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SUMMARY The efficacy of using self-expanding metallic stent (SEMS) for palliation of symptoms because of tumor recurrence after prior esophagogastrectomy has not been properly assessed despite the well recognized use of SEMS in patients without prior surgery. The aim of this study is to evaluate the efficacy and safety of using SEMS in patients who had prior esophagogastrectomy. The study group included 35 patients with carcinoma of esophagus or cardia documented to have loco-regional recurrence after esophagogastrectomy and in whom SEMS were placed for palliation. The median age was 67 (ranged 41–85). The indications for stenting were dysphagia caused by recurrence at the esophageal anastomosis (n= 4) and in the esophageal remnant (n= 5), or extrinsic compression from mediastinal nodal disease (n= 7); gastric outlet obstruction produced by extrinsic tumor compression (n= 13); and tracheo-esophageal fistulae (n= 6). Forty-three stenting procedures were performed, and the technical success rate was 97.6%. The dysphagia score improved from 4.66 to 2.54 (P < 0.001). All patients with tracheo-esophageal fistula had their symptoms successfully palliated. The immediate complication rate was 14% (n= 5); two patients had stent malpositioning, two had inadequate opening of their stents, and one had a failed stenting procedure. On follow-up, 15 (42.8%) patients required a total of 22 re-intervention procedures for various reasons: endoscopic dilatation (five dilatations in three patients), removal of foreign bodies (nine procedures in four patients), and insertion of a second SEMS related to tumor growth (eight stents in eight patients). There was no procedure-related mortality. The median survival was short at 42 days (range 5–290 days), mostly related to advanced disease stage. SEMS in patients with recurrent tumor after esophagogastrectomy is safe and effective.

Salvage surgery is one important therapeutic option after locoregional failure of definitive chemoradiotherapy (dCRT) in patients with advanced or recurrent esophageal carcinoma. We have performed cervical lymph node dissection as a salvage surgery after chemoradiotherapy in a patient with recurrent esophageal carcinoma. A 54-year-old Japanese man was admitted to our hospital because of multiple lymph node metastases after endoscopic submucosal dissection (ESD) for early-stage esophageal carcinoma. The patient underwent a circumferential ESD of early-stage esophageal carcinoma in another hospital. The esophageal carcinoma, measuring 75 × 60 mm in size, was a superficial spreading type located in the middle portion of the thoracic esophagus. Histology of the resected specimen revealed a moderately to poorly differentiated squamous cell carcinoma, and the depth of invasion was limited within the mucosal layer associated with a small area being attached to the muscularis mucosae. Five months after ESD, lymph node metastases in the regions of right recurrent nerve and the left tracheobronchus were found, for which dCRT was performed. These metastatic lymph nodes disappeared in the chest CT scan images. Lymph node metastasis in the region of the right recurrent nerve then reappeared 8 months after the completion of CRT. Considering the solitary lymph node metastasis and surgical invasiveness, lymph node dissection using a cervical approach was selected as a salvage surgery. Cervical approach for the lymph node dissection in the region of right recurrent nerve may be one feasible option as a minimally invasive salvage surgery for patients with recurrent esophageal carcinoma after dCRT.

Background Limited locally recurrent esophageal carcinoma is rare, and little is known regarding effectiveness of re-resection. Methods Medical records of 27 consecutive patients with locally recurrent esophageal carcinoma who underwent reoperation at our institution between February 1974 and January 2003 were analyzed. Results The original and recurrent cancer cell types were identical in all patients. Median disease-free interval was 19.4 months (range, 2.5 to 170 months). Recurrence was at the anastomosis in 23 patients (85%), esophageal remnant in 3 (11%), and stomach in 1 (4%). Ten patients had completion gastrectomy and partial esophagectomy, and 9 had resection of the anastomosis. The remaining 8 patients were found intraoperatively to have unresectable disease and underwent biopsy only. Re-resection was complete in 15 of the 19 patients resected (79%). Four patients had microscopic cancer at the resection margins. Reconstruction was with colon in 10 patients and esophagogastrostomy in 9. There were 2 deaths (operative mortality, 7%). Complications occurred in 16 patients (59%). Arrhythmia and anastomotic leak were the most common complications and each occurred in 7 patients (26%). Factors favorably associated with survival were disease-free interval greater than 2 years ( p ≤ 0.05) and complete re-resection ( p ≤ 0.02). Two-, three-, and five-year survival for patients completely re-resected was 62%, 44%, and 35%, respectively. Survival for patients who had incomplete re-resections was 18% at 2 years and zero at 3 years. Conclusions Re-resection of locally recurrent esophageal carcinoma is associated with considerable morbidity. However, long-term survival is possible in patients with a long disease-free interval or a complete re-resection.

