In Transhiatal Esophagectomy(THE) two approaches can be used by the surgeon: abdominal and cervical, without thoracotomy. A pioneer of this technique was Orringer, with the largest experience world-wide (1085 patients). THE is associated with a lower morbidity compared with the transthoracic approach, but much controversy exists on whether THE is a suitable operation for cancer, because it is not combined with en-bloc lymphadenectomy. However, overall, there are no statistical differences between the two. Frequently esophageal carcinoma is a systemic disease and thus, the biological behavior and the stage of tumor rather than the technique, play a major role.
Accurate staging of patients with esophageal cancer (EC) is essential for selection of appropriate treatment and to predict prognosis. In recent years, positron emission tomography using the positron emitting glucose analogue 18F- fluorodeoxyglucose (FDG-PET) has emerged as a particularly useful adjunct to anatomical imaging modalities as computed tomography (CT) and endoscopic ultrasonography (EUS). In the initial staging of EC the additional value of FDG-PET is its ability to identify distant metastases (stage IV disease), excluding patients from unnecessary surgery. The combination of FDG-PET and endoscopic ultrasonography with fine-needle aspiration (EUS-FNA) has been suggested as the most effective strategy for preoperative EC staging.
Symptomatic inoperable esophageal carcinoma represents a major clinical problem. With no treatment, swallowing deteriorates with a dramatic worsening of quality of life. At present, self-expanding metal stents (SEMS) are the most effective non surgical palliation in inoperable esophageal cancer. The different types of available SEMS, techniques, results and complications are discussed.
Esophageal carcinoma is often diagnosed at an advanced, non resectable stage. Only early stages show a better prognosis. Surgical treatment represents the gold standard. The various surgical techniques do not seem to affect survival. Based on the severity of esophageal cancer and on poor outcome achievable with surgery alone, multimodality treatments are the most suitable. The possible negative impact on the complication rate after neoadjuvant therapy is still debated. Most randomized trials have not demonstrated as yet an improvement in prognosis in patients undergoing a three-modality treatment. However, patients with complete pathologic response after surgical resection were shown to have a better prognosis. In conclusion, additional randomized trials are required, aimed at evaluating all technical and therapeutic variables which affect prognosis.
Malnourished cancer patients undergoing major surgical treatments are at a high risk of morbidity and mortality. As compared to patients affected by other tumors, the highest rate of malnutrition (78.9%) was found in those with esophageal cancer due to postoperative complications. The impact of perioperative nutritional support on outcome in esophageal cancer patients undergoing surgery is analyzed. Strategies that can be used to preserve or restore the nutritional condition in patients throughout treatment are illustrated. Oral supplementation, and enteral or parenteral nutrition are among several methods of support. Enteral option is to be preferred because the intestinal integrity is preserved, the risk of complications is reduced and costs are lower. Prevention or correction of nutrient depletion in severely malnourished esophageal cancer patients remarkably reduces or eliminates malnutrition-related morbidity and mortality. Therefore to identify and treat malnutrition is of the utmost importance.
Endoscopic palliation is the most suitable approach to improve quality of life in patients with esophageal cancer since diagnosis is often made at an advanced stage, when radical treatment is unfeasible. Endoscopy offers several techniques to palliate dysphagia either by stenting the stenosis or by reducing the tumor mass with thermoablation. A small number of randomized controlled trials is available to compare the efficacy of different techniques and the ideal palliation has not been defined as yet. Recently, the development of self-expandable covered metal stents has rapidly gained ground in the endoscopy units throughout the world as a simple, single step procedure for palliation of dysphagia.
Esophageal carcinomas are steadily rising worldwide; they rank sixth among tumors. Adenocarcinoma is the most common histological type in Western countries while squamous carcinoma is more common in the developing countries. Both types are preceded by pre-neoplastic lesions rappresented by Barrett's esophagus for adenocarcinoma and low and high grade dysplasia for squamous carcinoma. Some continuity exists between dysplastic lesions and frankly invasive tumors. Moreover rare hystological types have been described. The surgical pathologist plays an important role in evaluating small endoscopic biopsies as well as in examining surgical specimens from esophagectomy. In the former case the role is exclusively diagnostic while in the latter surgical radicality, cancer stage and outcomes of neoadjuvant therapies are assessed. All these data are crucial not only for prognosis but also for therapy planning.
