Antibodies, Monoclonal ; therapeutic use ; Antibodies, Monoclonal, Humanized ; Antineoplastic Agents ; therapeutic use ; Cadherins ; genetics ; metabolism ; Carcinoma, Papillary ; pathology ; Cetuximab ; Colorectal Neoplasms ; drug therapy ; genetics ; pathology ; Consensus ; Dissent and Disputes ; Drug Delivery Systems ; Epithelial-Mesenchymal Transition ; Gastrointestinal Neoplasms ; classification ; pathology ; Genes, ras ; Humans ; Mutation ; Neoplasm Invasiveness ; Neoplastic Syndromes, Hereditary ; genetics ; metabolism ; pathology ; Neuroendocrine Tumors ; classification ; pathology ; Precancerous Conditions ; pathology ; Stomach Neoplasms ; genetics ; metabolism ; pathology

OBJECTIVETo evaluate the influence of the number, station and field of metastatic lymph node on the prognosis of thoracic esophageal cancer and to investigate an ideal nodal staging method.

METHODSClinicopathological and follow-up data of the 204 patients who underwent thoracic esophagectomy from June 2001 to December 2009 were analyzed retrospectively and all the patients were re-staged according to the 7th edition of the AJCC TNM staging system. Log-rank test was applied to perform survival analysis according to lymph node metastasis staging(number, station, and field), Cox proportional hazard model was used to screen risk factors.

RESULTSThe follow-up rate was 93.1%(190/204). The median follow up time was 37.0(0-104) months. The overall and cancer-specific 5-year survival rates were 35.0% and 38.8%. When grouped according to the number of metastatic lymph node(0, 1-2, 3-6, ≥ 7), the 5-year survival rates of pN0, pN1, pN2 and pN3 were 47.8, 31.8%, 11.5% and 0 respectively(P=0.000). When grouped according to the number of stations of metastatic lymph node[N(0s), N(1s)(1 station LN metastasis), N(≥ 2s)(≥ 2 stations LN metastasis)], the 5-year survival rates of N(0s), N(1s), N(≥ 2s) were 47.8%, 31.5% and 11.3% respectively(P=0.000). When grouped according to the number of fields of metastatic lymph node, the 5-year survival rates of N0, 1 field, 2 fields and 3 fields involvement were 47.8%, 34.2%, 12.1% and 0 respectively(P=0.000). Cox regression showed that the number of stations [P=0.043, RR(95% CI)=1.540(1.013-2.342)], and the number of fields[P=0.010, RR(95%CI)=2.187(1.210-3.951)] of metastatic lymph node were the independent risk factors for survival.

CONCLUSIONSThe extent of metastatic lymph node is an independent risk factor for the prognosis of esophageal cancer patients. Revision of the current N-classification of TNM staging system according to the number of stations of metastatic lymph node may be more reasonable.

Aged ; Carcinoma, Squamous Cell ; mortality ; pathology ; Esophageal Neoplasms ; mortality ; pathology ; Female ; Humans ; Lymph Nodes ; pathology ; Lymphatic Metastasis ; pathology ; Male ; Middle Aged ; Neoplasm Staging ; Prognosis ; Retrospective Studies ; Survival Rate

OBJECTIVETo compare outcomes of left and right thoracic incision for middle and lower thoracic esophageal squamous cancer, and to determine reasonable surgical approach for thoracic esophageal squamous carcinoma.

METHODSOne hundred and twenty patients with middle or lower thoracic esophageal squamous cancer who received esophagectomy plus lymphadenectomy between January 2004 and December 2007 were divided into two groups including left(n=60) and right thoracic(n=60) approach. Clinical data were analyzed including the results of surgical resection, lymphadenectomy, postoperative complication, recurrence, and survival.

