Esophageal Surgery Division

Introduction
More than 250 new patients with esophageal carcinoma were admitted to the National Cancer Center Hospital in 2001. Treatment was determined according to the stage of the tumor. This division cooperates with the Gastrointestinal Oncology Division, the Radiation Oncology Division, and other divisions to provide a multidisciplinary team approach to treating patients. For example, 53 patients underwent endoscopic esophageal mucosal resection in the Endoscopy Division in 2001. More than 80 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 our institution, squamous cell carcinomas constitute the largest proportion of esophageal tumors, and the proportion of adenocarcinomas is less than 4%.

Routine Activities
The Esophageal Surgery Division consists of three staff surgeons, one chief resident 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, 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 of each month to discuss various themes.
Every week, an average of three patients with esophageal carcinoma undergo surgery. Radical esophagectomy was performed for 40% of the newly detected esophageal carcinomas in 2001. Eight patients received esophagectomy for salvage surgery after chemo-radiotherapy as their primary treatment. The operationrelated mortality rate was 1.7%.
Since 1982, the region 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 esopha-gectomy was introduced in 2000 and performed in 11 patients in 2001.

Research Activities
The efficacy of esophagectomy with three-field lymph node dissection for patients with squamous cell carcinoma of the lower thoracic esophagus was evaluated. Cervical or celiac lymph node metastasis had no significant influence on the overall survival rates of these patients treated with three-field lymph node dissection.
The results of patients with clinical Stage I squamous cell carcinomas treated with three-field lymph node dissection was investigated. Thirty-three percent of the patients exhibited lymph node metastasis with 5-year survival rate of 73%. Three-field lymph node dissection may be indicated even for patients with clinical Stage I cancer because this procedure provides possible cure by removing unsuspected lymph node metastasis.
The risk and benefit of esophagectomy with three-field lymph node dissection was evaluated in elderly patients over 70 years of age. This procedure could be carried out safely with satisfactory long-term results. For elderly patients with multiorgan dys-function, however, less invasive procedures might be more appropriate.
Comparison of surgical management of thoracic esophageal carcinoma was made between the National Cancer Center Hospital and Shanghai Chest Hospital in China. Significantly more stations of lymph nodes were dissected with more postoperative complication and a tendency toward better survival in the NCCH. Attention should be paid to more thorough lymph node dissection and meanwhile avoiding major postoperative complications, so as to improve therapeutic outcome.
Surgical therapy for 6 patients with a recurrent esophageal cancer at anastomosis after esopha-gectomy was reported. Frequent examination for the anastomotic site using endoscopy and long-term follow-up studies are desirable.

Clinical Trials
The analysis of the multi-institutional randomized controlled trial of postoperative adjuvant chemotherapy after radical esophagectomy (JCOG 9204) revealed better disease-free survival rates for patients with lymph node involvement. The next trial comparing preoperative and postoperative chemo-therapy with cisplatin and 5-FU with radical esophagectomy (JCOG 9907) is in the process of registration in cooperation with the Gastrointestinal Oncology Division and the Radiation Oncology Division.
Registration for a phase II trial of chemoradiotherapy without surgery for a Stage I lesion (JCOG 9708), consisting of two cycles of chemotherapy was closed in 2000. The preliminary analysis resulted in a CR rate of over 90% without treatment-related death. Comparison between surgery and chemoradiotherapy for a Stage I lesion is planned as the next clinical trial. Another phase II trial of chemoradiotherapy with cisplatin and 5-FU and concurrent radiotherapy (60 Gy) without surgery for a Stage II or III lesion (JCOG 9907) is in registration.

Y. TACHIMORI

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