W. Coosemans

Utility of Positron Emission Tomography for the Staging of Patients With Potentially Operable Esophageal Carcinoma

PURPOSEnA prospective study of preoperative tumor-node-metastasis staging of patients with esophageal cancer (EC) was designed to compare the accuracy of 18-F-fluoro-deoxy-D-glucose (FDG) positron emission tomography (PET) with conventional noninvasive modalities.nnnPATIENTS AND METHODSnSeventy-four patients with carcinomas of the esophagus (n = 43) or gastroesophageal junction (n = 31) were studied. All patients underwent attenuation-corrected FDG-PET imaging, a spiral computed tomography (CT) scan, and an endoscopic ultrasound (EUS).nnnRESULTSnFDG-PET demonstrated increased activity in the primary tumor in 70 of 74 patients (sensitivity: 95%). False-negative PET images were found in four patients with T1 lesions. Thirty-four patients (46%) had stage IV disease. FDG-PET had a higher accuracy for diagnosing stage IV disease compared with the combination of CT and EUS (82% v 64%, respectively; P: =.004). FDG-PET had additional diagnostic value in 16 (22%) of 74 patients by upstaging 11 (15%) and downstaging five (7%) patients. Thirty-nine (53%) of the 74 patients underwent a 2- or 3-field lymphadenectomy in conjunction with primary curative esophagectomy. In these patients, tumoral involvement was found in 21 local and 35 regional or distant lymph nodes (LN). For local LN, the sensitivity of FDG-PET was lower than EUS (33% v 81%, respectively; P: =.027), but the specificity may have been higher (89% v 67%, respectively; P: = not significant [NS]). For the assessment of regional and distant LN involvement, compared with the combined use of CT and EUS, FDG-PET had a higher specificity (90% v 98%, respectively; P: =. 025) and a similar sensitivity (46% v 43%, respectively; P: = NS).nnnCONCLUSIONnPET significantly improves the detection of stage IV disease in EC compared with the conventional staging modalities. PET improves diagnostic specificity for LN staging.

Three-field lymphadenectomy for carcinoma of the esophagus and gastroesophageal junction in 174 R0 resections: impact on staging, disease-free survival, and outcome: a plea for adaptation of TNM classification in upper-half esophageal carcinoma

Objective:To determine the impact of esophagectomy with 3-field lymphadenectomy on staging, disease-free survival, and 5-year survival in patients with carcinoma of the esophagus and gastroesophageal junction (GEJ). Background:Esophagectomy with 3-field lymphadenectomy is mainly performed in Japan. Data from Western experience with 3-field lymphadenectomy are scarce and dealing with relatively small numbers. As a result, its role in the surgical practice of cancer of the esophagus and GEJ remains controversial. Methods:Between 1991 and 1999, primary surgery with 3-field lymphadenectomy was performed in 192 patients, of whom a cohort of 174 R0 resections was used for further analysis. Results:Hospital mortality of the whole series was 1.2%. Overall morbidity was 58%. Pulmonary complications occurred in 32.8%, cardiac dysrhythmias in 10.9%, and persistent recurrent nerve problems in 2.6%. pTNM staging was as follows: stage 0, 0.6%; stage I, 9.2%; stage II, 27.6%; stage III, 28.7%; and stage IV, 33.9%. Overall 3- and 5-year survival was 51% and 41.9%, respectively. The 3- and 5-year disease-free survival was 51.4% and 46.3%, respectively. Locoregional lymph node recurrence was 5.2%; no patient developed an isolated cervical lymph node recurrence. Five-year survival for node-negative patients was 80.2% versus 24.5% for node-positive patients. Five-year survival by stage was 100% in stages 0 and I, 59.1% in stage II, 36.8% in stage III, and 13.3% in stage IV. Twenty-three percent of the patients with adenocarcinoma (25.8% distal third and 17.6% GEJ) and 25% of the patients with squamous cell carcinoma (26.2% middle third) had positive cervical nodes resulting in a change of pTNM staging specifically related to the unforeseen cervical lymph node involvement in 12%. Cervical lymph node involvement was unforeseen in 75.6% of patients with cervical nodes at pathologic examinations. Five-year survival for patients with positive cervical nodes was 27.7% for middle third squamous cell carcinoma. For distal third adenocarcinomas, 4-year survival was 35.7% and 5-year survival 11.9%. No GEJ adenocarcinoma with positive cervical nodes survived for 5 years. Conclusions:Esophagectomy with 3-field lymph node dissection can be performed with low mortality and acceptable morbidity. The prevalence of involved cervical nodes is high, regardless of the type and location of tumor resulting in a change of final staging specifically related to the cervical field in 12% of this series. Overall 5-year and disease-free survival after R0 resection of 41.9% and 46.3%, respectively, may indicate a real survival benefit. A 5-year survival of 27.2% in patients with positive cervical nodes in middle third carcinomas indicates that these nodes should be considered as regional (N1) rather than distant metastasis (M1b) in middle third carcinomas. These patients seem to benefit from a 3-field lymphadenectomy. The role of 3-field lymphadenectomy in distal third adenocarcinoma remains investigational.