RESULTSThe rate of surgical resection was 91.7%(55/60) in the left approach group and 95%(57/60) in the right approach group. There was no significant difference(P>0.05). But the average number of lymph nodes resected (4.60 vs. 8.32) and metastatic lymph nodes(0.57 vs. 1.33) were both significantly higher in the right approach group(P<0.01). There was no statistical difference in postoperative complications[26.7%(16/60) vs. 31.7%(19/60), P>0.05] between the two groups. However, the incidence of local recurrence was lower[43.3%(26/60) vs. 23.3%(14/60), P<0.05] in the right approach group than that in left-approach group. There was no significant difference in distant metastasis(P>0.05).

CONCLUSIONSThe resection rate is comparable between left and right approach for thoracic esophageal cancer. However, it is easier to perform systemic lymphadenectomy via right thoracic approach and therefore the local recurrence is reduced and long-term survival improved.

Adult ; Aged ; Carcinoma, Squamous Cell ; surgery ; Esophageal Neoplasms ; surgery ; Esophagectomy ; Female ; Humans ; Lymph Node Excision ; Male ; Middle Aged ; Retrospective Studies ; Treatment Outcome

OBJECTIVESTo evaluate the feasibility and safety of video-assisted thoracoscopic surgery (VATS), and to compare surgical results of VATS with standard median sternotomy (MS) and other minimal invasive approaches through various small incisions (SI).

METHODSTotally 111 patients underwent surgery for thymic disorders (maximun diameter ≤ 5 cm, clinical stage I-II for thymic tumors) during March 2010 to June 2012 was retrospectively reviewed. There were 46 male and 65 female patients with a mean age of (51 ± 15) years.Resection via VATS was carried out in 47 patients, via SI in 26 patients, and via MS in 38 patients. Demographic characteristics, operation time, number and cause of conversion, blood loss during operation, duration and amount of chest tube drainage, transfusion, morbidity, and length of hospital stay (LHS) were compared between the three groups.

RESULTSOf the 111 patients, 79 patients had thymic epithelia tumors (stage I 32 patients, stage II 39 patients, stage III 8 patients), 31 patients had benign cysts and 1 patient had tuberculosis.In the VATS group, there were 3 conversions among 38 patients through right-side approach, and 4 conversions among 9 patients through left-side approach. The causes for conversion included dense pleura adhesion, invasion of tumor into adjacent structures (pericardium, lung, or great vessels), and injury of the left inominate vein. There was no significant difference in operative time, blood loss or transfusion during operation, duration or amount of postoperative chest tube drainage among the 3 groups (P > 0.05). Average LHS was significantly shorter in the VATS group (5.7 ± 1.7) days than in the SI group (7.5 ± 2.2) days and the MS group (8.2 ± 1.9) days (F = 3.759, P = 0.002). Total thymectomy was performed in 74 patients, 25 patients (53.2%, 25/47) in VATS group, 11 patients (42.3%, 11/26) in SI group, and 38 patients (100%, 38/38) in MS group. The reset of the patients received tumor resection and partial thymectomy. Among all the subgroups, LHS was the shortest in VATS total thymectomy patients (5.0 ± 1.4) days (F = 5.844, P = 0.001). There was no perioperative mortality. The only major morbidity was a postoperative bleeding necessitating reintervention in SI group.

CONCLUSIONSVATS for benign thymic lesions and early-stage thymic tumors is safe and feasible.It is associated with shorter hospital stay compared with other minimal invasive approaches or standard sternotomy.

Adult ; Aged ; Female ; Humans ; Male ; Middle Aged ; Retrospective Studies ; Thymectomy ; methods ; Thymoma ; surgery ; Thymus Neoplasms ; surgery

OBJECTIVESTo evaluate the efficacy and advantage of minimally invasive esophagectomy for surgical treatment of submucosal esophageal cancer compared to conventional open procedure.

