- Email: [email protected]
The Port Site Recurrence after a Thoracoscopic and Video-Assisted Esophagectomy for Advanced Esophageal Cancer
CASE REPORT
The Port Site Recurrence after a Thoracoscopic and Video-Assisted Esophagectomy for Advanced Esophageal Cancer Satoshi Yamamoto, PhD, Katsunobu Kawahara, PhD, Takafumi Maekawa, PhD, Takeshi Shiraishi, PhD, and Takayuki Shirakusa, PhD
Introduction: Thoracoscopic or video-assisted thoracic esophagectomies have been performed for the last 10 years. Nevertheless, some reports have showed a risk of dissemination with endoscopic or video-assisted surgery for malignant disease. This institute experienced three cases of port site recurrence after a thoracoscopic esophagectomy for advanced esophageal cancer. Following those cases, induction chemo-radiation therapy was performed for patient with advanced esophageal cancer before thoracoscopic or videoassisted esophagectomy. Since introducing induction chemo-radiation therapy, no patients have experienced port site recurrence after a thoracoscopic or video-assisted esophagectomy for advanced esophageal cancer. In this study, the two patients groups are compared before and after the introduction of induction chemo-radiation therapy. Patients and Methods: Between November 1995 and December 2005, thoracoscopic and video-assisted esophagectomies were performed on 112 (72.7%) patients out of 154 who underwent a surgical resection for thoracic and abdominal esophageal cancer. The histologic type of cancer was squamous cell carcinoma in 109 (97.4%) patients and adenocarcinoma in 3 (2.6%). Ninety-one patients were men and 21 were women. The tumor was located in the upper thoracic esophagus in 22 (19.6%) patients, the middle thoracic esophagus in 49 (43.8%), the lower thoracic esophagus in 34 (30.4%), and the abdominal esophagus in 7 (6.2%). Results: Before December 1999, port site recurrence occurred in three cases of those of 29 patients with clinical T2–T4 esophageal cancer from 3 to 6 months after surgery, and pleural dissemination was observed in two of those patients. Since January 2000, induction chemo-radiation therapy (low-dose fluorouracil and platinum ⫹ 40 Gy radiation) has been performed to 31 patients with clinical T2–T4 disease, and port site recurrence has not occurred in any patients who received trimodality therapy. Department of Surgery II, Oita University Faculty of Medicine; and Department of Thoracic Surgery, Fukuoka University School of Medicine, Fukuoka, Japan. Disclosure: The authors declare no conflicts of interest. Address for correspondence: Satoshi Yamamoto, PhD, Department of Surgery II, Oita University Faculty of Medicine, Jonan-ku Nanakuma 7-45-1, 8140180 Fukuoka, Japan. E-mail: [email protected] Copyright © 2008 by the International Association for the Study of Lung Cancer ISSN: 1556-0864/09/0401-0131
Conclusions: We think that the trend toward less port site recurrences with induction therapy should be examined in future studies of videoassisted thoracic surgery esophagectomy to confirm our findings. Key Words: Thoracoscopic esophagectomy, Esophageal cancer, Induction therapy, Port site recurrence. (J Thorac Oncol. 2009;4: 131–134)
T
horacoscopic or video-assisted thoracic surgery esophagectomies have been performed routinely over the last 10 years.1–2 Nevertheless, some reports showed a risk of dissemination with endoscopic or video-assisted surgery for malignant disease.3–5 This institute experienced three cases of port site recurrence after a thoracoscopic esophagectomy for advanced esophageal cancer. Following those cases, induction chemo-radiation therapy was performed for patients with advanced esophageal cancer before thoracoscopic or videoassisted esophagectomy. Since introducing induction chemoradiation therapy, no patients have experienced port site recurrence after a thoracoscopic or video-assisted esopahgectomy for advanced esophageal cancer. In this study, the two patients groups are compared before and after introducing induction chemo-radiation therapy.
PATIENTS AND METHODS The criteria for performing a thoracoscopic and videoassisted esophagectomy for patient selection were (1) tumor limited to the esophageal wall, (2) no previous history of the right side major thoracic surgery, and (3) the patients ability to tolerate left side single-lung ventilation. Between November 1995 and December 2005, thoracoscopic and videoassisted esophagectomies were performed on 112 (72.7%) patients out of 154 who underwent surgical resection for thoracic and abdominal esophageal cancer. The histologic type of cancer was squamous cell carcinoma in 109 (97.4%) patients and adenocarcinoma in 3 (2.6%). The ages of the patients ranged from 40 to 79 years; mean 63 ⫾ 9 years. These patients included 91 (81.2%) men and 21 (18.8%) women. The tumor was located in the upper thoracic esophagus in 22 (19.6%) patients, the middle thoracic esophagus in 49 (43.8%), the lower thoracic esophagus in 34 (30.4%), and the abdominal esophagus in 7 (6.2%).