Surgical strategies in esophageal carcinoma with emphasis on radical lymphadenectomy.

From 1975 through 1988, 257 patients with carcinoma of the thoracic esophagus have been treated in our department. Operability was 90% (232/257); overall resectability, 77% (198/257), and for the operated group, 85% (198/232). Hospital mortality rate was 9.6% but decreased to 3% over the period 1986 to 1988. There were 65% squamous cell epitheliomas and 35% adenocarcinomas. Tumor, nodes, and metastases (pTNM) staging was as follows: stage I, 11.6%; stage II, 23.2%; stage III, 37.9%; stage IV, 27.3%. Overall survival rate was 62.5% at 1 year, 42.4% at 2 years, and 30% at 5 years. According to the pTNM staging, 5-year survival was 90% for stage I, 56% for stage II, 15.3% for stage III, and 0 for stage IV. There were no statistically significant differences according to tumor localization, pathologic type, sex, or age. Introducing extensive resection and extended lymphadenectomy seems to improve significantly survival in patients in whom an operation with curative intention was performed, the 1 year survival rate being 90.8% versus 72%; 2-year survival, 81% versus 46%; and 5-year survival, 48.5% versus 41% for radical and nonradical resections, respectively. Based on multivariate Cox regression analysis, only TNM stage and presence or absence of lymph nodes are important factors in predicting survival: stage 1 tumors have lower risk, and involvement of lymph nodes creates higher risk. Using this analysis, there was only for the patients with involved lymph nodes (N1) a significantly better prognosis when a radical lymph node dissection was performed (p = 0.0055). Barrett adenocarcinomas have no worse prognosis than other esophageal carcinomas, with a 5-year survival rate of 91.5% if lymph nodes are negative, and a 54% overall 5-year survival rate. Functional results after restoration of continuity with gastric tubulation were judged excellent to very good in 86.5% at 1 year, but infra-aortic anastomoses have a much higher incidence of peptic esophagitis: 53% versus 8% for cervical anastomoses. From this study it can be concluded that in experienced hands surgery today offers the best chances for optimal staging, potential cure, and prolonged high-quality palliation.

Three-field lymphadenectomy and pattern of lymph node spread in T3 adenocarcinoma of the distal esophagus and the gastro-esophageal junction

