Yohei Nagai

Minimally invasive esophagectomy for esophageal cancer: an updated review

PurposeThe surgical, postoperative and oncologic outcomes of minimally invasive esophagectomy (MIE) for esophageal cancer were reviewed to clarify the benefits of this surgical modality.MethodsA systematic literature search was performed using synonyms for minimally invasive or thoracoscopic esophagectomy. There were 18 retrospective cohort studies and 3 meta-analyses retrieved in this review.ResultsThere are several minimally invasive approaches for esophageal cancer. Total MIE using both the thoracoscopic and laparoscopic approach is increasingly performed. A longer operative time and less blood loss are observed with MIE in comparison to open esophagectomy (OE). Although the benefit of MIE for reducing morbidity and mortality rates is still under debate, a shorter hospital stay was common among the studies. The oncologic outcomes of MIE were not inferior to OE, while the number of retrieved lymph nodes was greater in MIE than OE in several studies.ConclusionTotal MIE using a combined thoracoscopic and laparoscopic approach can be performed safely, although the benefits for short-term outcomes are still controversial. Oncologic outcomes are favorable and MIE may have an advantage in lymph node dissection over OE. The benefits of MIE should therefore be confirmed by randomized controlled trials.

Induction chemotherapy with docetaxel/cisplatin/5-fluorouracil for patients with node-positive esophageal cancer.

Background: Despite improvements in the surgical management of esophageal cancer, the prognosis of patients with lymph node metastases is still unsatisfactory. Recently, survival benefit of neoadjuvant or induction chemotherapy for patients with esophageal cancer has been highlighted. Methods: Efficacy and toxicity of induction chemotherapy for esophageal cancer were reviewed. In addition, our experience on modified docetaxel/cisplatin/5-FU (DCF) as induction chemotherapy was also demonstrated. The modified DCF consisted of 60 mg/m2 of docetaxel on day 1, and 350 mg/m2 of 5-FU and 6 mg/m2 of cisplatin on days 1–5. Two courses have been administered as induction chemotherapy in 51 patients with node-positive esophageal cancer. Response was evaluated by RECIST v1.0 and changes in standardized uptake value by 18F-fluorodeoxyglucose positron emission tomography. Results: Induction chemotherapy may be beneficial for node-positive esophageal cancer, although the consensus has not yet been established. A regimen of induction chemotherapy should have a high response rate and cisplatin/5-FU may be underpowered as an induction setting. DCF can be a candidate for the regimen of induction chemotherapy for esophageal cancer, although severe adverse events have been reported. Several modified regimens to reduce the toxicity have been reported. The response rate of our series was 61% and a significant decrease in standardized uptake values was observed after the induction chemotherapy. Although high-grade neutropenia was still observed with this regimen, neither treatment-related death nor delay in the following treatment was observed. Conclusions: Modified DCF can be a regimen of induction chemotherapy for node-positive esophageal cancer because of its high efficacy, although an adequate care for severe neutropenia is needed.

Oxysterol binding protein-related protein-5 is related to invasion and poor prognosis in pancreatic cancer

In previous studies, the gene expression profiles of two hamster pancreatic cancer cells with different potentials for invasion and metastasis were analyzed. In the present study, we identified that one of the genes expressed strongly in the highly metastatic cell line is hamster oxysterol binding protein‐related protein (ORP)‐5. The aim of the present study was to clarify the relationship between ORP5 and invasion and poor prognosis of human pancreatic cancer. Invasion assays were carried out in both hamster and human pancreatic cancer cells by suppressing the ORP5 gene with short interfering RNA or inducing its expression by introducing an expression vector. To evaluate the relationship between ORP5 and the characteristics of human pancreatic cancer, 56 pancreatic cancer tissue specimens were analyzed and the ORP5 expression in each pancreatic cancer tissue specimen was analyzed by immunohistochemistry. In both the hamster and human pancreatic cancer cells, suppression of ORP5 significantly reduced the invasion rate of the cells and induction of ORP5 significantly enhanced the invasion rate of the cells. In the clinical sample, the median survival times of the patients with ORP5‐positive (n = 33) and ORP5‐negative (n = 23) cancer were 8.3 and 17.2 months, respectively (P = 0.02). Also, the 1‐year survival rates of patients with ORP5‐positive and ORP5‐negative cancer were 36.4 and 73.9%, respectively (P = 0.005). The ORP5 expression level was related to both invasion and poor prognosis in human pancreatic cancer. These findings suggest that the expression of ORP5 may induce cancer cell invasion, resulting in the poor prognosis of pancreatic cancer. (Cancer Sci 2008; 99: 2387–2394)

Usefulness of Transcription–Reverse Transcription Concerted Reaction Method for Detecting Circulating Tumor Cells in Patients With Colorectal Cancer

