Hiroko Sasahara

Optimal Lymphadenectomy for Squamous Cell Carcinoma in the Thoracic Esophagus: Comparing the Short- and Long-term Outcome among the Four Types of Lymphadenectomy

Controversy continues over the optimal extent of lymphadenectomy (regional versus three-field) for a potentially resectable squamous cell carcinoma in the thoracic esophagus. In the Consensus Conference of the International Society for Diseases of the Esophagus (ISDE), held in Munich in 1994, the types of lymphadenectomy were classified as standard, extended, total, or three-field lymphadenectomy. The objective of the present study was to determine the optimal procedure among these four types of lymphadenectomy. The mortality and morbidity rates, postoperative course, and survival rates were compared among 302 patients who underwent curative (R0) transthoracic esophagectomy with one of these four types of lymphadenectomy at Kurume University Hospital, Fukuoka, Japan, from 1986 to 1998. Three-field lymphadenectomy resulted in better survival than any other type of lymphadenectomy for patients with positive lymph node metastasis from a cancer in the upper or middle thoracic esophagus. A postoperative complication, such as recurrent laryngeal nerve paralysis, anastomotic leakage, and tracheal ischemic lesion, was significantly more common after three-field lymphadenectomy. However, the mortality rate was the same among the four procedures. Three-field lymphadenectomy was optimal for an upper or middle thoracic esophageal cancer with metastasis in the lymph node(s) based on improved long-term survival, whereas there was not a large difference in short-term and long-term outcomes after the four types of lymphadenectomy for a lower thoracic esophageal cancer.

Second-Line Combination Chemotherapy with Docetaxel for Cisplatin-Pretreated Refractory Metastatic Esophageal Cancer: A Preliminary Report of Initial Experience

Background and Aims: Patients with esophageal cancer often develop metastatic disease after esophageal resection and generally receive cisplatin-based chemotherapy or chemoradiotherapy. The efficacy and toxicity of the combination of docetaxel, 5-fluorouracil (5-FU) and cisplatin (DFC) as a second-line chemotherapy were evaluated in patients with postoperative metastatic esophageal cancer refractory to cisplatin-based chemotherapy. Patients and Methods: Twenty patients with metastatic esophageal cancer after esophagectomy refractory to cispatin-based therapy were included in this study. The DFC regimen consisted of docetaxel (60 mg/m2) on day 1, 5-FU (500 mg/day) on days 1–5 and cisplatin (10 mg/day) on days 1–5, being repeated every 3 weeks. Results: A total of 49 cycles (median 2, range 1–6) was administered to 20 patients. The median follow-up was 8 months (range 3–24). Of the 20 patients, 1 had a complete response, 6 had a partial response, 6 had stable and 7 had progressive disease. Median time to progression for all patients was 4 months (95% Cl 1.7–5.6). The median overall survival for all patients was 8 months (95% CI 5.7–10.3). The major toxicity was myelosuppression. Neutropenia of grade 3 or more occurred in 13 patients (65%), and thrombocytopenia of grade 3 occurred in 1 patient (5%). Febrile neuropenia was observed in 1 patient (5%). There was no treatment-related mortality. Conclusion: DFC is a feasible and promising regimen as a second-line therapy in metastatic/recurrent esophageal cancer refractory to cisplatin-based chemotherapy.

Adjuvant Chemotherapy after Radical Resection of Squamous Cell Carcinoma in the Thoracic Esophagus: Who Benefits?

Background: A definitive combined modality therapy superior to surgery alone has not yet been found for esophageal cancer. This retrospective study investigated the impact of postoperative adjuvant chemotherapy in patients who underwent curative (R0) esophagectomy with radical lymphadenectomy. Study Design: Two hundred and eleven patients with a squamous cell carcinoma in the thoracic esophagus who underwent transthoracic curative (R0) esophagectomy with radical lymphadenectomy, such as 3-field lymphadenectomy or total 2-field lymphadenectomy, between 1988 and 2000, were retrospectively reviewed. Ninety-four patients received postoperative chemotherapy – 2 courses of cisplatin (CDDP) plus fluorouracil (5-FU) or vindesine (VDS) – while the other 117 patients received surgery alone. The overall survival rate was compared between the two groups after being stratified by the numbers of the metastasis- positive lymph nodes. Results: Only in the subgroup of patients with 8 or more lymph nodes metastasis- positive, the surgery-with-postoperative-chemotherapy group had a significantly better survival than the surgery-alone group. No significant difference was found in survival between the two groups in any other stratified subgroup. Conclusions: Postoperative adjuvant chemotherapy following curative (R0) esophagectomy with radical lymphadenectomy such as 3-field lymphadenectomy or total 2-field lymphadenectomy provided a benefit only in patients having metastasis in a large number – 8 or more – lymph nodes.