Purpose: The aim was to assess the improvement in swallowing status, complication rate, and overall survival. Patients and Methods: Fifty-eight patients with advanced/recurrent esophageal carcinoma were treated for palliation with high-dose-rate intraluminal brachytherapy (HDR-ILRT) with a remote afterloading microSelectron unit (192Ir source) with or without external radiation from November 1994 to May 2000 at the Tata Memorial Hospital. The mean age was 64 years. The mid-third of the esophagus was involved in 38 patients (66%). The group was comprised of 37 previously untreated patients (29 with ≤50% Karnofsky performance status and old age, 4 with metastatic disease, and 4 with second primary esophageal lesions) and 21 patients with post-treatment recurrent tumors. Thirty-eight patients (65%) received intraluminal brachytherapy alone, whereas the remaining 20 patients (35%) received a combination of external and intraluminal radiation therapy. All patients received 2 fractions of HDR-ILRT 1 week apart with 600 cGy per fraction at 1 cm off axis. Results: Overall improvement in swallowing status was seen in 22 patients (48%), and 24 (41%) maintained pretreatment swallowing status. Median dysphagia-free survival was 10 months. Overall complication rates were 30%, with stricture seen in 9 patients (15%), ulceration in 6 (10%), and tracheo-esophageal fistula in 3 patients (5%). Complication rates were higher in the post-treatment group (38%) than in the previously untreated group (27%) (p = 0.29). The median overall survival for the entire group was 7 months. Median survival was better, although not significantly, for the previously untreated cohort: 7.8 months vs. 6 months for the post-treatment group (p = 0.77). Conclusion: HDR-ILRT brachytherapy achieves good palliation with acceptable complications in advanced/recurrent esophageal carcinoma.

The mortality rate of recurrent esophageal carcinoma remains high because of its resistance to chemotherapy and radiation therapy. We present a patient with recurrent esophageal carcinoma, which dramatically disappeared after treatment with the combination of continuous infusion of 5-fluorouracil and low-dose cis-Diamminedichloroplatinum-II (cisplatin) infusion (FP therapy). Furthermore, we immunohistologically found that glutathione S-transferases (GST)-pi, a marker of resistance to cisplatin, was faintly expressed both in the endoscopical biopsy specimens of recurrent tumor and in the resected specimens of esophageal carcinoma and metastatic lymph nodes. FP therapy was suggested to be effective for recurrent esophageal carcinoma. Immunostaining for GST-pi might be a prospective marker for the sensitivity of esophageal carcinoma to FP therapy, particularly cisplatin.

Dysphagia is an important and distressing symptom which has a significant impact on the quality of life of patients with carcinoma of the esophagus. Although endoscopic palliation of dysphagia due to unresectable or recurrent esophageal carcinoma can be provided by esophageal dilatation and intubation, laser ablation, injection of alcohol or sclerosants, or brachytherapy, these techniques are often unsuitable for the palliation of high esophageal tumors. We present a patient with recurrent carcinoma of the proximal esophagus who developed an inability to swallow as a complication of intubation with an esophageal stent. The dysphagia improved dramatically after the stent was removed.

