Esophageal Surgery Division
Introduction
More than 200 patients with
esophageal carcinoma were admitted to the National Cancer Center Hospital
in 1999. Treatment was determined by the stage of the tumor. This division
cooperates with the Gastrointestinal Oncology Division, the Radiation Oncology
Division, and other divisions to use a multidisciplinary team approach to
treating patients. For example, 28 patients with esophageal cancer limited
to the mucosa underwent endoscopic mucosal resection by the Endoscopy Division
last year. More than 50 patients received chemo-radiotherapy as their primary
treatment. We also cooperate with the Head and Neck Surgery Division for cervical
esophageal carcinomas and with the Gastric Surgery Division for tumors in
the esophago-gastric junction. In Japan, including at our institution, squamous
cell carcinomas constitute the largest proportion of esophageal tumors, and
the proportion of adenocarcinomas involving the lower esophagus is less than
5%.
Routine Activities
The Esophageal Surgery Division
consists of four staff surgeons and three rotating senior residents. A division
conference is held every Wednesday evening in which surgeons, medical oncologists,
radiation oncologists, endoscopists, radiologists, and pathologists who are
involved in the treatment of esophageal diseases meet and discuss the diagnosis,
stagings, and treatment plans for patients with esophageal tumors. A monthly
conference, clinical diagnosis, and pathology demonstration of the esophagus
is held on the evening of the fourth Friday to discuss various themes.
Every week, an average of three patients with esophageal
carcinoma undergo surgery. A radical esophagectomy was completed for 44% of
the newly detected esophageal carcinomas in 1999. One patient had additional
primary carcinoma arising in the remaining cervical esophagus after thoracic
esophagectomy. The operative mortality rate was 2.8%.
Since 1982, the area of lymph
node dissection has been extended to the whole upper mediastinum and neck
in addition to the lower mediastinum and abdomen. Endoscopic ultrasonography
and neck ultrasonography are performed routinely by the surgical staff as
a pretreatment evaluation to promote accurate three-field lymph node dissection.
Research Activities
The analysis of the multi-institutional
randomized controlled trial of postoperative adjuvant chemo-therapy with cisplatin
and 5-FU after radical esophagectomy (JCOG 9204) was presented at ASCO in
1999. Adjuvant chemotherapy had better disease-free survival and overall survival
rates for patients with lymph node involvement.
The result of the single institutional
trial of preoperative chemotherapy with cisplatin and 5-FU for patients with
intramural metastasis was presented at the World Congress of Surgery in 1999.
The pre-operative chemotherapy for patients with intramural metastasis had
no effect on prognosis.
In a publication in the Journal
of Surgical Oncology we reported no prognostic significance of the expression
of p53 in esophageal squamous cell carcinoma. A case report of fulminant nonocclusive
mesenteric ischemia developing just after esophagectomy was reported in Hepatogastro-enterology.
Clinical Trials
The next trial comparing preoperative
chemo-therapy and postoperative chemotherapy with radical esophagectomy (JCOG
9907) will begin in 2000, in cooperation with the Gastrointestinal Oncology
Division and the Radiation Oncology Division.
Registration of the multi-institutional
trial of chemoradiotherapy for locally unresectable lesions JCOG 9516) was
closed in 1998. The preliminary analysis resulted in a response rate of 68.3%
and a 2-year survival rate of 31.0%.
A phase II trial of chemoradiotherapy
without surgery for a Stage I lesion (JCOG 9708), consisting of two cycles
of chemotherapy with cisplatin and 5-FU and concurrent radiotherapy (60 Gy),
is ongoing without treatment-related death.
The result of single institutional
trials of postoperative tumor bed implant brachytherapy of 50 Gy for a residual
tumor after palliative resection is ongoing, according to the preliminary
result presenting long-term survivors.
|
Number
of Patients Who Underwent Esophagectomy |
|||
|
1998(n=82) |
1999(n=107) |
||
|
Histology |
|||
|
Squamous cell carcinoma |
80 |
101 |
|
|
Adenocarcinoma |
0 |
1 |
|
|
Others |
2 |
5 |
|
|
Tumor
location |
|||
|
Cervical |
4 |
11 |
|
|
Upper thoracic |
10 |
27 |
|
|
Middle thoracic |
54 |
43 |
|
|
Lower & Junctional |
14 |
36 |
|
|
Clinical
TNM Stage |
|||
|
Stage 1 |
18 |
13 |
|
|
Stage 2A |
10 |
24 |
|
|
Stage 2B |
11 |
14 |
|
|
Stage 3 |
24 |
36 |
|
|
Stage 4 |
18 |
20 |
|
|
Operative
procedure |
|||
|
Right thoracotomy |
74 |
91 |
|
|
Left thoracotomy |
7 |
||
|
Transhiatal |
3 |
5 |
|
|
Cervical |
4 |
3 |
|
|
Abdominal |
1 |
1 |
|
|
The
3-year and 5-year Survival Rates for Patients Who Underwent Esophagectomy
(1992-1996) |
||||
|
pTNM Stage |
Cumulative
survival rate (%) |
|||
|
Pts |
3-yr |
5-yr |
||
|
I |
68 |
86.8 |
78.8 |
|
|
IIA |
45 |
66.4 |
58.6 |
|
|
IIB |
54 |
59.3 |
50.9 |
|
|
III |
93 |
35.3 |
32.4 |
|
|
IV |
90 |
26.7 |
19 |
|
(Y.
TACHIMORI)
