Minimally Invasive Staging for Esophageal Cancer

Minimally Invasive Staging for

Anesthesiologist Monitor

EsophagealCance~ Mark j. Krasna , MD, FC CP

Thoracoscopy is an ex cellent means fo r staging es o phage al cancer. Staging of es ophage al carcinoma facilitate s prognostication and allocation of patients to appropriate treatment re gimens. Thoracoscopy is also useful in biopsie s of di rect mediastinal in vasion. Routine thoracoscopic and laparoscopic lymph node stag ing ha s be en used in patients with esophageal ca rcinoma w ith e xcellent re sults. Thoracoscopy can allocate patients for neoadjuvant th erapy and help avo id an unnece ssary thoracotomy in pati e nt s fo un d to have gross spread of loco re gi onal disease. (CHEST 199 7; 112 :191S-194S)

sophageal cancer, including both squamous cell carcinoma and adenocarcinoma, is the fastest-growi ng cance r in th e Unite d States . Most of th e esophageal cance rs are in an advanced stage (T3 or N 1) by the tim e they are evaluated by a thora cic surg eon. Lymp h nod e sp read has been shown to be an important ind ep endent pro gnost ic indicator in esophageal cance r. J Definitiv e staging of patients with esophageal cancer allows their correct assignm ent to treatment regimens according to disease stage . Thoracoscopy is an excellent means for staging intrathoracic malignancies. We have nsed thoracoscopy to allow evaluation of mediastinal lymp h nod es and the degree of direct invasion of sur rounding structu res.

II

Instruments

E

MATERI AL S AND M ETHODS

Th e patient is pla ced in th e lateral decubitus po sitio n with two television monit ors, one over th e patient's head and th e othe r ove r th e patie nt's legs (Fig. 1)2 Th is allows th e sur geon and the first assistant to visualize the same field eq ually, without "mirror imaging." The pati ent is intubated with a dou ble-lum en e ndotracheal tub e for one-lun g ventilation to achieve th e necessa ry exposure. The first incision is made along the posterior axillary line in the sixth int er cost al space , ami th e thoracoscop e is inserted and the chest explored. Two add itiona l incision s are mad e at th e fifth inte rcostal space, ant erior axillary line, and at th e seventh or eighth inter costal space , ante rior axillary line (Fig 2). CO 2 insufflation to com press th e underlying hm g has been used routin ely." At surg ical exploration, assessment of th e e ntire chest [or evide nce of lymph node involve me nt, pleural met astases, pu lmo nary met astases, or dir ect sp read is perfo rmed (Fig 3). A right-s ided thoracoscop y is cur re ntly used rout inely for esophageal cance r staging. Th is avoids the aorta and allows a m aximum number of lymph nod es from which biopsy spe cime ns 'From th e Division of Th oracic and Cardiovascular Sur gelY, Unive rsity of Maryland Scho ol of Medicine, Baltim ore . Reprint requ est s: Mark: j. Krasna , A[D, FC CP, Direct or of Ceueral Th ora cic Surgen j, Associate Prof essor of Sllrgery , Ulliocrsiu] of A[ary[wu! 1Hed ica[ Systelm , 22 S Greell St , Box 16 7, Baltimore, ut: 21201

Monitor

FIGURE 1. Room set up and pa tien t position for th oracoscopy. Hepri nted from Krasna and Mack.?

ca n be taken . Th e azygos vein can be divided with stapl e rs or sutur es to facilitate exposure. Th e medi astin al pleura ove rlying th e proximal esophagus is elevate d lateral to th e posterior edge of th e trachea . Using endoscopic shea rs with electrocaute ry, th e pleura is incised from the level of th e subclavian vessels down to th e azygos arch (Fig 4). Biopsy speci me ns are taken from lymph nodes using hem oclips lor he mostasis. Th e level 2R , 4R, 31', and 10 lymph nodes can be samp led in this way. Th e lun g is retract ed anter iorly by grasping the supe rior seg ment of th e right lower lobe, and the subca rinul space is ide ntified . Th e mediastinal pleura is incised from th e azygos vein to th e infe rior pulmonary vein. Biopsy specime ns of all nodes are again taken using he moclips Ior hem ostasis. Th e lower lobe is graspe d

