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Patients after esophagectomy for esophageal squamous cell carcinoma (SCC) occasionally develop metachronous SCC in the residual esophagus. Although most of these second primary lesions are detected as superficial cancer at follow-up endoscopy, it is often difficult to perform endoscopic resection for these lesions near the site of anastomosis. The objective of this study was to evaluate the effectiveness of argon plasma coagulation (APC) for superficial SCC in the residual esophagus after esophagectomy. Twelve patients (involving 15 s primary lesions) received APC for superficial SCC in the residual esophagus after esophagectomy. These lesions were difficult to perform endoscopic resection and they were treated using APC. There was no treatment-related complication. Complete remission (CR) was achieved in 13 (86.6%) of the 15 lesions: CR was achieved in 11 lesions (73.3%) after the first APC course, and in another 2 lesions (13.3%) after two or more APC courses. Of the 2 patients with persisting residual tumor, 1 patient received 12 times repeated-APC courses over 6 years, and eventually achieved local control without metastasis, the other patient received radiotherapy and cervical esophagectomy after treatment failure with APC. All patients survived except for one patient who died of old age and another patient who died of tongue cancer. APC was a safe treatment that was easy to perform. APC was concluded to be an effective treatment for superficial SCC in the residual esophagus after esophagectomy when endoscopic resection was difficult.

Background Killian-Jamieson diverticulum (KJD) is a rare diverticulum arising from a muscular gap in the anterolateral wall of the proximal cervical esophagus. The first choice of treatment for KJD remains controversial due to its rare incidence. Here, we report two cases of KJD for which we performed different surgery: diverticulectomy in one case and diverticulopexy in the other. Case presentation Case 1 involved a 58-year-old woman presenting progressive pharyngeal discomfort for the past year. She was diagnosed as KJD using endoscopic and radiographic findings. She underwent diverticulectomy with cricopharyngeal and proximal esophageal myotomy. Staple line leakage developed at 1 month after surgery and was successfully treated conservatively. At 5 months after surgery, she was asymptomatic. Case 2 involved a 77-year-old woman presenting dysphagia for the past 2 years. She had a history of bilateral breast cancer and had hypertension, asthma, and osteoporosis. Taking her age and medical history into account, we selected diverticulopexy with cricopharyngeal and proximal esophageal myotomy. The postoperative course was uneventful. At 2 years after surgery, she remained free of dysphagia. Conclusion The first choice of surgery for KJD is diverticulectomy. In a high-risk patient, diverticulopexy is a reasonable treatment. We recommend the addition of myotomy as a part of any surgical treatment.

Mucinous gastric carcinoma (MGC) is a rare histological subtype of undifferentiated gastric carcinoma, accounting for ~2.6-6.6% of all gastric cancer cases. The clinicopathological characteristics and prognosis of MGC are controversial. The present study aimed to determine the clinicopathological characteristics and prognosis of patients with MGC. We retrospectively compared the characteristics and postoperative survival of 70 patients with MGC and 2,492 non-MGC (NMGC) cases who underwent surgical resection between 1990 and 2010. MGC was characterised by larger tumor size, macroscopic Borrmann type 2 and 3, T4 invasion of the gastric wall, positive N2 and N3 lymph node metastasis, positive lymphatic vessel invasion, positive venous invasion, peritoneal metastasis and advanced tumor stage III and IV. The prognosis of MGC patients was worse compared to that of NMGC patients, as the former group consisted of more advanced-stage cases. When patients with similar disease stages were compared, the incidence of peritoneal metastasis was significantly higher among MGC patients. However, hepatic metastasis was found significantly more often in NMGC patients. Otherwise, the prognosis of MGC and NMGC patients with similar disease stages was not significantly different. Therefore, our findings indicated that, although MGC is more rare and mostly detected at an advanced stage, the diagnosis of the mucinous histological subtype was not an independent prognostic factor.

A 54-year-old man was admitted at our hospital with a complaint of sudden anterior chest pain. At 1 year previously he had undergone right transthoracic esophagectomy for cancer followed by reconstruction using a gastric tube through a posterior mediastinal route. Upper gastrointestinal endoscopy confirmed a gastropericardial fistula. He was therefore given emergency intensive proton pump inhibitor together with gastric tube decompression using a nasogastric tube. Transabdominal pericardial drainage was surgically performed through a retrosternal space at 4 days after the onset. On the 22nd day after the drainage operation, upper gastrointestinal endoscopy showed healing of the gastropericardial fistula, and he was discharged on the 38th postoperative day. A gastropericardial fistula in the gastric tube following esophagectomy for cancer could be treated with less-invasive procedures including surgical pericardial drainage. Our procedure may be recommended as initial emergency treatment before more invasive procedures such as gastric tube resection and muscle flap plombage.

Purposes The aim of this study was to determine the prognostic factors in salvage surgery following definitive chemoradiotherapy (dCRT) for esophageal cancer.

Situs inversus totalis (SIT) is a rare congenital anomaly in which the positions of the abdominal and thoracic cavity structures are reversed. The reported incidence of SIT is one in 10,000 to 50,000 live births. There are few reports of gastric cancer in individuals with SIT or of the potential complications of surgical intervention in such cases. We report the case of a 79-year-old woman with SIT who underwent surgical treatment for advanced gastric cancer at our hospital and review the pertinent literature. Prior to surgery, abdominal computed topography angiography with 3-dimensional reconstruction was performed to uncover any variations and to verify the exact structures and locations of vessels. Total gastrectomy with D2 lymphadenectomy and cholecystectomy were performed safely and with careful consideration of the mirror-image anatomy.