Journal of Thoracic Oncology • Volume 4, Number 1, January 2009
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(%)
Induction Chemo-Radiation Therapy
100
90 80 70
Survival Rate
From January 2000, induction chemo-radiation therapy was performed in 31 patients suspected to have a T2–T3 esophageal tumor detected by computed tomography (CT) scan and endoscopic ultrasonography. The radiotherapy was administered in 1.5 Gy fractions 6 days a week for 27 days. The 5-fluorouracil was given as a continuous infusion of 250 mg/body/d for 20 days along with the radiotherapy. One-hour infusion therapy for cisplatin was administered at a dose of 10 mg/body for 20 days along with the radiotherapy. The induction chemo-radiation group with 31 patients of clinical T2–T3 esophageal cancer treated after 2000 was compared with the group of 29 patients without induction chemo-radiation treated from November 1995 to December 1999.
(n = 112)
50 40 30 20 10 0
0
1
2
3
Stage 0 (n = 3)
(%)
RESULTS The overall 5-year survival rate was 52% (Figure 1). All patients with stage 0 disease were alive after 5 years. The 5-year survival rate was 87% in stage I disease, 70% in stage IIA disease, 68% in stage IIB disease, and 27% in stage III disease (Figure 2). There were no patients with stage IV disease who survived 4 years or longer (Figure 2). The 5-year survival rate of patients with node-negative disease was 75%, and for those with node-positive disease it was 31%. The patient characteristics of the induction chemoradiation group and noninduction chemo-radiation group are shown in Table 1. There is no significant difference between
5 (Years)
FIGURE 1. Overall survival of patients undergoing a thoracoscopic esophagectomy for esophageal cancer.
100
Stage I (n = 23)
90 80
Survival Rate
The technique for a thoracoscopic and video-assisted esophagectomy has been described previously.1 It usually induced three fields (neck, thoracic, and abdominal) lymph node dissection for the patients with esophageal cancer. The patients were placed in the left decubitus position, and left lung ventilation was initiated. Five or six thoracic ports for thoracoscopic devices were inserted from the fourth to eighth intercostal spaces in the anterior, middle, and posterior axillary lines. A 30-degree visual thoracoscope was then inserted through the port placed in the seventh intercostal space at the midaxillary line. The thoracic esophagus and mediastinal nodes were dissected with a harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH). Lymph nodes along the left recurrent laryngeal nerve were dissected with bipolar electric coagulator scissors to prevent heat injury to the nerve. After a total dissection of the thoracic esophagus, the esophagus was then divided at upper thorax. After insertion of a thoracic drainage tube, the patient was placed in the supine position. A collar incision in the neck and an 8-cm upper-median abdominal incision were made, and the surgeon used a headlamp to illuminate the peritoneal cavity. Bilateral neck and abdominal lymph node dissection was performed. The dissection of the lower thoracic and abdominal esophagus was performed via the transhiatal route. The esophagus was pulled into the abdominal cavity. A gastric tube was made and pulled up through the retrosternal route then it was anastomosed end-toend to the cervical esophagus with 4-0 monofilament absolvable sutures.
4
Survival Time
Surgical Procedures
132
60
Stage IIA (n = 21)
70 Stage IIB (n = 21)
60 50 40
Stage III (n = 19)
30 20 10 0
Stage IVA (n = 5)
Stage IVB (n = 19)
0
1
2
3
Survival Time
4
5 (Years)
FIGURE 2. Overall survival by pathologic stage of the patients undergoing a thoracoscopic esophagectomy for esophageal cancer.
TABLE 1.
Patient’s Characteristics of Both Groups Noninduction Group, Induction Group, n ⴝ 29 n ⴝ 31 (1995–1999) (2000–2005)
Age (yr) Gender (male/female) Squamous cell carcinoma Adenocarcinoma Upper thoracic Middle thoracic Lower thoracic Abdonimal c-T2 c-T3 c-T4 c-NO c-Ni Port site recurrence Pathologic response of induction therapy Grade 1a Grade 1b Grade 2 Grade 3
60.8 ⫾ 9.8 24/5 28
59.2 ⫾ 7.9 23/8 31
1 4 12 10 3 6 17 6 7 22 3
0 6 12 11 2 7 22 2 11 20 0
p
0.483
0.981
0.269 0.405 0.101
13 2 12 4
Copyright © 2008 by the International Association for the Study of Lung Cancer
Journal of Thoracic Oncology • Volume 4, Number 1, January 2009
both groups in age, gender, pathologic differentiation, tumor location, and clinical disease staging. Port site recurrence occurred in three patients from 3 to 6 months after surgery, and two patients experienced simultaneous pleural dissemination. All of those patients underwent a thoracoscopic esophagectomy between November 1995 and November 1999, and they had not received induction chemo-radiation therapy. The pathologic stage of the patient was T2N1M0 stage III, T3N1M0 stage III, and T3N1M1B stage IVB disease. These three patients underwent chest wall resection or tumor extraction and chemotherapy or radiation therapy for recurrent disease. They died of pleuritis carcinomatosa and lung metastasis 211, 353, and 798 days, respectively, after the esophagectomy. Since January 2000, induction chemo-radiation therapy has been performed for patients with clinical T2–T4 disease, and port site recurrence has not occurred in patients who received trimodality therapy.