FIGUHE 2. T rocar place me nt for right -sided th ora coscopy. CHEST / 112/ 4/ OCTOBER, 1997 SUPP LEMENT

1915

FI GURE ,5. Aort ic pulmon ary win dow lymph nod es are identified after incising the med iastin al pleura. Heprint ed fro m Krasna and Mack. 2

F IGURE 3. Dir ect spread of ca nce r to th e aort a (T4).

an d re tracted sup eriorly. The infe rior pu lmon ary ligame nt is divid ed usiug e nd oscopic shears wit h e lectrocaute ry. On ce the inferi or pulmo na ry vein is visua lized, the dissect ion is complete and biopsy specimens are taken from levels 7, 8, and 9 lymph nodes. The chest is irri gated ami examine d lor he mostasis or air leak from retraction. A single 24F chest tube is placed posteriorly ami secured with two O-silk sut ur es . Th e re maining incisions are closed with a 3-0 polyglactin subc utane ous and subc uticu lar suture . If pr eoperative noninvasive staging shows suspicious lymph nod es on the left side , a left thoracosco py is perf orm ed . Inspection of th e aor ticop ulmo na ry window will ide ntify level 5 and 6 lymph nod es. T he rem aind er of th e hem ith orax is examine d for evide nce of gross esophageal tum or exte nsion or met astatic disease to the lun g. The mediastinal pleura ove rlying the lym ph

nod es is incised usiug e lec troc aute ry (F ig .5). Th e incision is continu ed up to the apex of the tJiangle form ed by the phr eni c and vagus ne rves. In fe riorly, th e pleu ra is incised over the left main pulmon ary artery. Lymp h nod es in this region are mob ilized , and th e vascular pedicle is ligat ed with an endoscopic clip appli er . Laparoscopi c lymph node staging is now per form ed routinely. Th e pa tient is placed in th e supine position wit h both television monitors placed at the head of the table . Th e abdom en is prepared and d raped for a standard lap arot om y. Th e pr ocedure is begun with th ree I2-m m ports, altho ugh a fourth port may be neccssary in the left uppcr qu ad rant for retract ion of th e sto mach and place ment of tcn sion on th e gastrohe patic ligam cnt (F ig 6).4 A 30° lap aro scope is helpful lor exposur e of the ope rative field . \ Ve ge nerally use an op e rating scope to allow four instruments to be used with three tro cars . Afte r tho rou gh sur gical exploration of th e pe ritoneal cavity, th e surface of th e live r is insp ect ed and biopsy specim e ns are taken fro m gross abno rmalities and se nt lor fro ze n sec tion . Th e liver is ret racted with an expand able rim ret ract or, an d the lesser sac is e nte re d using sharp d issection th rou gh th e lesse r ome ntum , just to the right o f th e esophagus. The dissection is ca rri ed craniad toward the righ t crus of th e diaph ragm . Most of thi s dissection may be performed with elect rocaute ry, but occasiona l use of clips may be nec essary. Wh e n very large vesse ls are seen in this area , we have used an endoscopic vascular stap ler. Biopsy specimens are taken fro m lymph no des ide ntifled along th e lesser curve (Fig 7). Pu lsatio ns from th e right gastric artery are visible caudally, and division of the ome ntum may stop at th is po int. Exposur e of th e celiac axis is obtained by e levation of th e lesse r cu rve of the sto mach near the gastroesophag ea l junct ion . Th e left gast ric ar te ry is identified by its pulsation as it proj ect s straight up fro m the celiac axis and e nte rs the poste rior wall of th e stom ach , and small lymph nod es can usually be found. In cac hectic patie nts, we ge ne rally place a lap aro scopi c jeju nostomy imm edi atcly before terminating th e procedure . An infu sion port for che mo the rapy can also be placed at thi s tim e. H.ES ULTS

FIGURE 4. T he upper tl.lOracic esophagus is exposed, and biO!)Sy speeuue ns are take n from th e paraesophageal lymph noc es. Hepri nt ed from Krasna and Mack." 1928

Lymph nod e thoracoscopy staging was performecl in 46 pat ients with carcino ma of th e esophagus pr oved by biopsy speci men between Jun e 1992 and Ju ne 1995:5 LaparoMultim odality Therapy of Chest Malig nancie s-Update '96

--Operating Port Placement ,

-...