Mucosal (T1a) and submucosal (T1b) squamous cell carcinoma of the esophagus (ESCC) have often been analyzed together and are staged as the same category in the UICC/TNM staging system. The difference in surgical outcomes between T1a and T1b ESCC therefore remains unclear. The purpose of this study was to examine the differences in surgical outcomes between T1a and T1b ESCC, and to investigate the prognostic factors in T1 ESCC.A prospectively maintained database identified 145 previously untreated patients with pT1 ESCC who underwent radical transthoracic (n = 134) or transhiatal esophagectomy (n = 11). Median follow-up was 108 months.Of the 145 patients, 35 (24 %) had pT1a cancer and 110 (76 %) had pT1b cancer. Lymph node metastasis was present in 45 patients (31 %): 3 patients with pT1a cancer and 42 patients with pT1b cancer (P = 0.0003). The 5-year survival rate for the whole group was 77 %. The 5-year survival rate of the T1a patients was 94 % compared with 72 % for the T1b patients (P = 0.0282). In multivariate analysis, only the depth of tumor invasion (pT1a vs. pT1b) was an independent prognostic factor (hazard ratio 2.358; 95 % confidence interval 1.009–5.513; P = 0.0477).After esophagectomy, the prognosis of patients with pT1b ESCC is significantly worse than that of patients with pT1a ESCC. Infiltration into the submucosa is the only independent prognostic factor affecting survival. These findings suggested that T1a and T1b ESCC could be staged separately in the next version of UICC/TNM staging system.

Here we report on a 54-year-old man who had undergone left pneumonectomy for a primary lung cancer 25 years earlier and who underwent salvage blunt esophagectomy for a recurrent esophageal cancer after definitive chemoradiotherapy. The patient received chemoradiotherapy for a cancer in the upper thoracic esophagus at the clinical stage IA (T1bN0M0) because of a past history of left pneumonectomy for lung cancer, and the esophageal cancer showed complete response. At 1 year after chemoradiotherapy, local recurrence was found in the upper thoracic esophagus. Although chemotherapy using docetaxel was administered, this was not effective. Transhiatal esophagectomy as salvage surgery was successfully done by a combination of laparo-mediastinoscopy assisted blunt dissection with the eversion stripping method. The postoperative course was uneventful. The patient died of lung and brain metastasis at 23 months after the salvage surgery. Transhiatal esophagectomy may be an option as a salvage esophagectomy in cases with a history of major lung surgery.

Recently, several immune checkpoint inhibitors have been developed and are being used to treat malignant melanoma, lung cancer, and other cancers. Several reports have indicated that tumor-infiltrating lymphocytes (TILs) are associated with clinical and histopathologic risk factors in various cancers. However, the role of TILs in esophageal squamous cell carcinoma (ESCC) has not been well studied. This study aimed to investigate the perilesional status of TILs in ESCC and to show associations between TILs and clinical variables. The study enrolled 277 ESCC patients. Evaluation of TILs was performed according to the criteria of the International TILs Working Group 2014, and associations between TIL and clinicopathologic variables were examined. Most of the clinicopathologic factors were not statistically associated with TIL status. The number of patients who received adjuvant therapy was significantly larger in the TIL-negative group. Cancer-specific survival (CSS) of patients in the TIL-positive group was significantly better than in the TIL-negative group. Among the patients who received adjuvant therapy, CSS was significantly better in the TIL-positive group than in the TIL-negative group. Uni- and multivariate analyses identified tumor depth and TIL status as independent prognostic factors for CSS. Among the other clinicopathologic variables, TIL status was the strongest CSS indicator. Tumor-infiltrating lymphocyte status is a strong predictor of good prognosis for ESCC patients.

A 29-year-old woman who swallowed oil cleaner (strong hydroxide: NaOH) by mistake received conservative therapy because of having neither mediastinitis nor peritonitis. She complained of dysphagia 1 month after ingestion. Upper gastrointestinal series showed severe stricture in the middle and lower thoracic esophagus and in the antrum of the stomach. Gastrostomy and jejunostomy were performed on the 87th day after ingestion. Transthoracic subtotal esophagectomy and total gastrectomy followed by esophageal reconstruction using the colon with microvascular anastomosis through a retrosternal route was performed on the 148th day after the ingestion. On open thoracotomy, although dense mediastinal adhesions were found around the esophagus, esophagectomy could be achieved successfully. She was discharged 22 days after the second surgery without postoperative complication.

Reflux esophagitis (RE) is a known complication disturbing patients' quality of life after esophageal resection. It is generally recognized that bile reflux as well as acid reflux cause RE. However, the clinical influence of acid and bile reflux, and Helicobacter pylori (H. pylori) infection on RE in the cervical esophagus after esophagectomy is not yet clarified. Sixty patients who underwent cervical esophagogastrostomy following esophagectomy were enrolled in this study. They underwent examination for H. pylori infection, endoscopic examination, and continuous 24-hour pH and bilirubin monitoring, at 1 month after surgery. The influence of acid and/or bile reflux, H. pylori infection, and others on the development of RE were investigated. RE was observed in 19 patients (32%) at 1 month after esophagogastrostomy, mild RE in 16 (27%), and severe RE in 3 (5%). The percentage of time duration of both acid and bile reflux into the cervical esophagus was higher in patients with RE than in those without (P = 0.027, P 0.14 between non-RE and mild RE (P = 0.017). Acid and/or bile reflux was observed in 31 patients (52%), acid-only reflux in 6 (10%), bile-only reflux in 15 (25%), and acid-and-bile reflux in 10 (17%). Severe RE was observed only in patients having acid-and-bile reflux. On the univariate analysis, no infection of H. pylori, acid reflux, and bile reflux were determined to be the influencing factors to RE among the clinical factors including age, gender, route of esophageal reconstruction, H. pylori infection, and acid-and-bile reflux. In the subanalysis using the logistic model, there were significant correlations between bile reflux and RE irrespective of the presence of H. pylori infection (P = 0.016, P = 0.007). On the other hand, there was a significant correlation between acid reflux and RE only in patients without H. pylori infection (P = 0.039). In the early period after esophagogastrostomy, bile reflux could cause RE irrespective of H. pylori infection, while acid reflex could cause RE only in patients without H. pylori infection. There is a possibility that bile reflux plays an important role in the development of RE after esophagectomy.