Case Case 1 was a 50-year-old man with squamous cell carcinoma of the esophagus. A barium swallow showed an irregular stricture of the middle thoracic esophagus, and endoscopy showed a tumor stricture extending between 27 and 31 cm from the incisors. A CT scan confirmed the presence of a mass of the middle thoracic esophagus, separated from the tracheo-bronchial tree and the aorta and no evidence of distant metastasis. The patient underwent a videoassisted esophagectomy and gastric tube reconstruction via the retro-sternal route. The postoperative course was uneventful and the patient recovered well from the procedure. An esophagogram performed on the seventh postoperative day showed a patent esophago-gastric tube anastomosis and the absence of leaks, and the patient resumed oral feeding with a soft diet. The pathologic examination of the resected specimen confirmed a well differentiated squamous cell carcinoma infiltrating the layer of the proper muscle of the esophagus and cervical, paratracheal, and abdominal nodal metastasis (p-T2N1M1a). Three months after surgery, two 2 cm subcutaneous masses were evident in two port sites of the five port sites of video-assisted thoracotomy. A biopsy under local anesthesia revealed metastatic squamous cell carcinoma. A CT scan showed pleural thickness and dissemination. The patient had radiation therapy to the right pleural cavity; however, the patient died with multiple lung metastasis and pleuraitis carcinomatosa at 211 days after esophagectomy (Table 2). Case 2 was a 59-year-old man with squamous cell carcinoma of the esophagus. A barium swallow showed an irregular stricture of the lower thoracic esophagus, and an endoscopy showed a tumor stricture at 30 cm from the incisors, and the endoscope could not go through to the anal side of the tumor. A CT scan confirmed the presence of a mass of the middle thoracic esophagus, separated from the tracheo-bronchial tree and the aorta and no evidence of distant metastasis. The patient underwent a video-assisted esophagectomy and gastric tube reconstruction via the retrosternal route. The postoperative course was uneventful and patient recovered well from the procedure. An esophagogram performed on the seventh postoperative day showed a patent
TABLE 2.
Port Site Recurrence
Cases of Recurrence
Cases
50-yr-Old (Male) 59-yr-Old (Male) 48-yr-Old (Male)
T factor N factor M factor Tumor location
p-T2 p-N1 p-M1a Middle thoracic
p-T3 p-N1 p-M0 Lower thoracic
Interval of port site recurrence Therapy
3 mo
4 mo
Prognosis
p-T4 p-N1 p-M1a Abdominal esophagus 6 mo
Port site resection Port site resection Port site resection ⫹ radiation (40 ⫹ ⫹ radiation (60 Gy) chemotherapy Gy) (UFT) 211 d died 353 d died 798 d died
esophago-gastric tube anastomosis and the absence of leaks, and the patient resumed oral feeding with a soft diet. The pathologic examination of the resected specimen confirmed a moderately differentiated squamous cell carcinoma infiltrating the muscle layer of the esophagus and paratracheal and abdominal nodal metastasis (p-T3N1M0). Four months after surgery, a 3-cm subcutaneous mass was evident in a port site of the five port sites of video-assisted thoracotomy. A biopsy under local anesthesia revealed metastatic squamous cell carcinoma. A CT scan showed local pleural thickness. The patient had a right chest wall resection with IV–IX rib resection; however, the patient died as a result of pleuraitis carcinomatosa at 353 days after the esophagectomy. Case 3 was a 59-year-old man with squamous cell carcinoma of the esophagus. A barium swallow showed an irregular stricture of the abdominal esophagus, and an endoscopy showed a tumor stricture at 35 cm from the incisors. A CT scan confirmed the presence of a mass of the abdominal esophagus with paratracheal lymph node metastasis. The patient underwent a video-assisted esophagectomy and gastric tube reconstruction via the retro-sternal route. The postoperative course was uneventful and the patient recovered well from the procedure. An esophagogram performed on the seventh postoperative day showed a patent esophago-gastric tube anastomosis and the absence of leaks, and the patient resumed oral feeding with a soft diet. The pathologic examination of the resected specimen confirmed a moderately differentiated squamous cell carcinoma infiltrating over the muscle layer of the esophagus and paratracheal and abdominal nodal metastasis (p-T4N1M1a). Six months after surgery, a 3-cm subcutaneous mass was evident in a port site of the five port sites of video-assisted thoracotomy. A biopsy under local anesthesia revealed metastatic squamous cell carcinoma. A CT scan showed a 30 mm mass in the middle mediastinum. The patient had a radiation therapy for 60 Gy for the mediastinum and 30 Gy for the right chest wall, and the patient demonstrated a partial response. The patient died of pleuraitis carcinomatosa at 798 days after the esophagectomy.