PurposeThe CellSearch system (Veridex, LLC) is useful for detecting circulating tumor cells (CTCs) in various carcinomas, including colorectal cancer (CRC); however, there are some problems associated with its clinical use. A transcription–reverse transcription concerted reaction (TRC) method, which is a PCR-based technique producing more stable and reliable results, because it is a more simplified process compared with the conventional techniques, has been introduced for detecting micrometastasis in some carcinomas. We aimed to demonstrate the effectiveness of TRC method in the CTC detection.MethodsWe compared the two methods for the sensitivity for CTC detection using the colon cancer cell line and 42 whole-blood samples from patients with advanced or metastatic CRC. Furthermore, 25 patients with metastatic CRC were enrolled to investigate the correlation between CTC detection and prognosis in both methods.ResultsThe sensitivity of the TRC method was similar to that of the CellSearch system. The overall survival rate was significantly worse in the patients diagnosed as CTC-positive by the TRC method than in those diagnosed as CTC-negative; this finding was similar to the prognosis indicated by the CellSearch system. However, clinically, the TRC method could detect CTCs more rapidly and at a reduced cost compared with the CellSearch system.ConclusionsThe TRC method seems to be a useful alternative to the CellSearch system for clinically detecting CTCs in patients with metastatic CRC.

Lymphatic vessel invasion detected by the D2-40 monoclonal antibody is an independent prognostic factor in node-negative esophageal squamous cell carcinoma

D2‐40 staining has been reported to be useful for both identifying lymphatic vessel invasion (LVI) and counting lymphatic vessel density (LVD) in various cancers. The aim of this study was to clarify the prognostic significance of D2‐40 staining in patients with esophageal squamous cell carcinoma (ESCC).

Extensive lymphatic spread of cancer cells in patients with thoracic esophageal squamous cell carcinoma: detection of CEA-mRNA in the three-field lymph nodes.

The aim of this study is to clarify the extent of lymphatic spread of cancer cells using a novel genetic test to examine patients with thoracic esophageal squamous cell carcinoma (ESCC).

Pedunculated gastric conduit interposition with duodenal transection after salvage esophagectomy: An option for increasing the flexibility of the gastric conduit

A gastric conduit is the first choice for esophageal reconstruction because of its robust blood supply and the need for only a single anastomosis to re-establish continuity with good results. In cases where the stomach is unavailable, a colon conduit is preferentially selected as an esophageal substitute. However, a colon reconstruction is more highly nvasive compared with a gastric conduit reconstruction. alvage esophagectomy after definitive chemoradiotherapy s associated with high morbidity and mortality rates. Gasric conduit necrosis is one of the most critical complicaions after salvage esophagectomy, potentially leading to n-hospital death. Gastric conduit necrosis can occur when he upper part of the stomach is included in the radiation rea of definitive radiotherapy; a damaged stomach with dematous changes and/or redness should be resected (Fig. ). In such cases, we have previously performed free-jejunal raft interposition or used a colon conduit to avoid anasomosis of the damaged stomach to the cervical esophagus. ere, we present our experience with duodenal transecion, which preserves the right gastroepiploic vessels, enbling safe anastomosis at the lower level of the gastric onduit, where the effect of definitive radiation therapy is bsent. Given the non-necessity for microvascular anastoosis, this method might represent a suitable minimally nvasive technique that minimizes organ sacrifice in this urgical setting.

Primary Malignant Melanoma of the Esophagus With Extensive Intraepithelial Extension

Primary malignant melanoma of the esophagus (PMME) is an exceedingly rare tumor. The prognosis of PMME is very poor, and the 5-year survival rate is only 2.2% due to its aggressive biologic character. We present patient with PMME with wide extension into almost the entire esophagus, without endoscopic abnormalities. This patients presentation is extremely valuable because it has enabled us to observe the long-term natural progression of PMME, including recurrent disease with a wide range of atypical melanocytic cells in the entire esophagus.

Feeding Tube Insertion Through the Round Ligament of Liver: A Safe Approach to Placing a Feeding Tube for Retrosternal Gastric Tube Reconstruction after Esophagectomy

Esophagectomy for esophageal cancer is well known to be a highly invasive surgery, and a recent review reported the mortality rate to be 6.9%. In addition, the efficacy of early enteral eeding has been reported to contribute to improved outomes. The common approach to inserting a feeding tube is jejunostomy; however, late complications related to jejunostomy, such as volvulus and internal hernia, are encountered occasionally (Fig. 1A). Retrosternal gastric tube reconstruction is a commonly performed reconstructive method after esophagectomy. A feeding enterostomy can be placed through the gastric conduit in this type of reconstruction. However, fixation of the gastric antrum to the peritoneum is sometimes difficult because of the narrow space between the midline incision and the costal arch. Excess tension to the gastric wall can cause tube-related complications, such as leak or abscess formation (Fig. 1B). We developed a safe method to insert a feeding tube through the retrosternally reconstructed gastric tube using the round ligament of liver, which we will describe here.

Giant liposarcoma of the posterior mediastinum and retroperitoneum.

A 39-year-old Japanese man has been complaining of chest pain for 3 months and a CT revealed a huge tumour in the posterior mediastinum and retroperitoneum. The mediastinal tumour was continuous with the retroperitoneal one through the oesophageal hiatus and the lower oesophagus was completely surrounded by the tumour. MRI suggested lipogenic tumour. Resection of the tumour with oesophagectomy was performed through bilateral thoracotomy and laparotomy. Pathological examination revealed well-differentiated liposarcoma which was completely resected. The patient has been alive without recurrence for 14 months after surgery.