Aortic complications after esophageal cancer surgery are rare and usually fatal. Here, we report three patients who underwent thoracic endovascular aortic repair (TEVAR) for aortic complications after esophagectomy for cancer. In the first case, aortic rupture was caused by pyothorax due to residual tumor after esophagectomy. In the second case, aortic rupture was caused by pyothorax due to anastomotic leakage. In the third case, a pseudoaneurysm was caused by surgical injury during esophagectomy. TEVAR was safe and effective for severe aortic complications when graft infection was avoided. The first case died of sepsis on the 84th postoperative day, and the other two cases have survived 4 years and 2 years to date.

The aim of this study was to determine the factors influencing acidity in the gastric conduit after esophagectomy for cancer. Acidity and bile reflux in the stomach and in the gastric conduit were examined by 24-h pH monitoring and bilimetry in 40 patients who underwent transthoracic subtotal esophagectomy followed by esophageal reconstruction using a gastric conduit, which was pulled up to the neck through a posterior mediastinal route in 17 patients, through a retrosternal route in 10 patients, and through a subcutaneous route in 13 patients. They were examined at 1 week before surgery, at 1 month after surgery, and at 1 year after surgery. Helicobacter pylori infection was examined pathologically and using the (13) C-urea breath test. The factors influencing acidity of the gastric conduit were analyzed using the stepwise regression model. Gastric acidity assessed by percentage (%) time of pH 0.14 into the lower portion of the gastric conduit was significantly increased after surgery throughout the period from 1 month after surgery to 1 year after surgery. Multivariate analysis showed that the acidity in the gastric conduit was influenced by H. pylori infection and DGR at 1 month after surgery, and by H. pylori infection and the route for esophageal reconstruction at 1 year after surgery. Acidity in the gastric conduit was significantly decreased after surgery. Acidity in the gastric conduit for esophageal substitutes is influenced by H. pylori infection and surgery. DGR influences the gastric acidity in the short-term after surgery, but not in the long-term after surgery.

【背景】食道癌は重複癌を合併することが多く，とくに頭頸部癌や胃癌の合併が多い。食道癌術後の長期生存例が増加するとともに，胃管癌症例も増加している。【対象と方法】1982～2001年に食道癌手術 (胃管再建術) を施行した608例中，異時性胃管癌を発症した13例 (2.1％) を対象とし，治療成績について検討した。【結果】胃管癌発症時の年齢中央値は66歳，全例男性だった。食道癌手術から胃管癌発見までの期間は中央値6.5年だった。食道癌術後の再建経路は，胸壁前3例，胸骨後2例，後縦隔8例だった。胃管癌発見の契機は，定期的内視鏡検査9例，症状3例，検診異常1例だった。胃管癌の深達度は，T1が8例，T2が2例，T3が1例，T4が2例だった。治療法は，胃部分切除術3例，幽門側胃切除術2例，胃全摘術1例，内視鏡治療6例，ステント留置術1例だった。胃管癌治療後の5年生存率は29.6％だった。現在，5例が生存中で8例が死亡した。死因は，胃管癌死2例，肺癌死1例，手術死亡1例，他病死4例だった。【まとめ】食道癌術後は，長期生存例でも定期的な内視鏡検査が重要である。定期的内視鏡検査により胃管癌を早期に発見し，内視鏡治療にて治療することが肝要であると考える。

Esophageal cancer patients with distant organ metastasis have usually been treated only to palliate symptoms without multimodality therapy. The current study evaluates the role of multimodality therapy in esophageal squamous cell cancer patients with distant organ metastasis. Between February 1988 and January 2007, 80 esophageal squamous cell cancer patients with distant organ metastases were treated at our institution. Multimodality therapy was performed in 58 patients: 43 patients received chemoradiotherapy, 13 underwent surgery followed by chemotherapy and/or radiation therapy, and two received chemotherapy or chemoradiotherapy followed by surgery. Thirteen patients received single-modality therapy; chemotherapy, radiotherapy, or surgery alone. The remaining nine patients received best supportive care alone. The metastatic organ was the liver (n= 40), the lungs (n= 33), bone (n= 10), and other (n= 6). Nine patients had metastasis in two organs. There was no difference in the median survival among the sites of organ metastasis, lung, liver, or bone (P= 0.8786). The survival of patients treated with multimodality therapy was significantly better than that of the patients who received single-modality therapy or best supportive care alone (P < 0.0001). In patients treated with multimodallity therapy, there was no difference in survival for patients treated with surgery compared with patients treated without surgery (P= 0.1291). This retrospective study involves an inevitable issue of patient selection bias. However, these results suggested that multimodality therapy could improve survival of the esophageal squamous cell cancer patients with distant organ metastasis.