OBJECTIVEnLymph node metastasis in carcinoma of the esophagus and the gastro-esophageal junction is often underestimated by clinical staging. It is the aim of this study to provide support to the fact that three-field lymphadenectomy leads to a better pathological staging also in adenocarcinoma.nnnMETHODSnThe pattern of lymph node metastasis in adenocarcinoma of the gastro-esophageal junction (GEJ) and the distal esophagus was charted in a prospective way by using a database. An analysis was performed with regard to lymphatic spread in T3, N+ adenocarcinomas of the distal esophagus and the GEJ junction, which were treated with a radical resection including a three-field lymphadenectomy. Out of 324 patients with adenocarcinoma of the esophagus and GEJ, we selected a group of 37 patients with an adenocarcinoma T3, N+ of the distal (n = 17) or GEJ junction (n = 20), treated with a radical resection and three-field lymphadenectomy ( > 25 lymph nodes resected).nnnRESULTSnIn total, 2240 lymph nodes were removed, with a mean of 59.5 per patient. In the GEJ group the ratio of positive nodes was 15.9, in the distal 1/3 group this ratio was 12.7%. Abdominal lymph nodes were positive in all GEJ tumors and in 70% of the distal third carcinomas. Thoracic lymph nodes were positive in 40% of GEJ tumors, and 70.6% of the distal group. Cervical lymph nodes were positive in 20% of the GEJ tumors and in 35.3% of the distal tumors. In six patients only right-sided cervical nodes were affected. Three patients in the GEJ group had positive lymph nodes in the neck without any involvement of thoracic lymph nodes.nnnCONCLUSIONSn(1) Three-field lymphadenectomy improves accuracy of staging. (2) Cervical nodes are frequently involved. (3) Especially in tumors of the GEJ there is an important skipping phenomenon, i.e. positive lymph nodes in the neck in the absence of involvement of thoracic nodes. (4) Clinical staging remains deficient in regard to lymph node metastasis, especially cervical nodes. (5) The frequent unforeseen involvement of cervical lymph nodes in adenocarcinoma of the distal esophagus and GEJ tumors makes the interpretation of results of induction chemoradiotherapy questionable. (6) For the same reason, cervical lymph nodes should be included in the radiation field in case of induction chemoradiotherapy. (7) The similar pattern of lymph node involvement suggests similar oncological behavior of adenocarcinoma of the distal esophagus and the GEJ, questioning the actual TNM classification of these tumors as gastric carcinomas.

Surgery for non-small cell lung cancer with unsuspected metastasis to ipsilateral mediastinal or subcarinal nodes (N2 disease)

OBJECTIVEnAlthough the results after surgery for N2 disease are disappointing, there seems to be a subgroup of patients which may benefit from primary resection. These patients have clinically unrecognized N2 involvement that is discovered only at the time of thoracotomy (unsuspected or unforeseen N2 disease). It was the aim of this retrospective study to analyze the survival after resection for unforeseen N2 disease and to evaluate different prognostic factors. We were interested to see whether our strategy of rigorous staging of the mediastinum with mediastinoscopy or anterior mediastinotomy had an effect on the resectability rate and survival of unsuspected N2 disease.nnnMETHODSnBetween 1985 and 1990, 859 patients with potentially operable non-small cell lung cancer were referred to our surgical department. Despite rigorous preoperative staging with computed tomography scan and cervical mediastinoscopy and/or anterior mediastinotomy, 103 patients (14.5%) had unsuspected N2 disease at thoracotomy. The tumor could be completely resected in 90 patients (87.5%).nnnRESULTSnThe 5-year survival after complete resection was 22%. Histology of the tumor, number of involved levels and extent of nodal disease had no effect on survival.nnnCONCLUSIONnWe conclude that resection is justified in patients with unforeseen N2 disease. Rigorous staging of the mediastinum by cervical mediastinoscopy or anterior mediastinotomy results in a high resectability rate and avoids unnecessary thoracotomies. Mediastinoscopy plays a central role in the staging of patients with carcinoma of the lung.

Early and late functional results in patients with intrathoracic gastric replacement after oesophagectomy for carcinoma

The function of the gastric substitute after oesophagectomy for carcinoma was studied retrospectively in 80 patients. At 3 months and 1 year postoperatively, a clinical and endoscopical examination was performed. A modified Visick grading of the results was used for scoring the final result. At 3 months 90% of the patients lost weight, compared with their preoperative status. At 1 year postoperatively, however, only 10% of the patients noted a further weight loss. One-fourth of the patients suffered 3 months postprandial fullness and diarrhoea, while 18% had dumping symptoms. These symptoms are mostly temporarily and disappear almost completely at 1 year. Three months postoperatively, 27% of patients had dysphagia, and 15% had heartburn and/or regurgitation. At 1 year, heartburn and/or regurgitation were increasingly reported (up to 21%), while less dysphagia was noted (15%). Early stricture requiring one or more dilatations was present in 18.7% of the patients. Five patients developed a late anastomotic stricture; 4 were located at the level of the intrathoracic anastomosis and were associated with severe oesophagitis. At 1 year there was a statistically significant difference between patients with cervical anastomosis and those with intrathoracic anastomosis when comparing reflux symptoms (4% vs. 50%; p = 0.0001) and oesophagitis (8% vs. 53%; p = 0.001). In all, 86% of patients had an excellent or very good late functional result, but only 6% of patients who underwent cervical anastomosis have a Visick score 3 or 4 vs. 23% after intrathoracic anastomosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Esophageal Replacement with Colon in Children Using Either the Intrathoracic or Retrosternal route: An Analysis of Both Surgical and Long-Term Results