Given the overall poor prognosis of patients with esophageal carcinoma and considering the new therapeutic options, surgeons should accurately stage patients preoperatively to appropriately tailor their treatment. CT, MRI, PET and EUS are still inaccurate in evaluating local surgical resectability and in detecting abdominal and thoracic lymph node metastases. Minimally invasive surgical staging is a promising adjunct to esophageal cancer staging. The thoracoscopic and laparoscopic staging provide more accurate information for evaluating local invasion, lymph node and distant metastasis. The greater accuracy afforded by minimally invasive staging is essential for patients who should undergo radical surgical or multimodal treatment. According to data reported by many authors, it seems most useful to combine nonoperative staging procedures as CT/MRI and EUS with minimally invasive staging techniques.
Esophagorespiratory fistulas, especially in the upper third of the esophagus, are a complication of malignant esophageal tumors, whose management is difficult and prognosis is poor. Treatment is palliative and involves restoration of the ability to ingest food and prevention of aspiration by insertion of esophageal or tracheobronchial stents. In selected patients the insertion of a single stent may be insufficient for pallation therefore the placement of parallel stents may be indicated in patients with symptoms caused by malignant esophagorespiratory fistula. A case of esophagorespiratory fistula managed with insertion of parallel stents is presented.
Dysphagia represents one of the first possible presenting symptoms of tumors of the esophagus and is one of the main consequences of surgical intervention performed on these tumors. Its treatment is based on accurate evaluation of the residual functional deficit (as well as of the possible pre-existing deglutition deficit) and on implementing both general and specific rehabilitation treatment. These interventions should be carried out by a team of professionals who work together in an integrated and coordinated approach to the global caregiving of patients undergoing esophagectomy, taking into consideration the diverse physical and psychological problems associated with tumor pathology and its treatment modality.
Esophageal cancer with high incidence and mortality rates plays a major clinical and social role. Adjuvant radiotherapy, chemotherapy and combined chemoradiation are used for esophageal cancer patients after esophagectomy. Outcomes of these approaches are analyzed in the literature. Three randomized clinical trials and three retrospective series were reviewed; they provided a representative pattern of available data. From their analysis some critical aspects emerged in relation to the statistical design of the few, now available randomized clinical trials. The number of patients enrolled is too low to verify minimal improvements in outcomes. Therefore, to-date there is not definite evidence in the literature supporting the role of adjuvant chemotherapy in patients undergoing surgery for esophageal cancer.
Mortality rate after esophagectomy ranges from 2% to more than 25% and is related to preoperative and operative factors. Pulmonary complications are frequently seen after esophageal resection with a high mortality rate. The aim of preoperative pulmonary risk assessment is to identify patients who can undergo esophagectomy evaluating patient-related risk factors and their treatment. Preoperative pulmonary risk factors are smoking, respiratory diseases as COPD, elderly age and general condition. Careful medical history, physical examination and pulmonary function testing contribute to identify risk factors and strategies to reduce the risk of pulmonary complications.
Giant liposarcoma is an unusual variant of mediastinal tumors. The case of a 73-year-old woman is reported. She presented with a posterior mediastinal tumor invading the third middle tract of the thoracic esophagus and the adventitia of the descending aorta, close to the posterior pericardium; a neoplastic thrombus 2cm in size was located in the upper left pulmonary vein. The tumor was completely excised by left thoracotomy, in extracorporeal circulation. The postoperative course was uneventful and the patient received adjuvant chemotherapy. She is currently alive after 8 months, disease-free. The natural history, pathology, and prognosis of the disease are reviewed and management of such lesions is discussed.
The impact of esophageal cancer surgery, postoperatively as well as on quality of life (QoL) is still largely unknown. Clinical experience and the scarce existing literature concur that these patients show difficulty in returning to their original lifestyles and previous social activities, not just due to the difficulties common to all tumor pathologies but also for the specific dietary and digestive disturbances which characterize esophageal cancer therapy. As specific rehabilitation protocols are nonexistent in the literature, in this study a rehabilitation planning program, is proposed based on evaluation of postoperative and long-term problems which can be tackled with rehabilitation.