SUMMARY Esophageal small cell carcinoma (SmCC) has been regarded as a rare and aggressive tumor with early metastasis. The optimal treatment has not yet been established, and the role of surgery has remained controversial. In this retrospective study, we report seven cases studies of SmCC of the esophagus and analyze the clinical outcomes after surgery. Between 1986 and 2007, there were seven patients with esophageal SmCC treated surgically in our institution. All the patients with clinically limited disease underwent transthoracic esophagectomy with lymphadenectomy. Lymph node involvement was found in all cases irrespective of the depth of tumor invasion. Three of the seven patients were diagnosed as having an extensive disease on pathological examination after esophagectomy. Five patients received postoperative chemotherapy. Two patients are alive with no recurrence at 16 months and at 45 months after surgery. Another one without chemotherapy survived 93 months and died of another disease. The remaining four patients died of recurrent disease or another disease. The median overall survival to date of these patients was 16 months (range 12–93 months). Esophagectomy with lymphadenectomy resulted in a relatively better survival in some patients with esophageal SmCC. We concluded that surgery may be helpful as part of multimodality treatment in selected patients with esophageal SmCC.

Reflux esophagitis (RE) and columnar-lined esophagus (CLE) are frequently observed after esophagectomy. The incidence of these conditions according to time and to the route of esophageal reconstruction after esophagectomy remains unknown. The aim of this study was to clarify any changes and differences of the incidence of RE and CLE in patients who underwent gastric tube reconstruction after esophagectomy. A hundred patients who underwent cervical esophagogastrostomy after resection of the thoracic esophagus were included in this study. We reviewed their endoscopic findings at 1 month, at 1 year and at 2 years after surgery, and compared the incidence rates of RE and CLE with the passage of time and among the three reconstruction routes; a subcutaneous route, a retrosternal route, and a posterior mediastinal route. The incidence rate of RE was 42%, 37% and 38%, at 1 month, 1 year and at 2 years after surgery, respectively. There was no significant difference in the incidence of RE according to the time after surgery. The incidence rate of severe RE (Grade C and D in the Los Angeles Classification) was 9% percent at 1 month after surgery, 18% at 1 year after surgery and 22% at 2 years after surgery, significantly increasing with passage of time. The incidence rate of CLE was 0% at 1 month after surgery, 14% at 1 year after surgery and 40% at 2 years after surgery, significantly increasing with passage of time. No difference was observed in the incidence of RE and that of CLE among the three routes of esophageal reconstruction. Severe RE and CLE increase with passage of time after cervical esophagogastrostomy. Therefore, careful endoscopic follow-up is necessary for such patients irrespective of the route of esophageal reconstruction.

The quality of life in patients who have undergone surgery for esophageal cancer is frequently disturbed by postoperative gastroesophageal reflux disease or pharyngolaryngeal reflux disease. Recently, there have been many reports on gastroesophageal reflux disease after esophagectomy, and only a few on pharyngolaryngeal reflux disease. There is not yet any convenient endoscopic classification of reflux pharyngolaryngitis. We designed a new classification for reflux pharyngolaryngitis based on endoscopic findings. Our new classification consists of the five grades from 0 to IV based on (i) the extent and severity of erythema and/or edema in the pharynx and the larynx, and (ii) the extent and severity of granulation or scarring stenosis in the vocal cords. Ninety-three patients after cervical esophagogastrostomy after esophagectomy (the CEG group) and 28 patients after intrathoracic esophagogastrostomy (the TEG group) were reviewed in this study. We investigated the relation between the severity of reflux pharyngolaryngitis and clinical symptoms in these patients, and the correlation between this new classification of reflux pharyngolaryngitis and the Los Angeles classification of reflux esophagitis. Reflux esophagitis was more severe in the TEG group than in the CEG group, while there was no difference in the grading of reflux pharyngolaryngitis between the two groups. The pharyngolaryngeal symptoms and F-scale scores were not correlated with the severity of reflux pharyngolaryngitis in each group. The grading of reflux pharyngolaryngitis and that of reflux esophagitis was correlated in each group (P

目的：食道癌治療における化学放射線療法（chemoradiotherapy；以下，CRT）の増加に伴い，CRT後の遺残・再発に対するsalvage食道切除例が増加している．当科のsalvage食道切除の治療成績を検討し，治療適応を考察した．方法：1986～2008年に，50 Gy以上のCRT施行後の遺残・再発に対し食道切除を施行した18例を対象とした．結果：cStage I-III（nonT4）/cStage III（T4）-IVaのCRTの効果は，有効6例/7例，無効1例/4例で，CRT終了から手術までの期間は，中央値6か月/2か月だった．前者/後者の手術根治度は，治癒切除2例/4例，姑息切除5例/7例だった．前者の術後1年生存率は，14％で2年生存例はなかった．後者の術後1, 3, 5年生存率は，おのおの36％，18％，9％だった（p＝0.5725）．治癒切除例の術後1, 3, 5年生存率は，おのおの83％，33％，17％だったが，姑息切除例では，1年生存例はなかった（p＝0.0005）．CRT有効例の術後1, 3, 5年生存率は，おのおの39％，15％，7％だったが，無効例では，1年生存例はなかった（p＝0.0106）．手術合併症は，17例（94％）に認め，重篤な合併症は姑息切除例での発生が多かった．salvage食道切除例の予後は，CRTの効果と手術根治度が関与しており，CRT前の進行度は予後に関与なかった．考察：salvage食道切除はCRTが有効な症例の再発で，治癒切除可能例においてのみその手術の意義があると考えられた．