Copyright © 2008 by the International Association for the Study of Lung Cancer
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DISCUSSION Thoracoscopic or laparoscopic surgery has been spreading worldwide over the last decade. Several surgical approaches have been performed using a thoracoscope or laparoscope for several malignant diseases. Therefore, there have been some reports of port site recurrence of laparoscopic surgery for abdominal malignancies,3,4 and some reports of dissemination of malignant tumors after video-assisted thoracic surgery.5 Nevertheless, there are few reports of port site recurrence of the thoracoscopic or video-assisted surgery for esophageal cancer.6 –9 Thoracoscopic or video-assisted esophagectomy has been used in this institute for T1–T3 esophageal cancer. The outcome of the thoracoscopic or video-assisted esophagectomy for the early stage esophageal cancer of T1–T2 is good.2 Nevertheless, three patients demonstrated port site recurrence of clinical T3 esophageal cancer. There are some theories of the port site recurrence of endoscopic surgery for malignant disease.10,11 A “gchimney theory” was described in a literature,12 that is the high gradient subsequent outflow of floating tumor cells through the port wound, which does not occur in a thoracotomy wound. Induction therapy for esophageal cancer has been performed for many years.13–16 Some reports show evidence of the efficacy of induction therapy for advanced esophageal squamous cell carcinoma.17,18 Hsu et al.18 showed a prolonged survival rate for patients with esophageal cancer after induction therapy using daily low dose cisplatin and continuous 5-fluorouracil. Therefore, induction chemotherapy using low dose cisplatin and continuous 5-fiuorouracil, in combination with 40 Gy radiation therapy has been administered to patients with esophageal cancer before a thoracoscopic or video-assisted esophagectomy since 2000. As a result, none of those patients have experienced port site recurrence.
3. 4.
5.
6. 7. 8.
9.
10.
11.
12.
13.
14.
15.
16.
CONCLUSIONS We think that the trend toward less port site recurrences with induction therapy should be examined in future studies of VATS esophagectomy to confirm our findings.
17.
REFERENCES 1. Kawahara K, Maekawa T, Okabayashi K, et al. Video-assisted thoracoscopic esophagectomy for esophageal cancer. Surg Endosc 1999;13: 218 –223. 2. Yamamoto S, Kawahara K, Maekawa T, Shiraishi T, Yoshinaga Y,
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18.
Shirakusa T. Minimally invasive surgery for stage I and II esophageal cancer. Ann Thoracic Surg 2005;80:2070 –2075. Paulucci V, Schaeff B, Schneider M, Gutt C. Tumor seeding following laparoscopy: international survey. World J Surg 1999;23:989 –997. Shoup M, Brennam MF, Karpeh MS, Gillern MS, McMahon RL, Conlon KC. Port site metastasis after diagnostic laparoscopy for upper gastrointestinal tract malignancies: an uncommon entity. Ann Surg Oncol 2002;9:632– 636. Downey RJ, McCormak P, LoCicero J. Dissemination of malignant tumors after video-assisted thoracic surgery: a report of twenty-one cases. J Thorac Cadiovasc Surg 1996;111:954 –960. Law S, Fok M, Chu KM, Wong J. Thoracoscopic esophagectomy for esophageal cancer. Surgery 1997;122:8 –14. Dixit AS, Martin CJ, Flynin P. Port-site recurrence after thoracoscopic resection of oesophageal cancer. Aust N Z J Surg 1997;67:148 –149. Segalin A, Bonavina L, Rosati R, Bettazza S. Parietal seeding of esophageal cancer after thoracoscopic resection. Dis Esophagus 1994; 7:64 – 65. Parekh K, Rusch V, Bauns M, Downey R, Ginsberg R. VATS port site recurrence: a technique dependent problem. Ann Surg Oncol 2001;8: 175–178. Yamashita J, Kurusu Y, Fjino N, Saisyoji T, Ogawa M. Detection of circulating tumor cells in patients with non-small cell lung cancer undergoing lobectomy by video-assisted thoracic surgery: a potential hazard for intraoperative hematogenous tumor cell dissemination. J Thorac Cardiovasc Surg 2000;119:899 –905. Murthy MS, Summaria LJ, Miller RJ, Wyse TB, Goldschmidt RA, Scanlon EF. Inhibition of tumor implantation at sites of trauma by plasminogen activator. Cancer 1991;68:1724 –1730. Hubens G, Pauwels M, Hubens A, Vermeulen P, Van Marck E, Eyskens E. The influence of a pneumoperitoneum on the peritoneal implantation of free intraperitoneal colon cancer cells. Surg Endosc 1996;10:809 – 812. Urschel JD, Vasan H. A meta-analysis of randomized controlled trials that compared neoajuvant chemoradiation and surgery to surgery alone for respectable esophageal cancer. Am J Surg 2003;185:538 –543. Imdahl A, Schoffel U, Ruf G. Impact of neoadjuvant therapy of perioperative morbidity in patients with esophageal cancer. Am J Surg 2004;187:64 – 68. Slater MS, Holland J, Faigel DO, Sheppard