and Li-Fraumeni-like syndrome was diagnosed.

Synchronous Primary Carcinosarcoma and Adenosquamous Carcinoma of the Esophagus

Reports of adenosquamous carcinoma and carcinosarcoma found at the same esophagus are rare in the literature. We report a case of synchronous adenocarcinoma and carcinosarcoma of the esophagus. The sarcomatous components were immunoreactive for vimentin. Carcinoma, sarcoma, and adenocarcinoma cells distinctively metastasized to different lymph nodes. Further investigations are required to reveal the biological behavior of the tumor.