症例は67歳の男性で，手指，顔面の紅斑と四肢の脱力感を主訴に近医を受診した．抗Jo-1抗体陽性のため皮膚筋炎と診断され，当院内科を紹介された．全身の悪性腫瘍検索のため施行した上部消化管内視鏡検査で，胸部食道扁平上皮癌が発見された．右開胸開腹食道亜全摘，3領域リンパ節郭清，胸壁前食道胃管吻合術を施行した．食道癌の最終診断は，T3N4M0, Stage IVaで，CDDP/5-FU少量連日投与による術後化学療法を施行した．化学療法中に手指の色素沈着および掻痒感が出現し，皮膚筋炎が増悪したため，2か月間の休薬期間を要し，化学療法を完遂した．しかし，食道癌の再発とともに皮膚筋炎が再燃し，術後1年2か月で癌死した．皮膚筋炎は悪性腫瘍を高率に合併するが，食道癌合併例の報告は少ない．文献的考察を加え報告する．

A case of esophageal stricture with Barrett’s esophagus after total gastrectomy is reported herein. A 72-year-old woman was referred to our hospital because of dysphagia due to a stricture in the esophagus for 5 years. She had earlier undergone total gastrectomy followed by Billroth II reconstruction consequent to a gastric ulcer at the age of 49 years. She was diagnosed as having an esophageal stricture with Barrett’s esophagus. The 24-h pH monitoring indicated significant reflux of alkaline duodenal contents into the esophagus. The patient underwent duodenal diversion with Roux-en-Y reconstruction. The postoperative course has been uneventful, with no dysphagia and no dilatation. No change in the extent of Barrett’s esophagus has been observed to date at 7 years postoperatively. This case presented with development of Barrett’s esophagus and subsequently of esophageal stricture solely by duodenal reflux. Duodenal diversion was concluded to have been effective for esophageal stricture with Barrett’s esophagus after total gastrectomy.

A 62-year-old woman was referred to our hospital with presenting pigmentation and/or dermal thickening in the nucha, face, axilla, abdomen, and hands. She also presented a history of weight loss of 4 kg during the previous 3 months. She was pathologically diagnosed as having acanthosis nigricans by skin biopsy. She subsequently underwent 18F-FDG-PET, CT, and upper gastrointestinal endoscopy, and then was diagnosed as having malignant acanthosis nigricans with squamous cell carcinoma in the esophagus at the clinical stage of T3, N0, M0, stage IIA in the UICC stage classification. She underwent subtotal esophagectomy through a left thoracotomy with thoracoabdominal two-field lymphadenectomy and esophageal reconstruction using a gastric tube through a retrosternal route. The postoperative course was uneventful, and she was discharged at 26 days after the surgery without any adjuvant therapy. At 6 months after the surgery, the dermal thickening and the pigmentation of the acanthosis nigricans were completely relieved. She is well without recurrence at 1 year to date after surgery. Although acanthosis nigricans is frequently associated with malignancy, malignant acanthosis nigricans with squamous cell carcinoma in the esophagus has been rare.

顆粒細胞腫の表面に併存した食道表在癌を経験したので報告する．症例は50歳の男性で，表在型食道癌の診断で当院紹介となった．上部消化管内視鏡検査で，長径12 mm大の粘膜下腫瘍様の病変で，頂部にヨード不染を示すびらんを認め，生検で高分化型扁平上皮癌と診断された．超音波内視鏡検査では，sm3の診断であった．食道癌Lt，0-Isep，T1bN0M0 Stage Iと診断し，根治的化学放射線療法を施行した．治療後，頂部のルゴール不染は消失したが，粘膜下腫瘍様の腫瘤は，丈は低くなったものの残存した．超音波内視鏡検査にて残存腫瘤は粘膜下層主体の粘膜下腫瘍と診断し，内視鏡的粘膜切除術を施行した．病理組織学的検査より食道顆粒細胞腫と診断された．最終的に顆粒細胞腫の表面に0-IIc型食道癌を合併したものと診断した．

症例は45歳の女性で，1年前に腹部食道癌に対し，左開胸開腹下部食道噴門側胃切除術を施行．術後診断はpT3N0M0 Stage IIで根治度Aであった．経過観察中，CTで気管前リンパ節の腫大を認めた．確定診断のため，胸腔鏡補助下リンパ節摘出術を施行した．組織学的には，強い中心乾酪壊死を伴う類上皮細胞肉芽腫とLanghans型巨細胞を認め，リンパ節結核の所見であった．結核菌の検出は確認できなかったが，術後に施行したツベルクリン反応は強陽性であり，病理組織学的検査よりリンパ節結核と診断した．抗結核薬を6か月間内服し，その後の経過は良好であった．現在，食道癌手術後3年，結核の診断後2年経過しているが，ともに再発・再燃は認めていない．腹部食道癌術後の上縦隔リンパ節再発，特に“気管前リンパ節再発”はまれであり，術後経過中に，この部位のリンパ節腫大を認めた場合は，癌以外の疾患，特に縦隔リンパ節結核も鑑別の一つとして考慮すべきである．

Background There remains controversy over what constitutes the optimal rational extent of lymphadenectomy, in other words, the concept of rational lymphadenectomy, for cancer of the cervical esophagus. The purpose of this study was to propose the concept of a rational N category for cancer of the cervical esophagus that indicates more clearly which cluster(s) of lymph nodes should be resected during resection of a cancer of the cervical esophagus.