BC, Deveney CW. Does neoadjuvant chemoradiation downstage esophageal carcinoma? Am J Surg 2001;181:440 – 444. Struschke M, Stahl M, Wilke H, et al. Induction chemotherapy followed by concurrent chemotherapy and high-dose radiotherapy for locally advanced squamous cell carcinoma of the upper-thoracic and midthoracic esophagus. Am J Clin Oncol 2000;23:233–238. Manzoni G, Pedrazzani C, Laterza E, et al. Induction chemoradiotherapy for squamous cell carcinoma of the thoracic esophagus: impact of increase dosage on long-term results. Ann Thorac Surg. 2005;80:1176 – 1184. Hsu CH, Yen KH, Lui LT, et al. Concurrent chemoradiotherapy for locally advanced esophageal cancer—a pilot study by using daily lowdose cisplatin and continuous infusion of 5-Fuorourscil. Anticancer Res 1999;19:4463– 4468.
Copyright © 2008 by the International Association for the Study of Lung Cancer
The Port Site Recurrence after a Thoracoscopic and Video-Assisted Esophagectomy for Advanced Esophageal Cancer Satoshi Yamamoto, PhD, Katsunobu Kawahara, PhD, Takafumi Maekawa, PhD, Takeshi Shiraishi, PhD, and Takayuki Shirakusa, PhD
Introduction: Thoracoscopic or video-assisted thoracic esophagectomies have been performed for the last 10 years. Nevertheless, some reports have showed a risk of dissemination with endoscopic or video-assisted surgery for malignant disease. This institute experienced three cases of port site recurrence after a thoracoscopic esophagectomy for advanced esophageal cancer. Following those cases, induction chemo-radiation therapy was performed for patient with advanced esophageal cancer before thoracoscopic or videoassisted esophagectomy. Since introducing induction chemo-radiation therapy, no patients have experienced port site recurrence after a thoracoscopic or video-assisted esophagectomy for advanced esophageal cancer. In this study, the two patients groups are compared before and after the introduction of induction chemo-radiation therapy. Patients and Methods: Between November 1995 and December 2005, thoracoscopic and video-assisted esophagectomies were performed on 112 (72.7%) patients out of 154 who underwent a surgical resection for thoracic and abdominal esophageal cancer. The histologic type of cancer was squamous cell carcinoma in 109 (97.4%) patients and adenocarcinoma in 3 (2.6%). Ninety-one patients were men and 21 were women. The tumor was located in the upper thoracic esophagus in 22 (19.6%) patients, the middle thoracic esophagus in 49 (43.8%), the lower thoracic esophagus in 34 (30.4%), and the abdominal esophagus in 7 (6.2%). Results: Before December 1999, port site recurrence occurred in three cases of those of 29 patients with clinical T2–T4 esophageal cancer from 3 to 6 months after surgery, and pleural dissemination was observed in two of those patients. Since January 2000, induction chemo-radiation therapy (low-dose fluorouracil and platinum ⫹ 40 Gy radiation) has been performed to 31 patients with clinical T2–T4 disease, and port site recurrence has not occurred in any patients who received trimodality therapy. Department of Surgery II, Oita University Faculty of Medicine; and Department of Thoracic Surgery, Fukuoka University School of Medicine, Fukuoka, Japan. Disclosure: The authors declare no conflicts of interest. Address for correspondence: Satoshi Yamamoto, PhD, Department of Surgery II, Oita University Faculty of Medicine, Jonan-ku Nanakuma 7-45-1, 8140180 Fukuoka, Japan. E-mail: [email protected] Copyright © 2008 by the International Association for the Study of Lung Cancer ISSN: 1556-0864/09/0401-0131
Conclusions: We think that the trend toward less port site recurrences with induction therapy should be examined in future studies of videoassisted thoracic surgery esophagectomy to confirm our findings. Key Words: Thoracoscopic esophagectomy, Esophageal cancer, Induction therapy, Port site recurrence. (J Thorac Oncol. 2009;4: 131–134)
T
horacoscopic or video-assisted thoracic surgery esophagectomies have been performed routinely over the last 10 years.1–2 Nevertheless, some reports showed a risk of dissemination with endoscopic or video-assisted surgery for malignant disease.3–5 This institute experienced three cases of port site recurrence after a thoracoscopic esophagectomy for advanced esophageal cancer. Following those cases, induction chemo-radiation therapy was performed for patients with advanced esophageal cancer before thoracoscopic or videoassisted esophagectomy. Since introducing induction chemoradiation therapy, no patients have experienced port site recurrence after a thoracoscopic or video-assisted esopahgectomy for advanced esophageal cancer. In this study, the two patients groups are compared before and after introducing induction chemo-radiation therapy.