A total of 28 colon esophageal replacements performed in children for long gap esophageal atresia (22 patients), and intractable caustic stricture (6 patients) were reviewed. Emphasis was placed on identifying the pros and cons of the different reconstruction techniques: intrathoracic route (ITR) (19 patients) and retrosternal route (RSR) (9 patients). No hospital mortality occurred, whereas a higher morbidity rate occurred among patients operated on using the ITR as opposed to the RSR (68%vs 55%;P not significant). Six patients developed an anastomotic fistula (21% with the ITRvs 22% with the RSR;P not significant), whereas an anastomotic stenosis occurred in 13 patients (67% with the RSR, and 37% with the ITR;P<0.07). Overall, dysphagia was the most prevalent symptom at 3 months follow-up, but had significantly decreased at the final follow-up (54%vs 16%;P<0.0027). Functional results improved significantly during the follow-up (score 1–2vs score 3–4; Fisher test:P=0.001). However, despite the higher morbidity rate, better functional results were achieved using the ITR as opposed to the RSR.

Laparoscopic antireflux surgery and the thoracic surgeon: what now?

OBJECTIVEnMinimal invasive antireflux surgery is now a well accepted technique gaining a wide spread popularity. Simultaneously there is a growing tendency to fit all surgical candidates into one single type of operation, i.e. laparoscopic Nissen antireflux operation. This study evaluates the impact of this new technology on the strategy and practice of a major referral centre for antireflux surgery.nnnMETHODSnAn analysis was made of indications for the different types of antireflux techniques performed between July, 1993 and 1995. If on Barium swallow the gastro-oesophageal (GO) junction proved to be reducible, a laparoscopic approach was proposed, if not, an open transthoracic access was preferred.nnnRESULTSnOne hundred and fifteen patients were operated. Fifty five patients underwent a minimal invasive approach: 49 Nissen (are the total fundoplication) and 3 Lind (are the partial fundoplication) operations through laparoscopy, 3 Belsey Mark IV through video assisted thoracic surgery (VATS). Sixty patients were treated by open surgery for following reasons: conversion to open surgery in 2 cases, redo surgery in 15 cases, previous other major abdominal surgery in 12, irreducible GO junction in 5, paraoesophageal or mixed type hernia in 12, Barrett and or oesophagitis IV in 4, combined antireflux surgery and feeding gastrostomy in 5, abdominal partial fundoplication by principle in 1, associated motility disorder in 1, combined reflux and gastric ulcer disease in 2, and severe emphysema in 1. In the laparoscopic series reflux control at 1 year post surgery as measured by 24 h pH study in 28 patients was obtained in 89.5%. One patient required a reoperation for symptomatic recurrence.nnnCONCLUSIONSn(1) Laparoscopic antireflux surgery is a feasible and well accepted technique; (2) careful study of each individual patient is of paramount importance to choose the correct type of operation and access as well. Therefore, fitting every patient into a single type of operation, i.e. laparoscopic Nissen, should be avoided; (3) thoracic surgeons with a major interest in GO reflux disease should familiarize themselves with laparoscopic antireflux procedures.