METHODSClinical data of consecutive 168 patients with stage T1b submucosal esophageal cancer undergoing minimally invasive esophagectomy (MIE, esophagectomy by thoracoscope, stomach freeing by laparoscope or open abdomen, cervical esophagogastric anastomosis) or conventional open esophagectomy (OE) at the Shanghai Chest Hospital between January 1, 2012 and December 31, 2014 were reviewed retrospectively. Intraoperative and postoperative information was compared between the two groups.

RESULTSBoth groups were equally stratified by sex, body mass index and age. No patient of MIE group was transferred to open operation. As compared to the OE group, the MIE group had significantly more harvest lymph nodes (median 12 vs. median 9, P=0.004), lower rate of postoperative pneumonia [5.8% (4/69) vs. 21.2% (21/99), P=0.011] and pleural effusion [8.7% (6/69) vs. 23.2% (23/99), P=0.027], and shorter hospital stay (median 11 d vs. median 14 d, P=0.041), but positive margin was found in 1 case. There were no significant differences of respiratory failure, pneumothorax, atrial arrhythmia, pulmonary embolism, recurrent nerve palsy, anastomotic leak, reoperations and 30-day mortality between the two groups. Multivariate logistic analysis revealed recurrent nerve palsy, anastomotic leak and surgical approach were found to be the main factors of hospital stay within postoperative 12 days, while leakage when the in-hospital time more than 12 days. Kaplan-Meier analysis showed that the surgical approach was the independent factor of hospital stay, MIE could shorten the hospital stay (P=0.013).

CONCLUSIONMIE should be considered as the standard approach in the treatment of T1b submucosal esophageal cancer.

Anastomotic Leak ; China ; Esophageal Neoplasms ; surgery ; Esophagectomy ; Humans ; Kaplan-Meier Estimate ; Laparoscopy ; Length of Stay ; Minimally Invasive Surgical Procedures ; Operative Time ; Postoperative Complications ; Retrospective Studies

OBJECTIVETo evaluate THE clinical significance of the 2009 UICC staging system for thoracic esophageal squamous cell carcinoma.

METHODSTwo hundred and nine patients with thoracic esophageal squamous cell carcinoma undergone selective cervico-thoraco-abdominal lymphadenectomy were reviewed retrospectively and restaged according to the new 2009 UICC staging system. The relationship between individual stages and survival were analyzed accordingly.

RESULTSThe five-year overall and cause-specific survivals were 35.0% and 38.8%, respectively. Depth of invasion (T, P = 0.004), number of metastatic lymph nodes (N, P < 0.001), distant lymph node metastasis (M, P = 0.003), complete resection (R, P = 0.005) were significantly related to postoperative survival. On the other hand, location of primary tumor (L, P = 0.743) and histological grade (G, P = 0.653) were not significantly related to long-term prognosis. Upon stratification, the 5-year survival for T4a (32.0%) was significantly better than that of T4b (0, P < 0.001), but was similar to that of T3 (28.4%, P = 0.288). Patients without nodal involvement (47.8%, P < 0.001) and those with single station nodal disease (37.5%, P < 0.001) had significantly better survival than patients having 2 or more stations of lymph node metastasis (11.3%). Also patients without nodal involvement and those with metastasis confined to a single field (34.2%) had significantly better survival than patients having nodal diseases in 2 fields (12.1%) and 3 fields (0, P < 0.001). The 5-year survival for cervical metastasis after complete resection was 20.0%. Upon multivariate analysis, depth of tumor invasion (P = 0.001, RR = 1.635), numbers of metastatic nodal stations (P = 0.043, RR = 1.540) and fields (P = 0.010, RR = 2.187) were revealed as independent risk factors for long-term survival.

CONCLUSIONSThe new UICC staging system effectively predicts long-term prognosis for thoracic esophageal squamous cell carcinoma. Depth of tumor invasion and extent of lymph node involvement are two most important prognostic factors. To improve surgical outcomes, much effort is needed to increase the accuracy of preoperative staging and to include effective induction therapies into a multidisciplinary setting.