Prognosis of inoperable or recurrent esophageal carcinoma is, at best, poor. Once an esophagotracheal fistula has developed, the overall condition of the patient declines rapidly. Aspiration pneumonia and severe coughing are common. The introduction of esophageal tubes does not always seal the fistula sufficiently and may compromise the airway causing stridor and dyspnea. In 30 patients (25 male, 5 female; age 23 to 74 years; mean, 56 years) with very large fistulas and airway problems, we inserted an airway stent (Dynamic) (n = 12) or an esophageal tube combined with a Dynamic airway stent (n = 18) with the aim of sealing the fistula and restoring patency of the airway and GI passage. The tracheobronchial Dynamic stent was chosen because its slightly concave, flexible posterior silicone membrane adapts ideally to the convex esophageal tube. The stents were well tolerated and significantly improved the quality of life. Of 30 patients, 16 could breathe and swallow unimpaired until shortly before their death. Moderate complaints persisted in five patients, dysphagia in eight patients, and dyspnea in one patient. Mean survival time in the double stent group was significantly greater (110 days) than in the airway stent-only group (24 days) or comparable groups in the literature treated with esophageal tubes only. We conclude that carefully selected patients can benefit from double stenting of esophagus and airways.

To evaluate the effect of the extended lymphadenectomy for thoracic esophageal carcinoma, the pattern of recurrence in the 50 patients with pT3 tumors who underwent esophagectomy with cervical, mediastinal, and abdominal lymph node dissection (3-F) (group A) was compared with that of 100 patients at pT3 who underwent esophagectomy without upper mediastinal and cervical lymphadenectomy (2-F) (group B). The cumulative 5-year survival rate for 115 patients who underwent 3-F was 50.9%. Cumulative 5-year survival rates for patients in groups A and B were 36.8% and 22.0%, respectively. The survival curve for group A was significantly better than group B (P = 0.02332). Lymphatic recurrence was noted less frequently in group A (8/23) than in group B (31/49) (χ2 = 5.1149), whereas the rate of hematogenous recurrence was similar. Extension of the field of lymph node dissection reduced the lymph node recurrence in patients with thoracic esophageal carcinoma, which may have positively affected patient survival. © 1996 Wiley-Liss, Inc.

The feasibility and effectiveness of radiotherapy in the management of recurrent esophageal carcinoma (REC) is reported. A consecutive cohort of 54 patients with rcT1-4, rcN0-1, or cM0 recurrent esophageal carcinoma (69% squamous cell carcinoma, 31% adenocarcinoma) was treated between 1988 and 2010. The initial treatment for these patients was definitive radiochemotherapy, surgery alone, or neoadjuvant radiochemotherapy + surgical resection in 8 (15%), 33 (61%), and 13 (24%) patients, respectively. The median time to recurrence from initial treatment was 19 months (range 4–79 months). The site of the recurrence was anastomotic or local, nodal, or both in 63%, 30%, and 7% of patients, respectively. Salvage radio(chemo)therapy was carried out with a median dose of 45 Gy (range 30–68 Gy). Median follow-up time for surviving patients from the start of R(C)T was 38 months (range 10–105 months). Relief of symptoms was achieved in 19 of 28 symptomatic patients (68%). The median survival time was 12 months (95% confidence interval (CI) 7–17 months) and the median recurrence-free interval was 8 months (95% CI 4–12 months). The survival rates at 1, 2, and 3 years were 55 ± 7%, 29 ± 6%, and 19 ± 5%, respectively. The recurrence-free survival rates at 1, 2, and 3 years were 44 ± 7%, 22 ± 6%, and 15 ± 5%, respectively. A radiation dose ≥ 45 Gy and conformal RT were associated with a better prognosis. RT is feasible and effective in the management of recurrent esophageal carcinoma, especially for relief of symptoms. Toxicity is in an acceptable range. The outcome of REC is poor; however, long-term survival of patients with recurrent esophageal carcinoma after radiochemotherpy might be possible, even with a previous history of radiotherapy in the initial treatment. If re-irradiation of esophageal carcinoma is contemplated, three-dimensional conformal techniques and a minimum total dose of 45 Gy are recommended.