症例は67歳，男性．腹部大動脈周囲リンパ節を含む多発リンパ節転移を伴う進行胃癌を認め，根治切除困難と考え，5-Fu 500mg+CDDP 10mg/day投与（day1～5，8～12），2週休薬を2コース施行した．さらに，TS-1 120mg/dayを21日間投与とCDDP 40mg/dayをday8，15，22に投与した．原発巣は肉眼所見で潰瘍瘢痕となり，生検では癌細胞は検出されなかった．リンパ節腫大はCT上完全に消失した．奏効度CRと判断し，幽門側胃切除術+リンパ節郭清（D2+No.16のサンプリング）を施行した．術後病理組織学的診断では胃および摘出リンパ節に癌細胞は認められず，組織学的効果判定Grade3と判断した．術後は，TS-1の内服（4週内服2週休薬）を1年行い，現在術後2年経過にて再発の徴候はない．大動脈周囲リンパ節転移陽性進行胃癌に対する術前化学療法が有効で根治手術が可能であった1例を経験したので報告する．

症例は87歳, 男性. 血便, 肛門痛を主訴に当院受診となった. 32歳時に痔瘻を指摘され切開の既往があった. 3時, 9時方向に痔瘻の手術瘢痕と2次口を認め, 直腸指診では肛門管の6時方向に母指頭大の疼痛伴う弾性硬な腫瘤を触知した. また肛門縁より約4cmの直腸左側壁より前壁にかけて可動性のない硬結伴う腫瘤を触知した. 瘻孔からの排膿は認めなかった. 精査の結果, 直腸Rb腫瘍の生検で中分化型腺癌の診断を得た. 痔瘻部結節からの生検では悪性所見は認めなかった. 痔瘻を伴う直腸癌の診断で腹会陰式直腸切断術, D2郭清を施行した. 病理組織診断で直腸癌は中分化型腺癌2型, 40×45mm, pA, pN1 (1/7), sH0, cP0, cM0, fStage, IIIa, であった. 痔瘻部には粘液癌を認め, 直腸癌と痔瘻癌は組織学的にも連続性は認められなかった. 今回, 直腸と痔瘻部の重複癌の1例を経験した. 直腸癌と痔瘻癌の重複は稀であり文献的考察を加え報告する.

This case report describes a small cell carcinoma in the esophagus with a squamous cell carcinoma that developed multiple fistulae. Autopsy findings demonstrated that both the primary tumor and the metastatic lymph nodes became necrotic and caused an abscess cavity spreading into the mediastinal, retroperitoneal, and subcutaneous spaces. An esophageal stent was effective for palliation.

Here, we report a case of long-term survival after resection of an adenocarcinoma in Barrett's esophagus with metastasis to Virchow's node. A 71-year-old woman was referred to our hospital with a tumor in the lower third of the thoracic esophagus, located just beneath the tracheal bifurcation because of an hiatal hernia. On admission, she had a palpable lymph node in Virchow's node. The esophageal tumor and this lymph node were biopsied. They were pathologically found to be an adenocarcinoma in the esophagus which had metastasised to the lymph node. She underwent transthoracic esophagectomy with three-field lymph node dissection. The pathological diagnosis was adenocarcinoma in Barrett's esophagus with the UICC stage classification of pT1, pN1, pM1-LYM, Stage IVB. She received postoperative chemotherapy of cisplatin combined with 5-fluorouracil. The patient is well without recurrence at 14 years to date after surgery. We recommend thoracoabdominal esophagectomy with three-field lymphadenectomy for an advanced carcinoma in the upper and middle thoracic esophagus regardless of histological types.

はじめに: 食道癌は他臓器癌との重複が多いことはよく知られている. 重複癌の中でも頭頸部領域癌と胃癌の重複が最も多い. 対象と方法: 1982年から2001年までに当科に入院した食道癌1,050例のうち, 他臓器重複癌を合併した241 例を対象とし, 検討を加えた. 結果: 重複癌の頻度は23% であった. 5年ごとの集計では, 12%, 19%, 26%, 31% と年ごとに増加していた. 対象臓器は頭頸部領域癌 (40%) と胃癌 (29%) が多かった. 10 年ごとに前後期に分けると, 頭頸部領域癌の比率は33%から42%へ増加したが, 胃癌の比率は変わらなかった. 食道癌治療後の他臓器重複癌による死亡は, 5.5%に認めた. その原因として, 頭頸部領域癌が40%と最も多く, 次いで肺癌が17%, 肝細胞癌が16% であったのに対し, 胃癌の比率は9% と少なかった. 重複癌の頻度は増加したが, 他臓器重複癌による死亡の比率は次第に減少していた. これは重複癌への対策が効を奏した結果と考えられた. 考察: 食道癌の治療においては, 再発だけでなく, 重複癌を念頭に置いた, follow-upが重要である.

Background: A definitive combined modality therapy superior to surgery alone has not yet been found for esophageal cancer. This retrospective study investigated the impact of postoperative adjuvant chemotherapy in patients who underwent curative (R0) esophagectomy with radical lymphadenectomy. Study Design: Two hundred and eleven patients with a squamous cell carcinoma in the thoracic esophagus who underwent transthoracic curative (R0) esophagectomy with radical lymphadenectomy, such as 3-field lymphadenectomy or total 2-field lymphadenectomy, between 1988 and 2000, were retrospectively reviewed. Ninety-four patients received postoperative chemotherapy – 2 courses of cisplatin (CDDP) plus fluorouracil (5-FU) or vindesine (VDS) – while the other 117 patients received surgery alone. The overall survival rate was compared between the two groups after being stratified by the numbers of the metastasis- positive lymph nodes. Results: Only in the subgroup of patients with 8 or more lymph nodes metastasis- positive, the surgery-with-postoperative-chemotherapy group had a significantly better survival than the surgery-alone group. No significant difference was found in survival between the two groups in any other stratified subgroup. Conclusions: Postoperative adjuvant chemotherapy following curative (R0) esophagectomy with radical lymphadenectomy such as 3-field lymphadenectomy or total 2-field lymphadenectomy provided a benefit only in patients having metastasis in a large number – 8 or more – lymph nodes.