Carcinoma, Squamous Cell ; pathology ; surgery ; Esophageal Neoplasms ; pathology ; surgery ; Esophagectomy ; Female ; Follow-Up Studies ; Humans ; International Agencies ; Lymph Node Excision ; Lymph Nodes ; pathology ; surgery ; Lymphatic Metastasis ; Male ; Middle Aged ; Neoplasm Invasiveness ; Neoplasm Staging ; methods ; Retrospective Studies ; Survival Rate

OBJECTIVETo analyze the differences in perioperative morbidity and lymph node dissection between minimally invasive esophageal carcinoma resection and open procedure.

METHODSFrom January to December 2011, 72 patients with esophageal cancer underwent surgery. Thirty-four patients underwent video-assisted esophagectomy, and 38 underwent open procedure. In the minimally invasive group, there were 7 thoraco-laparoscopic cases, 16 thoracoscopic cases, and 11 laparoscopic cases.

RESULTSThe early cases (T1-T2) were more common in the minimally invasive group than that in the open group [79.4%(27/34) vs. 55.3%(21/38), P<0.05]. The complication rate was 41.2%(11/34) in the open group and 42.1%(16/38) in the minimally invasive group, and the difference was not statistically significant (P>0.05). However, the functional complication in minimally invasive group was significantly lower than that in open group [2.9%(1/34) vs. 28.9%(11/38), P<0.01], while technical complications (anastomotic leak and recurrent laryngeal nerve injury) were significantly more common( 38.2% vs. 10.5%, P<0.05). Lymph node group number in minimally invasive group was comparable with the open group (9.1 vs. 11.2, P>0.05), but the number of node in minimally invasive group was significantly lower (13.5±5.9 vs. 17.8±5.2, P<0.05). When stratified by time period, early 17 cases were associated with similar technical complication rate with the late 17 cases (P>0.05), while thoracic lymph node group number, number of node, and positive node were improved in the late phase (all P>0.05).

CONCLUSIONSMinimally invasive esophagectomy reduces functional morbidity, while technical complication including anastomotic leak and recurrent laryngeal nerve injury may be increased. Endoscopic lymph node dissection may be comparable to open surgery.

Esophageal Neoplasms ; surgery ; Esophagectomy ; adverse effects ; methods ; Female ; Humans ; Laparoscopy ; adverse effects ; Lymph Node Excision ; methods ; Male ; Middle Aged ; Morbidity ; Postoperative Complications ; Retrospective Studies ; Thoracoscopy ; adverse effects ; Treatment Outcome

OBJECTIVETo compare the differences in biological behavior and clinical features between adenocarcinoma of the esophagogastric junction (AEG) and lower thoracic esophageal squamous cell cancer (LESC), and to explore reasonable procedures for each cancer.

METHODSClinical data of 111 patients with AEG and 126 patients with LESC who underwent surgery from January 2004 to April 2012 were retrospectively reviewed. Data pertaining to resection rate, lymph node metastasis, and postoperative complication rate were analyzed.

RESULTSThe resection rate was 94.6% for AEG and 97.6% for LESC, and the difference was not statistically significant (P<0.05). The rate of lymph node metastasis in the mediastinum in patients with AEG was significantly lower [6.3%(7/111) vs. 32.5%(41/126), P<0.01], while the rate of lymph node metastasis in the abdomen was significantly higher [57.7%(64/111) vs. 34.1%(43/126), P<0.01]. The rate of lymph node metastasis in mediastinum of AEG was 12.5%(4/32) for Siewert I and 4.7%(3/64) for Siewert II, and there was no lymph node metastasis in Siewert III (n=15). For AEG patients who underwent trans-abdominal surgery, the rate of positive lymph node in the middle and lower mediastinum was significantly lower than trans-thoracic surgery [0/22 vs. 7.9% (7/89), P<0.05]. LESC via right thorax with two-field or three-field lymph node dissection was associated with a significantly higher rate of positive lymph node metastasis in the upper mediastinum than that of single incision via left thorax [17.9%(12/67) vs. 0/59, P<0.01]. The postoperative complication rates were 23.4%(26/111) and 27.0%(34/126) respectively, and the difference was not statistically significant(P>0.05).