Computed tomographic (CT) scans were retrospectively reviewed for evidence of (a) intragastric soft-tissue mass or gastric wall thickening, (b) extragastric soft-tissue mass or mediastinal lymph node enlargement (local-regional disease), (c) abdominal lymph node enlargement, and (d) metastatic disease to distant organs.Fifty-eight patients with a clinical suspicion of recurrent esophageal carcinoma underwent CT. The thoracic level of local-regional recurrence was compared with the level of the primary tumor.Proof of recurrence status was obtained in 52 of 58 patients. Of the 58 patients, 36 (62%) had CT findings of recurrence, 16 (28%) had no CT findings of recurrence, and six (10%) had CT findings questionable for recurrence. CT accuracy for determining recurrence status was 87%. There was no correlation between the level of primary tumor and that of recurrence.At CT, tumor recurrences were most commonly seen as some combination of local-regional disease, distant metastases, and abdominal lymph node enlargement. CT findings isolated to one region were seen only occasionally.

われわれは胸部食道癌切除後6年3か月経過して発見された遺残食道再発と思われる1例を経験したので報告する.症例は52歳男性で, 6年3か月前に当科にて胸部食道癌に対して右開胸.開腹胸部食道全摘, 胸壁前食道胃吻合を施行されている.術後経過は良好であり, 近医にて経過観察されていたが, 再び嚥下困難が生じるようになった.上部消化管造影および内視鏡検査にて吻合部付近の狭窄が指摘され, 精査目的で当科再入院となった.前回の摘出標本の病理組織学的検討より遺残食道再発と思われた.頸部食道切除および胃管上部部分切除, 両側頸部郭清を行い, 手術用顕微鏡を用いた血管吻合法を併用して遊離空腸を用いて再建した.術後経過は良好で, 再手術後4年経過したが再発の兆候を認めていない.

Despite an increase in radical surgery for esophageal carcinoma, many patients continue to develop recurrent disease. Some reports have suggested that recurrent tumors should be treated aggressively with a combination of chemotherapy and radiotherapy. The aim of this study was to assess the comparative utility of computed tomography (CT) and magnetic resonance imaging (MRI) for the evaluation of recurrence after curative resection of cancer of the esophagus and gastroesophageal junction. To maximize survival benefit, detection of tumor recurrence as early and accurately as possible is important. Twenty-three patients who developed recurrent tumors after curative transthoracic esophagogastrectomy for esophageal carcinoma were analyzed retrospectively. The CT and MRI findings were correlated with pathology or with endoscopic and clinical follow-up. Primary tumor recurrence was detected at the anastomosis side in 19 patients (intraluminal mass in 13 and as diffuse or focal wall thickening in six). Distant recurrence was seen in the liver (n = 5), lung (n = 4), bone (n = 3), abdominal lymph node (n = 4), pleural effusion (n = 2) and pericardial effusion (n = 1). CT and MRI were found equal in showing the intraluminal mass, liver metastasis, pleural and pericardial effusion. Thickening of esophageal wall was demonstrated in nine patients using CT, but only seven of these tumor recurrences were confirmed by MRI, the remaining two were related to secondary fibrosis. Both CT and MRI showed diffuse gastric wall thickening determined as false tumor recurrence due to severe gastritis in one case. There were two (50%) false negatives for lung metastasis in MRI and one bone metastasis (33%) false negative in CT. CT was found superior in the demonstration of lung metastasis and MRI was superior in the evaluation of wall thickening and bone metastasis.

Background Recent advances in chemoradiotherapy for esophageal carcinoma have resulted in improved survival rates. However, there are few options for recurrent dysphagia due to refractory carcinoma after failure of primary chemoradiotherapy. The aim of this study was to evaluate the safety and efficacy of self-expandable metallic stent placement for patients with recurrent esophageal carcinoma where definitive chemoradiotherapy has failed. Methods Thirteen consecutive patients with recurrent squamous cell carcinoma of the esophagus, in whom self-expandable metallic stents were placed after failure of primary chemoradiotherapy, were studied retrospectively. All patients had esophageal obstruction or malignant fistula. Results The oral alimentation status of nine of 13 patients (69%) improved after successful placement of the stent. Following placement of the stent, fever (>38 degrees C) and severe chest pain occurred in 85% (11/13) of the patients. In all patients examined, C-reactive protein was elevated within 1 week of the operation. Esophageal perforation occurred in three patients. Stent-related mediastinitis and pneumonia developed in six (46%) and three (23%) patients, respectively. Seven of the 13 patients (54%) died of stent-related pulmonary complications. Conclusion Although the placement of a self-expandable metallic stent for patients with recurrent esophageal carcinoma after failure of chemoradiotherapy improved their oral alimentation status, we found that this treatment increases the risk of life-threatening pulmonary complications.

