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国立がん研究センター 中央病院

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Department of Esophageal Surgery

Yuji Tachimori, Hiroyasu Igaki, Kazuo Koyanagi, Jun Iwabu

Introduction

More than 300 new patients with esophageal tumors are admitted to the National Cancer Center Hospital (NCCH) every year. The multidisciplinary treatment plans are determined by the stage of the tumor in close cooperation with other teams. The Department of Esophageal Surgery cooperates in particular with the Department of Gastrointestinal Medical Oncology and the Department of Radiation Oncology for preoperative chemotherapy and chemoradiotherapy and salvage surgery after definitive chemoradiotherapy, and the Department of Endoscopy for diagnosis and endoscopic resection. We also maintain close cooperation with the Department of Head and Neck Surgery for cervical esophageal carcinomas and with the Department of Gastric Surgery for adenocarcinomas in the esophagogastric junction. Patients who required a laryngectomy for resection of cervical esophageal cancer were operated on in the Department of Head and Neck Surgery. Most patients with Siewert Type III adenocarcinoma were operated on in the Department of Gastric Surgery. In our Department, squamous cell carcinomas still constitute the largest proportion of esophageal tumors, and 11 patients with adenocarcinomas of the esophagogastric junction underwent an esophagectomy in 2015.

Routine activities

The Department of Esophageal Surgery consists of three staff surgeons, one chief resident and 1-2 rotating senior residents. A multidisciplinary conference (Esophageal Tumor Board) is held weekly 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. Every week, 2-3 patients with esophageal cancer undergo surgery. One hundred and four patients underwent esophagectomy including four patients with cervical esophageal cancer, three with carcinosarcoma, six with malignant melanoma, three with neuroendocrine tumors, and one with large Schwannoma. Two patients with gastric cancer after esophagectomy underwent gastric conduit resection and reconstruction. Preoperative chemotherapy was recommended for 56 patients and preoperative chemoradiotherapy was recommended for 4 patients with resectable Stage II-IV esophageal squamous cell cancer. A three-field dissection, including the whole upper mediastinum and supraclavicular area in addition to the lower mediastinum and abdomen, was performed on 72 patients as our standard procedure. Video-assisted thoracic surgery was introduced for esophagectomy as minimally invasive surgery in 44 patients. Two hospital deaths occurred due to postoperative complications including postoperative pneumonia and cardiac attack after esophagectomy.

In a paradigm shift toward organ-sparing therapy, the number of patients who receive definitive chemoradiotherapy as their primary treatment for resectable tumors is increasing. A persistent or recurrent loco-regional disease is not infrequent after definitive chemoradiotherapy. Nineteen patients underwent salvage esophagectomy after the failure of definitive chemoradiotherapy in 2015. A three-field dissection is avoided for salvage esophagectomy.

Research activities

Several translational studies are being carried out in cooperation with the National Cancer Center Research Institute. A study of DNA methylation in biopsied specimens is also ongoing to estimate the efficacy of preoperative chemotherapy in patients with advanced esophageal cancer.

Clinical trials

A multi-institutional randomized controlled trial comparing standard preoperative chemotherapy (5FU and cisplatin), an intensive one (5FU and cisplatin plus docetaxel), and preoperative chemoradiotherapy (5FU and cisplatin plus 41.4 Gy irradiation) for Stage II-III esophageal cancer (JCOG1109) is ongoing. A new multi-institutional randomized controlled trial comparing minimally invasive esophagectomy versus open thoracic esophagectomy (JCOG1409) started registration in 2015. A Phase II trial for definitive chemoradiotherapy with or without salvage esophagectomy (JCOG0909) has finished registration. A new Phase II trial for a trimodality strategy with docetaxel plus 5FU and cisplatin (DCF) induction chemotherapy for locally advanced unresectable esophageal cancer followed by conversion surgery for responders and chemoradiotherapy for non-responders (COSMOS) launched in 2013 and has finished registration.

Education

We accepted many surgeons from foreign countries, especially from Asia. A dramatic increase in the incidence of adenocarcinoma has been seen in Western patients. However, in Asian patients, including Japanese patients, squamous cell carcinoma remains the predominant type of esophageal cancer. Japanese strategies and surgical techniques for esophageal squamous cell carcinoma are instructive for Asian surgeons.

Table 1. Number of patients

Table 2. Type of surgical procedure

List of papers published in 2015

Journal

  1. Takahashi T, Yamahsita S, Matsuda Y, Kishino T, Nakajima T, Kushima R, Kato K, Igaki H, Tachimori Y, Osugi H, Nagino M, Ushijima T. ZNF695 methylation predicts a response of esophageal squamous cell carcinoma to definitive chemoradiotherapy. J Cancer Res Clin Oncol, 141:453-463, 2015
  2. Koyanagi K, Igaki H, Iwabu J, Ochiai H, Tachimori Y. Recurrent Laryngeal Nerve Paralysis after Esophagectomy: Respiratory Complications and Role of Nerve Reconstruction. Tohoku J Exp Med, 237:1-8, 2015
  3. Tachimori Y, Ozawa S, Numasaki H, Fujishiro M, Matsubara H, Oyama T, Shinoda M, Toh Y, Udagawa H, Uno T, The Registration Committee for Esophageal Cancer of the Japan Esophageal Society. Comprehensive registry of esophageal cancer in Japan, 2007. Esophagus , 12:101-129 , 2015
  4. Tachimori Y, Ozawa S, Numasaki H, Fujishiro M, Matsubara H, Oyama T, Shinoda M, Toh Y, Udagawa H, Uno T, The Registration Committee for Esophageal Cancer of the Japan Esophageal Society. Comprehensive registry of esophageal cancer in Japan, 2008. Esophagus, 12:130-157, 2015
  5. Tachimori Y, Ozawa S, Numasaki H, Matsubara H, Shinoda M, Toh Y, Udagawa H, Fujishiro M, Oyama T, Uno T, The Registration Committee for Esophageal Cancer of the Japan Esophageal Society. Efficacy of lymph node dissection for each station based on esophageal tumor location. Esophagus, 1-8, 2015
  6. Nozaki I, Kato K, Igaki H, Ito Y, Daiko H, Yano M, Udagawa H, Mizusawa J, Katayama H, Nakamura K, Kitagawa Y. Evaluation of safety profile of thoracoscopic esophagectomy for T1bN0M0 cancer using data from JCOG0502: a prospective multicenter study. Surg Endosc, 29:3519-3526, 2015
  7. Yokota T, Ando N, Igaki H, Shinoda M, Kato K, Mizusawa J, Katayama H, Nakamura K, Fukuda H, Kitagawa Y. Prognostic Factors in Patients Receiving Neoadjuvant 5-Fluorouracil plus Cisplatin for Advanced Esophageal Cancer (JCOG9907). Oncology, 89:143-151, 2015
  8. Kataoka K, Nakamura K, Mizusawa J, Fukuda H, Igaki H, Ozawa S, Hayashi K, Kato K, Kitagawa Y, Ando N. Variations in survival and perioperative complications between hospitals based on data from two phase III clinical trials for oesophageal cancer. Br J Surg, 102:1088-1096, 2015