Proximal gastrectomy (PG) is a widely accepted, efficient treatment for upper-third early gastric cancer. However, it is associated with reduced quality of life (QOL) following surgery, and cancer recurrence in the remaining stomach. Various reconstruction methods have been proposed, but the optimal method has yet to be determined. We investigated the clinicopathological characteristics, reconstruction methods, and postoperative complications in 101 cases of PG, and additionally compared 93 cases of early gastric cancer treated by PG, and 38 cases treated by total gastrectomy (TG). We found that esophagogastrostomy was superior in terms of operation time, intraoperative blood loss, and postoperative hospital stay, while no significant differences were observed in postoperative complications compared with jejunal interposition or jejunal pouch interposition. We found more cases of multiple gastric cancers and advanced-stage cancer in the TG group than in the PG group. The TG group also had a significantly higher proportion of cases with large tumor diameters, low degrees of differentiation, many lymph node metastases, and advanced-stage disease. There were no differences in the recurrence rate or survival rate between the PG and TG groups. The PG group also showed significantly better results in operating time, intraoperative blood loss, and postoperative complications, with a tendency toward shorter hospital stays. In conclusion, PG is a curative but less invasive treatment for upper-third early gastric cancer, and esophagogastrostomy can be considered the most satisfactory reconstruction method following PG.

食道癌術後の再建胃管潰瘍経過中に発見された胃管癌を経験した.症例は68歳男性, 5年前に胸部中下部食道癌にて右開胸開腹食道亜全摘,胸壁前経路胃管再建術を施行.術後10カ月,胃角部小彎に深い潰瘍を認めた. PPI投与開始し, 3カ月後には潰瘍はほぼ治癒していたため, H2-プロッカーに変更.しかし, 7カ月後に再発を認めた.胃管内24時間pHモニタリングで夜間のpHの著明な低下とHP菌の検出を認め, PPIに変更し治療を続行.この間の生検では悪性所見を認めず, HP菌は陰性化した. 1999年11月,潰瘍部より中分化型腺癌が検出され,胃管部分切除術を施行.組織学的には, 2.0cm大のUI-IVの潰瘍を伴ったsm2癌であった.食道癌と胃管癌の重複癌においては,胃管癌の程度に予後が左右されると言われているため,定期的な内視鏡検査による早期発見早期治療が必要と思われる.

The objective of this study was to compare the effects of two types of enteral supplements, an antioxidant-enriched enteral nutrition (AeEN) and an immune-enhancing enteral nutrition (IeEN), on the nutrition, immunoinflammatory response, antioxidant capacity and clinical outcomes in patients after esophagectomy for cancer.Patients (n = 20) undergoing esophagectomy for cancer were randomized in this single-center, open-label study. Two types of enteral supplements were used for 5 days before surgery and 7 days after surgery. The circulating levels of nutritional markers, immunoinflammatory markers, oxidative stress markers, and the antioxidant capacity were compared throughout the perioperative period, and the patients' clinical outcomes were also compared.The circulating levels of nutritional markers decreased after surgery, but the changes were not significantly different between the AeEN group and the IeEN group throughout the perioperative period. Surgery increased the immunoinflammatory markers, and the levels were not significantly different between the groups after surgery. Surgery also increased the levels of oxidative stress markers, but there were no significant differences between the groups throughout the study period.The results of this pilot study suggest that AeEN and IeEN have a similar effect on nutrition, the immunoinflammatory response, antioxidant capacity and clinical outcomes after esophagectomy for cancer. These findings, therefore, warrant further studies on a larger scale.

Background Photodynamic therapy (PDT) has been found to be safe and effective in patients with small early esophageal squamous cell carcinoma (SCC). However, its efficacy for widespread superficial SCC has not yet been confirmed. Objective To assess the long-term survival, complications, and recurrence of PDT for large superficial esophageal SCC. Design Retrospective study. Setting Tertiary referral center. Patients A total of 38 patients with superficial SCC of the esophagus. All patients had a large unifocal lesion or multifocal lesions that were too large to be resected endoscopically. In addition, all patients were physiologically unfit for esophagectomy or had refused surgery. Interventions PDT with porfimer sodium. Main Outcome Measurements Clinical follow-up, long-term survival, complications, and recurrence were evaluated. Results Thirty-one patients (82%) had mucosal cancer (T1m), and 7 (18%) had submucosal cancer (T1sm). No patient had lymph node involvement. Nineteen patients had other primary malignancies. Complete remission was achieved in 33 (87%). At the time of writing, 28 patients (74%) were alive without recurrence. After a median follow-up period of 64 months (range, 7-125 months) after PDT, the overall 5-year survival rate was 76%. There was no treatment-related mortality. Limitations Retrospective study with a small number of patients. Conclusions This long-term follow-up study revealed that PDT was a potentially curative treatment for large superficial esophageal SCC. PDT might be a reasonable alternative to esophagectomy or to endoscopic resection for patients with superficial SCC of the esophagus without lymph node metastasis.