We treated a complete obstruction of the left mainstem bronchus due to nonresectable recurrent esophageal carcinoma with a combination of laser therapy, radiation therapy, and the placement of an expandable metallic stent. The patient survived 1 year after the first therapy, with good quality of life. We conclude that a combination of laser ablation, radiotherapy, and stent placement can improve survival and quality of life for the patients with complete malignant bronchial obstruction.

Biopsy tissue from a 72-year-old Japanese woman with metastasis to the cervical lymph nodes of recurrent esophageal carcinoma was adapted for culturing on the surface of lethally X-irradiated confluent monolayers of Balb/c 3T3 cells, and a continuous-growing tumor cell line was developed. These cells were found to contain keratinous material by immunohistochemical staining. We confirmed that these cells were of human origin by performing chromosome analysis. Thus, this line, designated as KSE-2 line, was considered to have originated from metastatic squamous-cell carcinoma of the human esophagus. When the attachment and growth of KSE-2 was examined on various culture surfaces, the confluent monolayers of Balb/c 3T3 cells were found to be more suitable than other substrata, such as plastic and collagen-coated dishes. The fixation of confluent monolayers of 3T3 cells with 3% glutaraldehyde had almost no affect on the colony-forming efficiency of the KSE-2 cells. In addition, the period of lag phase after inoculation of KSE-2 cells on fixed as well as nonfixed monolayers was shorter than that on plastic dishes. The conditioned medium from lethally X-irradiated 3T3 cells did not enhance the attachment and proliferation of KSE-2 cells on both nonfixed and fixed confluent monolayers. From these results, the surface structure itself of the 3T3 confluent monolayer was considered to play an important role in the favorable attachment and proliferation of KSE-2 cells.

In a Phase II study, patients with measurable metastatic or recurrent esophageal carcinoma randomly received after Adriamycin (ADR), 60 mg/M2 I.V. q three weeks, or methotrexate (MTX), 40 mg/M2 I.V. q one week, or 5-fluorouracil (5-FU), 500 mg/m2 I.V. x 5 days q five weeks. Objective partial response rates for 72 patients were 5% for ADR (one of 20), 12% for MTX (three of 26), and 15% for 5-FU (four of 26). There were no complete responses. Median duration of response was 13 weeks. Median survival was 14 weeks (eight weeks for ADR, 14 weeks for MTX, and 15 weeks for 5-FU). Factors of liver metastasis, adjacent anatomic involvement, time from initial diagnosis to study entry, and prior radiation were found to be significant determinants of survival. Adriamycin did not appear to benefit patients with advanced measurable squamous cell carcinoma of the esophagus. Methotrexate and 5-fluorouracil showed comparable activity and survival, although methotrexate was slightly more toxic.

The introduction of any new technique in medicine requires verification of variations of the normal appearance that may simulate disease. The subsequent case of CT of the chest demonstrates a patient with known carcinoma of the esophagus treated with external radiation therapy. A CT chest examination for evaluation of possible recurrent disease was performed 1.5 years after the therapy. This report demonstrates a spurious interpretation of CT of the chest for recurrent esophageal carcinoma.

Nine long-term survivors of carcinoma of the esophagus treated with preoperative x-ray therapy were assessed. Eight lived or are living more than five years after treatment. One was lost to follow-up. None has had recurrent esophageal carcinoma. In view of these findings, the authors recommend preoperative radiotherapy for esophageal cancer.