- '"

. e l :( \, - -- . D....: C ( I'

•B

FI G UH E

6. Setup and trocar pla cem ent for luparoscop ic lymph nod e staging. Heprinted fro m Krasu a.:'

scopic lymph node samplin g was done in the last 20 patients as well. Thoracoscopy was aborted in three patients du e to adh esions . Thoracic lymph node staging was NO in 40 patients and N 1 in three; celiac lymph nodes were negative in 14 and positive in six patients. Esopha geal resection was perform ed in 31 patients afte r lymph node thora coscopy. Eighteen of these patients also und erwent lymph node laparoscopy. Th oracoscopic lymph node staging showed NO status in 29 patients and N1 in two pat ients . Two of the 29 NO patients (7%) wer e found at resection to have para esophageal lymph node involvement (N 1) and wer e thu s und erstaged by lymph node thoracoscopy. Th e overall accuracy of thoracoscopy in detectin g thoraci c lymph node involvem ent was 94% (29/3 1 cases). Laparoscopic lymph node staging found negative celiac lymph nodes in 13 patient s and positive lymph nodes in five pat ients. After esophagectomy, the final staging of the

FIG UHE

(12mm) A: liver retract ion (12mm) B: Camera port C: Operating port and (12mm) jejunostomy site (12mm) 0 : operating port

7. Lesser cu rvatu re lymph nod es seen at laparoscopy,

13 patients originally staged as NO was NO in 12 and positive celiac lymph nodes in one patient. Th e overall accur acy of laparoscopy in detecting lymph node metastases was 94% (17/18 patients). Six of 20 patients und er going laparos copy thus had unsuspected celiac axis lymph node involvement missed by standard nonin vasive techniques. Three percent of thoracic and 17% of celiac lymph nodes were downst aged after preoperative chemoradiothe rapy. DIS C USSION

Lymph node staging has been shown to be an important independent pro gnosticator in esophageal cancer." Th e importance of this classification was described by Skinner et aI, in a study in which operative lymph node staging was used to det ermine which patients needed exte nded resection . Th e patt ern of lymph nod e spread in esophageal cance r typically includes met astasis to at least one thoracic lymph node station in almost all cases despit e the level of the primary tum or." Radiographic staging is generally not accurate for esophageal cance r. Although plain chest radiography may show mediastinal invasion or displacem ent of the airway, this is rarely apparen t. Upper G1 contrast studies can not e the length , circumference, and degree of obstruction of esophageal cancers, but they do not estimate the depth of invasion. CT imaging can show loss of fat planes between the esophagus and surrounding tissues, as well as displacement of the airway du e to tumor growth . CT imaging can also identify enlarged lymph nod es suspicious for tumor involvement (T4 and N1 disease ). MHI has recently been described in the staging of esophageal cance r. Although it can well differenti ate invasion from abutment of surrounding stru ctures, this mod ality is also highly sensitive but highly nonsp ecific." With the advent of esophageal ultrasonography (E US), it was thou ght that the delineation of depth of invasion of esophageal cancer would be clarified . Although E US has CHEST / 112 / 4 / OCTOB ER, 1997 SUPPLEMENT

1935

pr oved useful in T staging, its ability to identify malignant lymph nodes is still limited .' ? Recent reports of transE US-guided lymph node biopsies for lung cancer promise new possibilities for minimally invasive staging of esophageal cancer. I I Mlmay et al 12 described the use of mediastinoscopy and "mini-laparotomy" in 1977. In this series of 30 patient s, 5 had positive lymph nodes at mediastinoscopy and 16 had positive lymph nodes at "mini-laparotomy." This supports th e use of an operative staging tool to different iate localized from advanced esophageal cancer. With the evolution of video technology in the 1990s, thoracoscopy has become an important addition to the tho racic surgical armament arium . In 1993, the results of a pilot trial of left thoracoscopic staging for esophageal cance r were reported . 13 In this study of 14 patients , 12 had correct thoracic lymph node staging and 2 patients had missed celiac lymph node involvement. These results led us to perform routine laparoscopic lymph node staging thereafter. In a multi-in stituti onal study done at three Cancer and Leukemia Group B institutions, > 49 patient s unde rwent thor acoscopic and laparoscopic staging for esophageal cance r.>' This study showed an accuracy of > 90% for both staging techniques. The continued refinem ent of preresection lymph node staging will facilitate the allocation of patient s to neoadjuvaut treatm ent pro grams that will provide the most benefit and pose the fewest risks. Preope rative thoracoscopic lymph node staging may prove to be useful in esophageal cancer as cervical mediastinoscopy staging has proved to be for lung cancer. Thoracoscopic staging of local disease spread may preclud e attem pted resection in patient s fou nd to have T4 disease. A prospective cooperative group trial (Cancer and Leuk emia Group B 9380) is now underway to evaluate the role of thoracoscopic and laparoscopic lymph node staging in esophageal cancer. CONCL USIONS