CONCLUSIONSAEG and LESC show different lymph node metastasis pattern and should be operated differently. Lymphadenectomy in mid-lower mediastinum should be emphasized in Siewert I and Siewert II type cancers.

Adenocarcinoma ; surgery ; Aged ; Carcinoma, Squamous Cell ; surgery ; Esophageal Neoplasms ; surgery ; Esophagectomy ; methods ; Esophagogastric Junction ; pathology ; surgery ; Esophagus ; pathology ; surgery ; Female ; Humans ; Lymph Node Excision ; methods ; Lymphatic Metastasis ; Male ; Middle Aged ; Retrospective Studies ; Treatment Outcome

OBJECTIVESTo optimize perioperative respiratory and circulatory management so as to improve the surgical results of thoracotomy in elderly patients.

METHODSRespiratory and circulatory status was prospectively monitored and postoperative complications were documented in 58 elderly patients aged over 65 years underwent thoracotomy. The results were compared with those from 56 young patients aged under 65 years in the same time period. Based on the study results, the original perioperative management model was modified and prospectively studied in the following 179 elderly patients. Again the results were compared with 477 younger patients concomitantly treated.

RESULTSThrough optimized perioperative management, the in-hospital mortality (4.9% vs. 1.1%, P = 0.033) and overall morbidity (58.6% vs. 21.8%, P < 0.01) were significantly decreased. This was most significant in the decrease of functional complications (51.7% vs. 14.5%, P < 0.01), especially the cardiovascular (22.4% vs. 7.3%, P = 0.001) and respiratory complications (20.7% vs. 7.3%, P = 0.004). There was no difference in technical complications between the two time periods. Comparing with the original model, the optimized perioperative management strategy resulted in significant decrease in acute lung injury (17.2% vs. 6.7%, P = 0.016), respiratory failure (6.9% vs. 1.7%, P = 0.041), as well as cardiac arrhythmia (20.7% vs. 7.3%, P = 0.004) in the early postoperative period.

CONCLUSIONSOptimization of perioperative management through careful preoperative functional evaluation, intraoperative protective ventilation, postoperative close monitoring of water balance, and timely intervention, may help improve surgical results in the elderly.

Aged ; Aged, 80 and over ; Female ; Humans ; Male ; Middle Aged ; Monitoring, Physiologic ; Perioperative Care ; Postoperative Complications ; Prospective Studies ; Thoracotomy ; Treatment Outcome

Most patients with esophageal cancer have advanced disease at presentation. The efficacy of surgical resection alone is often unsatisfactory in patients with stage III or more advanced cancer according to the seventh edition of UICC staging system for esophageal cancer. The systematic multidisciplinary treatment is important. Mounting evidence indicates that preoperative concurrent chemoradiotherapy is the most effective induction therapy to down-stage tumor and increase radical resection rate. For the esophageal squamous cell carcinoma patients with multi-stations and multi-fields lymph node metastasis, preoperative induction chemotherapy would be a viable option. For locally advanced cancers which have been surgically resected, postoperative adjuvant radiotherapy maybe helpful to improve local control for the insufficient surgical dissection. The role of adjuvant chemotherapy also needs further studies. Thoracic esophageal squamous cell carcinoma and lower esophageal adenocarcinoma which is common in western countries are different. We need more prospective clinical studies to establish our treatment modalities for esophageal cancer.
Carcinoma, Squamous Cell ; drug therapy ; radiotherapy ; surgery ; Chemotherapy, Adjuvant ; Combined Modality Therapy ; Esophageal Neoplasms ; drug therapy ; radiotherapy ; surgery ; Humans ; Prospective Studies ; Radiotherapy, Adjuvant