Tatsuji Tsubuku

A new N category for cancer of the cervical esophagus based on lymph node compartments

BackgroundThere remains controversy over what constitutes the optimal rational extent of lymphadenectomy, in other words, the concept of rational lymphadenectomy, for cancer of the cervical esophagus. The purpose of this study was to propose the concept of a rational N category for cancer of the cervical esophagus that indicates more clearly which cluster(s) of lymph nodes should be resected during resection of a cancer of the cervical esophagus.MethodsThis study reviews the actual incidence of metastasis in the resected lymph nodes in a consecutive series of 36 patients with a cancer of the cervical esophagus who underwent curative resection. The regional lymph nodes were subsequently classified into three compartments based on the metastatic rates and prognosis after lymphadenectomy.ResultsIn cases of cancer in the cervical esophagus with invasion into the pharynx (CePh), high rates of positive metastasis were found in the cervical paraesophageal (101) and in the deep cervical nodes (102), and resection of those nodes showed improved prognosis. In cases of cancer in the cervical esophagus without invasion into the pharynx (Ce/CeUt), high rates of positive metastasis were found in the cervical paraesophageal (101) and in the recurrent nerve nodes (106rec), and resection of those nodes showed improved prognosis. In both cases, however, resection of the mediastinal nodes except for the recurrent nerve nodes (106rec) showed no improvement in prognosis. Only in cases where the cancer involves the pharynx did resection of the peripharyngeal nodes (103) show improved prognosis.ConclusionsThe Compartment-I (N1) nodes for cancer of the cervical esophagus with invasion into the pharynx (CePh) were concluded to be the cervical paraesophageal (101) and the deep cervical nodes (102); the Compartment-II (N2) nodes to be the peripharyngeal (103), the supraclavicular (104), and the recurrent nerve nodes (106rec); and the Compartment-III (N3) nodes to be the superficial cervical (100) and the upper thoracic paraesophageal nodes (105). The Compartment-I (N1) nodes for cancer of the cervical esophagus without invasion into the pharynx (Ce/CeUt) were concluded to be the cervical paraesophageal (101) and the recurrent nerve nodes (106rec); the Compartment-II (N2) nodes to be the deep cervical (102) and the supraclavicular nodes (104); and the Compartment-III (N3) nodes were concluded to be the superficial cervical (100) and the upper thoracic paraesophageal nodes (105).

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.

Giant gastrointestinal stromal tumor in the esophagus

We report a case of a 74-year-old woman with an esophageal gastrointestinal stromal tumor (GIST). Endoscopic examination suggested a submucosal tumor in the middle-lower thoracic esophagus. Computed tomography showed a solid mass 95 × 56 × 44 mm in size, suggesting an esophageal mesenchymal tumor. Endoscopic ultrasonography-guided fine-needle aspiration biopsy was positive for c-kit and CD34, and negative for both S-100 and desmin, on immunohistochemical examination, confirming this to be a GIST. The patient underwent transthoracic esophagectomy with esophageal reconstruction using a gastric tube through the subcutaneous route. The tumor was completely resected, and there was no lymph node metastasis. The pathological examination confirmed the tumor to be at high risk for recurrence because of its size and the presence of necrosis. We are carefully following the patient conservatively with no adjuvant chemotherapy such as imatinib mesylate.

A RARE CASE OF TESTICULAR NECROSIS AFTER SIGMOIDECTOMY FOR CANCER

症例は64歳，男性．左下腹部痛を主訴に来院した．精査の結果，S状結腸癌を認めS状結腸切除術を施行した．術中所見で，腫瘍は外側鼠径窩の位置で後腹膜に浸潤固定しており，同部位で精巣動静脈，精管を巻き込んでいた．精巣動静脈，精管を合併切除し腫瘍を摘出した．術後より発熱を認め左精巣は腫大した．超音波検査で血流信号がなく，血流障害による精巣壊死が疑われ手術を施行した．手術所見で，精巣は暗黒色に腫大し壊死しており左精巣摘出術を施行した．S状結腸切除に際し精巣動静脈合併切除をしても精巣は壊死しないのが一般的である．精巣への血流は精巣動脈だけではなく，外陰部動脈，精管動脈，挙睾筋動脈，膀胱動脈や前立腺動脈から血管が分枝し，さらにそれらが吻合枝を有しているからと考えられる．今回われわれは非常に稀な精巣壊死症例を経験したので若干の文献的考察を加えて報告する．

Malignant acanthosis nigricans with esophageal cancer

A 62-year-old woman was referred to our hospital with presenting pigmentation and/or dermal thickening in the nucha, face, axilla, abdomen, and hands. She also presented a history of weight loss of 4 kg during the previous 3 months. She was pathologically diagnosed as having acanthosis nigricans by skin biopsy. She subsequently underwent 18F-FDG-PET, CT, and upper gastrointestinal endoscopy, and then was diagnosed as having malignant acanthosis nigricans with squamous cell carcinoma in the esophagus at the clinical stage of T3, N0, M0, stage IIA in the UICC stage classification. She underwent subtotal esophagectomy through a left thoracotomy with thoracoabdominal two-field lymphadenectomy and esophageal reconstruction using a gastric tube through a retrosternal route. The postoperative course was uneventful, and she was discharged at 26 days after the surgery without any adjuvant therapy. At 6 months after the surgery, the dermal thickening and the pigmentation of the acanthosis nigricans were completely relieved. She is well without recurrence at 1 year to date after surgery. Although acanthosis nigricans is frequently associated with malignancy, malignant acanthosis nigricans with squamous cell carcinoma in the esophagus has been rare.