Locoregional adoptive immunotherapy resulted in regression in distant metastases of a recurrent esophageal cancer

Abstract. Esophageal cancer is one of the most common malignant diseases. However, postoperative recurrences are still resistant to currently available radiochemotherapy. We recently reported a study on the initial clinical efficacy of locoregional adoptive immunotherapy for advanced esophageal cancer. We report here our clinical experience of remarked responses in distant metastatic lesions in a patient with recurrent cancer after receiving this immunotherapy. A male patient underwent curative surgery, and presented with multiple recurrent metastases in the supraclavicular lymph nodes (LNs), liver, and abdominal aortic LNs. Autologous tumor-activated lymphocytes (AuTLs) generated ex vivo were regionally injected into supraclavicular LNs every 2 weeks 13 times. Mean numbers of the administrated cells were 0.8 × 109 cells/injection. AuTLs established from peripheral blood lymphocytes stimulated by autologous tumor cells with interleukin-2 were tested for their cytotoxicity before every treatment. During immunotherapy, Grade 2 diarrhea and fever were observed. The clinical partial responses were obtained in all lesions and were sustained for 11 months. Because clinical toxicity was tolerable, this immunotherapy might be useful for patients with far-advanced esophageal cancers.

Radical esophagectomy and secondary anastomosis for high-risk patients with intrathoracic esophageal carcinoma

OBJECTIVE We have often conducted esophageal reconstruction via a thoracic subcutaneous route in high-risk patients to avoid major complications following anastomotic leakage. This type of reconstruction is nonphysiological, however, and presents a poor cosmetic appearance. In better risk patients, therefore, we usually conduct gastric-tube replacement via a posterior mediastinal route. We have recently begun gastric-tube replacement via the posterior mediastinal route with secondary anastomosis for high-risk patients to avoid anastomotic leakage. RESULTS From 1996 to 1999, secondary anastomosis was conducted in 25 patients with different degrees of risk--10 with diabetes mellitus, 7 with liver dysfunction, 3 with simultaneous laryngeal and/or pharyngeal cancer, 2 each with induction chemoradiotherapy, cardiac failure, renal dysfunction, respiratory failure, and cardiorespiratory dysfunction, and 1 with cerebral infarction. 6 patients had with multiple combined diseases. Secondary anastomosis was conducted 3-12 weeks (mean: 5.5 weeks) after esophagectomy. Stomach-tube necrosis was not seen in any of the 25 patients undergoing this 2-step procedure. Anastomosis leakage was seen in 5 of the 25 patients (20%), but was slight, in all but 1. CONCLUSION Our 2-step procedure has the following advantages: low risk of anastomotic leakage, radical surgery for esophageal cancer, the potential for early adjuvant therapy after esophagectomy, easy and early training in swallowing, and no cosmetic problem. Its disadvantages are prolonged hospitalization, multiple surgery, and esophageal stoma formation. Secondary anastomosis thus appears helpful in treating high-risk patients with advanced esophageal cancer.

Small cell carcinoma in the esophagus rapidly developing multiple fistulae

This case report describes a small cell carcinoma in the esophagus with a squamous cell carcinoma that developed multiple fistulae. Autopsy findings demonstrated that both the primary tumor and the metastatic lymph nodes became necrotic and caused an abscess cavity spreading into the mediastinal, retroperitoneal, and subcutaneous spaces. An esophageal stent was effective for palliation.

Corrosive Stricture of both the Hypopharynx and the Esophagus after Swallowing Strong Hydroxide: Report of Two Cases Treated Surgically

アルカリ飲用による腐蝕性咽頭食道狭窄に対し, 食道バイパス術を施行した2例を経験したので報告する. 症例1: 47歳の男性で, 統合失調症に対し加療中, 10%水酸化カリウム液を盗飲した. 経過中に食道穿孔を来し, 縦隔・頸部ドレナージ術を施行. 発症から209病日に咽頭喉頭頸部食道切除, 胸壁前咽頭結腸胃吻合術, 永久気管瘻造設術を施行し, 経口摂取可能となり術後95病日に退院した. 症例2: 58歳の女性で, 自殺目的にパイプ洗浄剤を服用した. 発症より323病日に胸壁前咽頭結腸胃吻合術を施行するも術後誤嚥が改善せず, 術後181病日に喉頭挙上術, さらに術後219病日に喉頭摘出術を追加し, 経口摂取可能となり退院した. 腐蝕性咽頭食道狭窄の患者はしばしば背景に精神科疾患を有していたので, 術式特に喉頭を温存するか否かの選択には下咽頭病変の程度, 本人・家族の希望, 患者背景などさまざまな条件を考慮する必要がある.