PATIENTS AND METHODS The criteria for performing a thoracoscopic and videoassisted esophagectomy for patient selection were (1) tumor limited to the esophageal wall, (2) no previous history of the right side major thoracic surgery, and (3) the patients ability to tolerate left side single-lung ventilation. Between November 1995 and December 2005, thoracoscopic and videoassisted esophagectomies were performed on 112 (72.7%) patients out of 154 who underwent surgical resection for thoracic and abdominal esophageal cancer. The histologic type of cancer was squamous cell carcinoma in 109 (97.4%) patients and adenocarcinoma in 3 (2.6%). The ages of the patients ranged from 40 to 79 years; mean 63 ⫾ 9 years. These patients included 91 (81.2%) men and 21 (18.8%) women. The tumor was located in the upper thoracic esophagus in 22 (19.6%) patients, the middle thoracic esophagus in 49 (43.8%), the lower thoracic esophagus in 34 (30.4%), and the abdominal esophagus in 7 (6.2%).
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(%)
Induction Chemo-Radiation Therapy
100
90 80 70
Survival Rate
From January 2000, induction chemo-radiation therapy was performed in 31 patients suspected to have a T2–T3 esophageal tumor detected by computed tomography (CT) scan and endoscopic ultrasonography. The radiotherapy was administered in 1.5 Gy fractions 6 days a week for 27 days. The 5-fluorouracil was given as a continuous infusion of 250 mg/body/d for 20 days along with the radiotherapy. One-hour infusion therapy for cisplatin was administered at a dose of 10 mg/body for 20 days along with the radiotherapy. The induction chemo-radiation group with 31 patients of clinical T2–T3 esophageal cancer treated after 2000 was compared with the group of 29 patients without induction chemo-radiation treated from November 1995 to December 1999.
(n = 112)
50 40 30 20 10 0
0
1
2
3
Stage 0 (n = 3)
(%)
RESULTS The overall 5-year survival rate was 52% (Figure 1). All patients with stage 0 disease were alive after 5 years. The 5-year survival rate was 87% in stage I disease, 70% in stage IIA disease, 68% in stage IIB disease, and 27% in stage III disease (Figure 2). There were no patients with stage IV disease who survived 4 years or longer (Figure 2). The 5-year survival rate of patients with node-negative disease was 75%, and for those with node-positive disease it was 31%. The patient characteristics of the induction chemoradiation group and noninduction chemo-radiation group are shown in Table 1. There is no significant difference between
5 (Years)
FIGURE 1. Overall survival of patients undergoing a thoracoscopic esophagectomy for esophageal cancer.
100
Stage I (n = 23)
90 80
Survival Rate
The technique for a thoracoscopic and video-assisted esophagectomy has been described previously.1 It usually induced three fields (neck, thoracic, and abdominal) lymph node dissection for the patients with esophageal cancer. The patients were placed in the left decubitus position, and left lung ventilation was initiated. Five or six thoracic ports for thoracoscopic devices were inserted from the fourth to eighth intercostal spaces in the anterior, middle, and posterior axillary lines. A 30-degree visual thoracoscope was then inserted through the port placed in the seventh intercostal space at the midaxillary line. The thoracic esophagus and mediastinal nodes were dissected with a harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH). Lymph nodes along the left recurrent laryngeal nerve were dissected with bipolar electric coagulator scissors to prevent heat injury to the nerve. After a total dissection of the thoracic esophagus, the esophagus was then divided at upper thorax. After insertion of a thoracic drainage tube, the patient was placed in the supine position. A collar incision in the neck and an 8-cm upper-median abdominal incision were made, and the surgeon used a headlamp to illuminate the peritoneal cavity. Bilateral neck and abdominal lymph node dissection was performed. The dissection of the lower thoracic and abdominal esophagus was performed via the transhiatal route. The esophagus was pulled into the abdominal cavity. A gastric tube was made and pulled up through the retrosternal route then it was anastomosed end-toend to the cervical esophagus with 4-0 monofilament absolvable sutures.
