Esophageal Surgery Division
Introduction
More than 250 patients with esophageal carcinoma were admitted to the National Cancer Center Hospital in 2000. 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, 27 patients underwent endoscopic mucosal resection by the Endoscopy Division in 2000. More than 90 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 is less than 3%.
Routine Activities
The Esophageal Surgery Division
consists of three staff surgeons, one chief resident and three rotating senior
residents, after the retirement of Dr. H. Watanabe. 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, staging,
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 two
patients with esophageal carcinoma undergo surgery. A radical esophagectomy
was completed for 32% of the newly detected esophageal carcinomas in 2000.
Six patients received esophagectomy for salvage surgery after chemo-radiotherapy
as their primary treatment. The operative mortality rate was 1.1%.
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. Video-assisted thoracoscopic esophag-ectomy was introduced for selected patients in 2000.
Research Activities
The patients with cervical
lymph node metastasis had significantly better survival compared with that
of patients with hematogenous metastasis and the similar survival curve after
three-field dissection to that of patients with metastasis in the mediastinum
or abdomen. We proposed cervical lymph node metastasis should be included
in the N component.
The patients with submucosal
carcinoma of the thoracic esophagus had not negligible frequency of cervical
lymph node metastasis, acceptable overall hospital mortality after esophagectomy
with three-field dissection and favorable survival rates even with histologically
positive cervical nodes. Three-field lymph node dissection may be indicated
for patients with submucosal carcinoma of the thoracic esophagus.
The prognosis for patients with intramural metastasis of esophageal cancer is poor. We examined the role of preoperative chemotherapy in the management of patients with this disease. Preoperative chemotherapy with cisplatin and 5-fluorouracil was feasible in patients with IMM of esophageal carcinoma. This regimen, however, did not improve survival.
Clinical Trials
The analysis of the multi-institutional randomized controlled trial of postoperative adjuvant chemo-therapy with cisplatin and 5-FU after radical esophagectomy (JCOG 9204) revealed better disease-free survival and overall survival rates for patients with lymph node involvement. The next trial comparing preoperative and postoperative chemotherapy with radical esophagectomy (JCOG 9907) was started in 2000, in cooperation with the Gastrointestinal Oncology Division and the Radiation Oncology Division.
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), was closed in 2000. The preliminary analysis resulted in a CR rate of over 90% without treatment-related death. Another phase II trial of chemoradiotherapy without surgery for a Stage II or III lesion (JCOG 9907) was started in 2000.
|
Number of Patients Who Underwent Esophagectomy |
||
|
|
1999 (n=107) |
2000 (n=89) |
|
Histology |
|
|
|
Squamous cell carcinoma |
101 |
81 |
|
Adenocarcinoma |
1 |
6 |
|
Others |
5 |
2 |
|
Tumor location |
|
|
|
Cervical |
11 |
3 |
|
Upper thoracic |
27 |
11 |
|
Middle thoracic |
43 |
37 |
|
Lower & Junctional |
36 |
38 |
|
Clinical TNM Stage |
|
|
|
Stage 1 |
13 |
12 |
|
Stage 2A |
24 |
14 |
|
Stage 2B |
14 |
8 |
|
Stage 3 |
36 |
39 |
|
Stage 4 |
20 |
16 |
|
Operative procedure |
|
|
|
Right thoracotomy |
91 |
76 |
|
Left thoracotomy |
7 |
5 |
|
Transhiatal |
5 |
4 |
|
Cervical |
3 |
0 |
|
Abdominal |
1 |
4 |
|
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)