Esophagocoloplasty for congenital, benign and malignant diseases. Surgical and long-term functional results

OBJECTIVEnAim of this report is to evaluate the results of 100 consecutive esophagocoloplasties performed for congenital, benign and malignant diseases.nnnMETHODSnFrom 1982 until 1993 one hundred consecutive esophagocoloplasties were performed. Fifty eight for benign diseases: 22 congenital atresias (group A), 36 acquired benign lesions (group B), and 42 for malignancy (group C). As 72% of the patients had undergone previous gastric or esophageal surgery, coloplasty had to be performed in 48 patients by necessity. In 85 patients the colon graft was vascularized by the ascending branch of left colic artery and in 95 the reconstruction was fashioned in isoperistaltic way.nnnRESULTSnFifty one complications occurred in 42 patients resulting in a hospital mortality of 8%. However, for all benign diseases (group A + B) mortality rate was 0, being 19% in malignancy (group C). Morbidity was significantly higher in group A + C as compared to group B (p < 0.0009). Anastomotic leak was the most frequent complication occurring in 13 patients however healing spontaneously in 11 patients (84.6%). Early revisional surgery was performed in 11 patients. Functional results were evaluated according to a new grading system, including the four main symptoms (dysphagia, pain, regurgitations, diarrhoea) and weight status, the latter for adult patients. Fifty one patients from group A and B were followed for at least one year and evaluated. The were divided in two groups: 25 pediatrics (0.18 years). Anastomotic stenosis occurred in 19 patients but resolved after one or more dilatations in 16 at final follow-up. Dysphagia decreased from 43.1% 3 months postoperatively to 17.6% at last follow-up (p < 0.01). In adult patients there was a strong correlation between dysphagia and weight loss (p < 0.02). This correlation was not found in children. No differences were detectable when comparing preoperative mean weight of adult patients with mean weight of adult patients with mean weight at last follow-up. Of all 51 patients, 82.3% had an excellent (grade 1) or very good (grade 2) result at final evaluation versus 49% at 3 months follow-up (p < 0.0001). Only one patient had an unsatisfactory final result.nnnCONCLUSIONSnEsophagocoloplasty is a valuable and for some patients an essential technique in reconstruction of esophageal continuity. Mortality can be kept very low, especially in benign diseases, guaranteeing satisfactory results in the majority of patients, despite an initial substantial perioperative morbidity.

Prognostic value of the circumferential resection margin and its definitions in esophageal cancer patients after neoadjuvant chemoradiotherapy

The accepted importance of a positive circumferential resection margin (CRM) (defined as R1 in the TNM classification) is based on histopathology of the resection specimen obtained after primary surgery in esophageal cancer patients. The aim of this study is to look for the prognostic value of CRM after neoadjuvant chemoradiotherapy and to compare the clinical significance of a histologically CRMxa0<xa01 mm from the cut margin (Royal College of Pathologists definition of R1) to a positive cut margin (College of American Pathologists definition of R1) and toxa0≥1 mm margin (R0) resections in patients with ypT3-esophageal tumors after neoadjuvant chemoradiotherapy.u2003Between 2000 and 2014, 458 patients who received esophagectomy after neoadjuvant chemoradiation therapy were selected. Overall (OS) and disease-free survival (DFS) were calculated by means of Kaplan-Meier curves and compared by Cox regression analysis.u2003There were 163 (35.9%) patients who had a ypT3 tumor; in 118 (72.4%) resection was complete (R0). In 37 (22.7%) patients a CRMxa0<xa01 mm was found and 8 (4.9%) had a circumferential R1-resection. CRM involvement was inversely correlated with tumor regression grading, lymph node capsular involvement, and number of positive lymph nodes.u2003On univariate analysis, no statistically significant difference was found between R0-resection and CRMxa0<xa01 mm (Pxa0=xa00.103) for OS, but DFS showed a significant difference (Pxa0=xa00.025). Circumferential R1-resections showed a significant difference compared to R0-resections for OS and DFS (both Pxa0=xa00.002). In multivariate analysis, extracapsular lymph node involvement and circumferential R1-resection were withheld as independent prognosticators for OS, whereas extracapsular lymph node involvement, absence of regression on the primary tumor and circumferential R1-resection were withheld for DFS. After correcting for different variables in the multivariate model, CRMxa0<xa01 mm showed no statistical difference compared to R0-resections neither for OS nor for DFS.u2003After neoadjuvant chemoradiotherapy, CRM is correlated with biological behavior of the tumor and with therapy response. Furthermore it is an independent prognosticator for OS and DFS. However CRMxa0<xa01 mm itself is no independent prognosticator for OS nor DFS survival in multivariable analysis. These results suggest that the definition of R1-resection should be limited to true invasion of the section plane.