4
Survival Time
Surgical Procedures
132
60
Stage IIA (n = 21)
70 Stage IIB (n = 21)
60 50 40
Stage III (n = 19)
30 20 10 0
Stage IVA (n = 5)
Stage IVB (n = 19)
0
1
2
3
Survival Time
4
5 (Years)
FIGURE 2. Overall survival by pathologic stage of the patients undergoing a thoracoscopic esophagectomy for esophageal cancer.
TABLE 1.
Patient’s Characteristics of Both Groups Noninduction Group, Induction Group, n ⴝ 29 n ⴝ 31 (1995–1999) (2000–2005)
Age (yr) Gender (male/female) Squamous cell carcinoma Adenocarcinoma Upper thoracic Middle thoracic Lower thoracic Abdonimal c-T2 c-T3 c-T4 c-NO c-Ni Port site recurrence Pathologic response of induction therapy Grade 1a Grade 1b Grade 2 Grade 3
60.8 ⫾ 9.8 24/5 28
59.2 ⫾ 7.9 23/8 31
1 4 12 10 3 6 17 6 7 22 3
0 6 12 11 2 7 22 2 11 20 0
p
0.483
0.981
0.269 0.405 0.101
13 2 12 4
Copyright © 2008 by the International Association for the Study of Lung Cancer
Journal of Thoracic Oncology • Volume 4, Number 1, January 2009
both groups in age, gender, pathologic differentiation, tumor location, and clinical disease staging. Port site recurrence occurred in three patients from 3 to 6 months after surgery, and two patients experienced simultaneous pleural dissemination. All of those patients underwent a thoracoscopic esophagectomy between November 1995 and November 1999, and they had not received induction chemo-radiation therapy. The pathologic stage of the patient was T2N1M0 stage III, T3N1M0 stage III, and T3N1M1B stage IVB disease. These three patients underwent chest wall resection or tumor extraction and chemotherapy or radiation therapy for recurrent disease. They died of pleuritis carcinomatosa and lung metastasis 211, 353, and 798 days, respectively, after the esophagectomy. Since January 2000, induction chemo-radiation therapy has been performed for patients with clinical T2–T4 disease, and port site recurrence has not occurred in patients who received trimodality therapy.
Case Case 1 was a 50-year-old man with squamous cell carcinoma of the esophagus. A barium swallow showed an irregular stricture of the middle thoracic esophagus, and endoscopy showed a tumor stricture extending between 27 and 31 cm from the incisors. A CT scan confirmed the presence of a mass of the middle thoracic esophagus, separated from the tracheo-bronchial tree and the aorta and no evidence of distant metastasis. The patient underwent a videoassisted esophagectomy and gastric tube reconstruction via the retro-sternal route. The postoperative course was uneventful and the patient recovered well from the procedure. An esophagogram performed on the seventh postoperative day showed a patent esophago-gastric tube anastomosis and the absence of leaks, and the patient resumed oral feeding with a soft diet. The pathologic examination of the resected specimen confirmed a well differentiated squamous cell carcinoma infiltrating the layer of the proper muscle of the esophagus and cervical, paratracheal, and abdominal nodal metastasis (p-T2N1M1a). Three months after surgery, two 2 cm subcutaneous masses were evident in two port sites of the five port sites of video-assisted thoracotomy. A biopsy under local anesthesia revealed metastatic squamous cell carcinoma. A CT scan showed pleural thickness and dissemination. The patient had radiation therapy to the right pleural cavity; however, the patient died with multiple lung metastasis and pleuraitis carcinomatosa at 211 days after esophagectomy (Table 2). Case 2 was a 59-year-old man with squamous cell carcinoma of the esophagus. A barium swallow showed an irregular stricture of the lower thoracic esophagus, and an endoscopy showed a tumor stricture at 30 cm from the incisors, and the endoscope could not go through to the anal side of the tumor. A CT scan confirmed the presence of a mass of the middle thoracic esophagus, separated from the tracheo-bronchial tree and the aorta and no evidence of distant metastasis. The patient underwent a video-assisted esophagectomy and gastric tube reconstruction via the retrosternal route. The postoperative course was uneventful and patient recovered well from the procedure. An esophagogram performed on the seventh postoperative day showed a patent
TABLE 2.