Thoracoscopy appear s to be highly effective in intrathoracic TNM staging. Tho racoscopy may facilitate allocation of patient s to appropriate adjuvant therapy protocols prior to resection. Th oracoscopy is also useful to determine resectability on the basis of invasion of mediastinal structures (T 4 tumors), thu s avoiding unnecessary thoracotomies in patie nts who may have advanced locoregional disease precluding a compl ete resection. In developing

1945

this new staging tool for standard use in intrath oracic malignancies, thora coscopic staging must be corre lated with both the preope rative assessment using radiographic means and with the final biopsy diagnosis made at the time of tho racoto my. This will standa rdize the technique and determin e its overall efficacy. REFERENCES 1 Ameri can Joint Committee on Cancer. Manu al for stagi ng of cancer. 2nd ed . In : Beah rs OH, Meye rs M, eds. Philadelphia: JB Lippincott , 1983; 61 2 Krasn a MJ, Mack MJ, eds. Atlas of th oracoscopi c surg ery . St. Louis: Qu ality Medical l'ublishin g Inc, 1994 3 W olfe r RS, Krasn a MJ, Hasnain JU, e t a!. Hemodynam ic effects of carbon dioxide ins ufflatio n durin g thoracoscopy. Ann Th orac Surg 1994; 58:404-08 4 Kras na MJ. Thoracoscopic staging for esoph ageal can ce r. In : Reed C , ed. Chest clinics of Kor th America. Philadelph ia: WB Sau nders, 1995; 489-513 5 Krasna MJ, Flowers JL , Atta r S, e t a!. Co mb ined thoracoscopic and lap aroscop ic lymph nod e staging: th e University of Maryland expe rie nce. Thorac Cardiovasc Surg 1996; Ill : 800-07 6 E llis F E Jr, Wa tkins E Jr , Krasna MJ, et a!. Staging of carc inoma of the esophagus and cardia: a comparison of diffe rent staging criteria . J Surg On col 1993; 52 :231-35 7 Skinne r DB , Little A, Fe rguson MK, et al. Selection of op er ation for esophageal cancer based on staging. Ann Thorac Surg 1986; 204:391-40 1 8 Akiyama H, Ts uru maru M, Kawamura T, et a!. Prin ciples of surgical treatment for carci noma of the esophagus. Ann Surg 1981; 194:438-46 9 Maas R, Nicholas V, Grimm H , et al. MHI of esophageal carcinoma with ECG gating at 1.5 Tes la. In: Ferguso n M N, Littl e AG, Skin ner DB , eds. D iseases of the eso phag us. New York: Futura Publishin g, 1990 ; 145-50 10 Rice TW, Boyce GA, Sivall MV. Eso phageal ultrasound and th e preoperative staging of carcinoma of the esophagus . J Th orac Ca rdiovasc Sur g 199 1; 101:536-43 II Silvestri GA, Hoffman BJ, Bhutani MS, et a!. E ndoscopic ultrasou nd with fine needl e aspiration in the diagnosis and stag ing of lun g cance r. Ann Th ora c Surg 1997 (in press ) 12 Murray GF , Wilcox BH, Starek PJ. Th e asses sme nt of operability of esophageal carci noma. Ann Thorac Sur g 1977; 23:393-99 13 Krasna MJ, McL aughlin JS. Thoracoscop ic lymph node stag ing for esoph ageal cance r. Ann Thorac Surg 1993; 56:6 71-74 14 Krasna MJ, Heed C, Sugarb aker D . Thoracoscopi c staging for esophageal cancer. Ann Th orac Surg 1995; 60:1337-40

Multimodality Therapy of Chest Malignanc ies-Update '96