Esophageal cancer is essentially a disease of the elderly. Several studies suggested that age per se should not be considered a risk factor for surgical mortality and morbidity, and access to surgical treatment should not be denied only on the basis of age. Indeed, advanced age may represent an indicator of several factors such as comorbidity or poor physical performance which in turn can increase surgical risk and dramatically reduce life expectancy. Therefore, a careful preoperative assessment of these factors, with particular regard to comorbid conditions (such as cardiovascular and pulmonary diseases), the physiological status, and social habits is necessary in elderly adults. In consideration of the need of a multidisciplinary assessment to identify comorbidities and operative risk, a close collaboration of pneumologists, cardiologists, radiologists, oncologists, thoracic surgeons, anesthesiologists, geriatric specialists, physical therapists is highly recommendable.
The case of a 67-year-old male patient affected by ingravescent obstructive jaundice, calcific choledocholithiasis and cardiopathic hypertension, is presented. On sonography, marked dilatation of intra- and extrahepatic bile ducts with a hyperechoic round neoformation was visualized. CT was performed to ascertain the nature of the lesion. However, it did not confirm the lithiasic nature of the stenosis. Sampling for ERCP was inadequate. Cholangiopancreatography was therefore necessary to establish a correct diagnosis and the subsequent therapeutic approach. Distal choledochal obstruction was evidenced, suspicious for lithiasis obstruction. A definitive diagnosis could not be established on exclusive imaging findings. Surgery was performed with the diagnosis of cholangiocarcinoma with lithiasis.
There is a relationship between a given radiation dose and the resulting biological effect in the management of head and neck cancer. Radiation mucositis represents a frequent complication in cancer chemoradiation. Its prevention and treatment are major goals in radiation therapy schedules. Critical tissues can be spared using high conformal radiation therapy (3DCRT) based on consensus guidelines for target volume. Current approaches to radiation mucositis with respect to the dose and volume impact are illustrated. The monitoring system of late toxicity used by the authors is presented.
Surgical resection remains the mainstay treatment for esophageal cancer and the failure of surgery alone is attributed to the systemic nature of the disease at the time of presentation. In an effort to improve local control of the disease that should correspond to a benefit in survival, postoperative adjuvant schemes of treatment have been explored. Current standard treatment, and future implications in light of the new knowledge are analyzed, based on the present literature. The possibility of different treatments in relation to different histology findings, is stressed.
The case of a 34-year-old female patient come to the Emergency Department for neurological symptoms of recent onset is presented. No-contrast CT documented the presence of a neoformation approximately 3 cm in size in the 4th ventricle. For an in-depth diagnostic study of the lesion contrast enhanced MRI was performed. The examination detected a second minute (< 1cm) intraparenchymal nodule highly suspicious of metastasis from primary extra-cerebral neoplasm. The differential diagnosis of infratentorial lesions is discussed. It is concluded that the diagnostic combination of standard MRI with contrast sequences in the three conventional planes plays a major role in typing the nature of focal brain lesions.
The radiation-induced cardiovascular pathology represents a major cause of morbidity and mortality in patients undergoing therapeutic chest irradiation. There is a broad range of clinical manifestations probably associated with dose, volume and technique of irradiation. From the assumption that prevention is the best way to manage radiation-induced cardiotoxicity, based on the pathophysiogenesis of heart structures, a number of reports of the literature are reviewed. They consider the incidence of cardiovascular disease in patients affected by Hodgkin's lymphoma and breast cancer. The dosimetric prevention is takled in terms of therapeutic procedures and doses (IMRT, 3DCRT) with particular reference to the impact on cardiotoxicity of parameters as maximum heart distance (MHD), mean lung dose (MLD), normal tissue complication probability (NTCP) and V30. The different evaluation criteria of cardiotoxicity are reported, based on the review of the major scoring scales of acute and late complications, which have been worked out in the course of time (LENT-SOMA, RTOG, CTC v.2.0 and CTC v.3.0). The monitoring system of late toxicity used by the authors is presented.