Port Site Recurrence
Cases of Recurrence
Cases
50-yr-Old (Male) 59-yr-Old (Male) 48-yr-Old (Male)
T factor N factor M factor Tumor location
p-T2 p-N1 p-M1a Middle thoracic
p-T3 p-N1 p-M0 Lower thoracic
Interval of port site recurrence Therapy
3 mo
4 mo
Prognosis
p-T4 p-N1 p-M1a Abdominal esophagus 6 mo
Port site resection Port site resection Port site resection ⫹ radiation (40 ⫹ ⫹ radiation (60 Gy) chemotherapy Gy) (UFT) 211 d died 353 d died 798 d died
esophago-gastric tube anastomosis and the absence of leaks, and the patient resumed oral feeding with a soft diet. The pathologic examination of the resected specimen confirmed a moderately differentiated squamous cell carcinoma infiltrating the muscle layer of the esophagus and paratracheal and abdominal nodal metastasis (p-T3N1M0). Four months after surgery, a 3-cm subcutaneous mass was evident in a port site of the five port sites of video-assisted thoracotomy. A biopsy under local anesthesia revealed metastatic squamous cell carcinoma. A CT scan showed local pleural thickness. The patient had a right chest wall resection with IV–IX rib resection; however, the patient died as a result of pleuraitis carcinomatosa at 353 days after the esophagectomy. Case 3 was a 59-year-old man with squamous cell carcinoma of the esophagus. A barium swallow showed an irregular stricture of the abdominal esophagus, and an endoscopy showed a tumor stricture at 35 cm from the incisors. A CT scan confirmed the presence of a mass of the abdominal esophagus with paratracheal lymph node metastasis. The patient underwent a video-assisted esophagectomy and gastric tube reconstruction via the retro-sternal route. The postoperative course was uneventful and the patient recovered well from the procedure. An esophagogram performed on the seventh postoperative day showed a patent esophago-gastric tube anastomosis and the absence of leaks, and the patient resumed oral feeding with a soft diet. The pathologic examination of the resected specimen confirmed a moderately differentiated squamous cell carcinoma infiltrating over the muscle layer of the esophagus and paratracheal and abdominal nodal metastasis (p-T4N1M1a). Six months after surgery, a 3-cm subcutaneous mass was evident in a port site of the five port sites of video-assisted thoracotomy. A biopsy under local anesthesia revealed metastatic squamous cell carcinoma. A CT scan showed a 30 mm mass in the middle mediastinum. The patient had a radiation therapy for 60 Gy for the mediastinum and 30 Gy for the right chest wall, and the patient demonstrated a partial response. The patient died of pleuraitis carcinomatosa at 798 days after the esophagectomy.
Copyright © 2008 by the International Association for the Study of Lung Cancer
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Journal of Thoracic Oncology • Volume 4, Number 1, January 2009
Yamamoto et al.
DISCUSSION Thoracoscopic or laparoscopic surgery has been spreading worldwide over the last decade. Several surgical approaches have been performed using a thoracoscope or laparoscope for several malignant diseases. Therefore, there have been some reports of port site recurrence of laparoscopic surgery for abdominal malignancies,3,4 and some reports of dissemination of malignant tumors after video-assisted thoracic surgery.5 Nevertheless, there are few reports of port site recurrence of the thoracoscopic or video-assisted surgery for esophageal cancer.6 –9 Thoracoscopic or video-assisted esophagectomy has been used in this institute for T1–T3 esophageal cancer. The outcome of the thoracoscopic or video-assisted esophagectomy for the early stage esophageal cancer of T1–T2 is good.2 Nevertheless, three patients demonstrated port site recurrence of clinical T3 esophageal cancer. There are some theories of the port site recurrence of endoscopic surgery for malignant disease.10,11 A “gchimney theory” was described in a literature,12 that is the high gradient subsequent outflow of floating tumor cells through the port wound, which does not occur in a thoracotomy wound. Induction therapy for esophageal cancer has been performed for many years.13–16 Some reports show evidence of the efficacy of induction therapy for advanced esophageal squamous cell carcinoma.17,18 Hsu et al.18 showed a prolonged survival rate for patients with esophageal cancer after induction therapy using daily low dose cisplatin and continuous 5-fluorouracil. Therefore, induction chemotherapy using low dose cisplatin and continuous 5-fiuorouracil, in combination with 40 Gy radiation therapy has been administered to patients with esophageal cancer before a thoracoscopic or video-assisted esophagectomy since 2000. As a result, none of those patients have experienced port site recurrence.
3. 4.
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6. 7. 8.
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CONCLUSIONS We think that the trend toward less port site recurrences with induction therapy should be examined in future studies of VATS esophagectomy to confirm our findings.
17.
REFERENCES 1. Kawahara K, Maekawa T, Okabayashi K, et al. Video-assisted thoracoscopic esophagectomy for esophageal cancer. Surg Endosc 1999;13: 218 –223. 2. Yamamoto S, Kawahara K, Maekawa T, Shiraishi T, Yoshinaga Y,
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Copyright © 2008 by the International Association for the Study of Lung Cancer