Pharyngolaryngeal reflux has been generally accepted as a cause for pharyngolaryngitis, hoarseness, aspiration pneumonia, chronic cough, and nocturnal asthma. Although patients who have undergone gastric conduit reconstruction after esophagectomy are at a high risk to pharyngolaryngeal reflux disease (PLRD), PLRD after esophagectomy is still unknown. The aim of this study is to investigate the correlation between reflux pharyngolaryngitis and acid reflux into the hypopharynx and into the cervical esophagus in patients who have undergone cervical esophagogastrostomy. We enrolled 62 patients who received follow-up endoscopy and 24-h pH monitoring after cervical esophagogastrostomy. These included 26 at 1 month after surgery and 36 at 1 year or more after surgery. We investigated: (i) the correlation between the extent of reflux pharyngolaryngitis and that of reflux esophagitis based on endoscopic findings; and (ii) the correlation between the extent of reflux pharyngolaryngitis and that of acid exposure -'% time pH < 4' measured by 24-h pH monitoring - in the hypopharynx and in the cervical esophagus, and of acidity in the gastric conduit. There was no difference in acid exposure between the hypopharynx and the cervical esophagus according to time after surgery. However, the acidity in the gastric conduit was significantly more at one year or more after surgery compared with acidity at 1 month after surgery (P= 0.001). There was a significant correlation between acid exposure in the hypopharynx and that in the cervical esophagus (P < 0.001), although acid exposure in the hypopharynx was significantly less than that in the cervical esophagus (P < 0.001). A significant correlation between reflux pharyngolaryngitis and reflux esophagitis was observed (P < 0.001). There was a significant correlation between reflux pharyngolaryngitis and acid exposure in the hypopharynx (P= 0.021), and also that in the proximal esophagus (P= 0.001). The correlation between the extent of reflux pharyngolaryngitis and the acidity in the gastric conduit was not observed. These findings are consistent with pharyngolaryngitis being caused by gastro-esophago-pharyngolaryngeal reflux in patients after cervical esophagogastrostomy, despite the upper esophageal sphincter strongly preventing acid reflux from the cervical esophagus into the hypopharynx.

We report the case of a 50-year-old man with a double aortic arch who underwent esophagectomy for cancer in the middle thoracic esophagus at clinical Stage IIA (T3N0M0), based on the TNM classification (UICC 2002). The patient underwent esophagectomy with three-field lymphadenectomy following neoadjuvant chemotherapy. In such a case, it is important to recognize the anatomy in the upper mediastinum, especially the relationship between the right and left aortic arch, and the recurrent laryngeal nerves using computed tomography (CT) and three-dimensional CT. At first, we performed a cervical lymphadenectomy in order to isolate the bilateral recurrent laryngeal nerves, then mediastinal lymphadenectomy through a right thoracotomy. However, we could not confirm the bilateral recurrent laryngeal nerves during mediastinal lymphadenectomy, and were thus unable to resect them. The postoperative course was uneventful. The patient died of multiple liver metastasis 4 years after the surgery, with no evidence of recurrence in any lymph node.

The need for surgery after chemoradiotherapy for a T4N0-1M0 squamous cell carcinoma in the thoracic esophagus was evaluated. A series of 53 patients were enrolled in this prospective nonrandomized trial from among 124 patients with an esophageal cancer assessed as T4 in Kurume University Hospital from 1994 to 2002. After the first chemoradiotherapy cycle, which consisted of radiotherapy in a total dosage of 36 Gy and chemotherapy using cisplatin (CDDP) and 5-fluorouracil (5FU), the patients each decided, after being informed of the efficacy of the chemoradiotherapy, whether to undergo surgery. All patients, including those who had undergone surgery and those who had not, later underwent a second chemoradiotherapy cycle consisting of radiotherapy in a total dosage of 24 Gy and chemotherapy using CDDP and 5FU, as far as practicable. Among the responders to the first chemoradiotherapy cycle, there was no significant difference in the long-term (5-year) survival rate between the 18 patients who underwent esophageal surgery and the 13 patients who did not (23% vs. 23%). Among the nonresponders, the 11 patients who underwent surgery showed a tendency toward longer survival than the five patients who had had no surgery. The nonresponders had 1- and 2-year survival rates of 64% and 33%, respectively. The corresponding rates for the 5 nonsurgical patients who completed the two chemoradiotherapy cycle were 20% ands 20%, respectively. For a T4N0-1M0 squamous cell carcinoma in the thoracic esophagus, full-dosage chemoradiotherapy (definitive chemoradiotherapy) is preferred for responders to a half-dose of chemoradiotherapy as much as esophagectomy, whereas esophagectomy may be preferred for nonresponders.

Esophageal cancer is one of the most common malignant diseases. However, postoperative recurrences are still resistant to currently available radiochemotherapy. We recently reported a study on the initial clinical efficacy of locoregional adoptive immunotherapy for advanced esophageal cancer. We report here our clinical experience of remarked responses in distant metastatic lesions in a patient with recurrent cancer after receiving this immunotherapy. A male patient underwent curative surgery, and presented with multiple recurrent metastases in the supraclavicular lymph nodes (LNs), liver, and abdominal aortic LNs. Autologous tumor-activated lymphocytes (AuTLs) generated ex vivo were regionally injected into supraclavicular LNs every 2 weeks 13 times. Mean numbers of the administrated cells were 0.8 x 10(9) cells/injection. AuTLs established from peripheral blood lymphocytes stimulated by autologous tumor cells with interleukin-2 were tested for their cytotoxicity before every treatment. During immunotherapy, Grade 2 diarrhea and fever were observed. The clinical partial responses were obtained in all lesions and were sustained for 11 months. Because clinical toxicity was tolerable, this immunotherapy might be useful for patients with far-advanced esophageal cancers.