Diagnostic performance of diffusion-weighted magnetic resonance imaging in assessing lymph node metastasis of esophageal cancer compared with PET.

BACKGROUND: Although diffusion-weighted magnetic resonance imaging (DWI) for detecting lymph node (LN) metastasis is reported to be a successful modality for primary malignant tumors, there are few studies relating to esophageal cancer. This study aimed to clarify the diagnostic performance of DWI for assessing LN metastasis compared with positron emission tomography (PET) in patients with esophageal squamous cell cancer (eSCC). METHODS: Seventy-six patients with histologically proven eSCC who underwent curative esophagectomy without neoadjuvant treatment were reviewed retrospectively. Harvested LNs were divided into 1229 node stations with 94 metastases. Diagnostic abilities and prognostic significance were compared. RESULTS: In a station-by-station evaluation, the sensitivity was higher in DWI than PET (67% vs. 32%, P < 0.001). DWI showed more than 80% sensitivity for middle- and large-sized cancer nests and large area of cancer nests. The DWI-N0 group had a better 5-year relapse-free survival rate than the DWI-N+ group (78.5% vs. 34.2%, P < 0.001), as did the PET-N0 group. DWI-N status was an independent prognostic factor (hazard ratio [HR], 2.642; P = 0.048), as was PET-N status (HR 2.481; P = 0.033). CONCLUSIONS: DWI, which depends on cancer cell volume followed by elevated intranodal density, is a non-invasive modality and showed higher sensitivity than PET. It has clinical impact in predicting postoperative survival for patients with eSCC alongside its diagnostic ability and has significant performance in clinical practice.

Endoscopic occlusion with silicone spigots for the closure of refractory esophago-bronchiole fistula after esophagectomy.

A 65-year-old man with cT1bN0M0 stage I middle thoracic esophageal cancer underwent subtotal esophagectomy and gastric tube reconstruction through the posterior mediastinal route after preoperative carbon-ion radiotherapy and chemotherapy in a clinical trial. Anastomotic leakage occurred, but it spontaneously improved. At six months after the operation, he was rehospitalized with a cough and dysphagia. An esophago-bronchiole fistula and stenosis of the gastric tube were observed. He first underwent stent placement in the gastric tube. Two weeks later, the syringeal epithelium was burned by argon plasma coagulation after stent removal. Endoscopic occlusion was then performed for the fistula with two guidewire-assisted silicone spigots. Two weeks later, he was discharged on an oral diet, and he has not developed recurrence of the fistula or cancer for three years. This is the first report of endoscopic occlusion with a guidewire-assisted silicone spigot through the esophagus.

Heterogeneity of Glucose Metabolism in Esophageal Cancer Measured by Fractal Analysis of Fluorodeoxyglucose Positron Emission Tomography Image: Correlation between Metabolic Heterogeneity and Survival.

BACKGROUND: Intratumoral heterogeneity is a well-recognized characteristic feature of cancer. The purpose of this study is to assess the heterogeneity of the intratumoral glucose metabolism using fractal analysis, and evaluate its prognostic value in patients with esophageal squamous cell carcinoma (ESCC). METHODS: 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) studies of 79 patients who received curative surgery were evaluated. FDG-PET images were analyzed using fractal analysis software, where differential box-counting method was employed to calculate the fractal dimension (FD) of the tumor lesion. Maximum standardized uptake value (SUVmax) and FD were compared with overall survival (OS). RESULTS: The median SUVmax and FD of ESCCs in this cohort were 13.8 and 1.95, respectively. In univariate analysis performed using Cox's proportional hazard model, T stage and FD showed significant associations with OS (p = 0.04, p < 0.0001, respectively), while SUVmax did not (p = 0.1). In Kaplan-Meier analysis, the low FD tumor (<1.95) showed a significant association with favorable OS (p < 0.0001). In wthe multivariate analysis among TNM staging, serum tumor markers, FD, and SUVmax, the FD was identified as the only independent prognostic factor for OS (p = 0.0006; hazards ratio 0.251, 95% CI 0.104-0.562). CONCLUSION: Metabolic heterogeneity measured by fractal analysis can be a novel imaging biomarker for survival in patients with ESCC.

Naso-esophageal extraluminal drainage for postoperative anastomotic leak after thoracic esophagectomy for patients with esophageal cancer.

Postoperative anastomotic leaks and subsequent mediastinal abscess are serious complications. The purpose of this study was to assess the efficacy of naso-esophageal extraluminal drainage after thoracic esophagectomy with gastric conduit reconstruction using a posterior mediastinal route. About 50 of 365 patients (13.7%) with esophageal cancer and postoperative anastomotic leak after curative esophagectomy was investigated. Beginning in June 2009, naso-esophageal extraluminal drainage by inserting a naso-esophageal aspiration tube into the abscess cavity when percutaneous abscess drainage was introduced which was ineffective or technically impossible. Twenty-five patients underwent naso-esophageal extraluminal drainage concomitantly with enteral nutrition. Twenty-one (84%) patients had major leaks, one (4%) minor leak and three (12%) had endoscopically proven conduit necrosis. None of the naso-esophageal extraluminal drainage cases (100%) required reintervention or reoperation and all experienced complete cure (100%) during hospitalization. Endoscopic balloon dilatation was performed for four patients after discharge because of anastomotic stricture. Patients with leaks were divided into two groups: current group (n = 32), treated after June 2009, and preceding group (n = 18), treated prior to the introduction of naso-esophageal extraluminal drainage. Significantly more patients in the preceding group suffered respiratory failure (28% vs. 61%, p = 0.024), and higher reoperation rate (0% vs. 17%, p = 0.042) and hospital mortality (0% vs. 22%, p = 0.013). In the current group, 31 (97%) patients experienced complete cure during hospitalization. Naso-esophageal extraluminal drainage and concomitant enteral nutritional support are less invasive, and effective and powerful methods to treat even major leakage after esophagectomy. These methods may be an alternative management to improve mortality for patients with esophageal cancer.

Assessment for diagnosis of lymph node metastasis in esophageal cancer using endoscopic ultrasound elastography.

BACKGROUND: We performed endoscopic ultrasound real-time tissue elastography to more accurately diagnose lymph node metastasis of esophageal cancer. The aim of this study was to evaluate the ability of EUS elastography to distinguish benign from malignant lymph nodes in esophageal cancer patients. METHODS: The present study had two steps. As the first step (study 1), we developed diagnostic criteria for metastatic lymph nodes using elastography and verified the validity of the criteria. Three hundred and twenty-two lymph nodes from 35 patients treated by surgical resection were included in the study. As the second step (study 2), we preoperatively examined the lymph nodes of esophageal cancer patients with EUS elastography and compared its diagnostic performance with that of the conventional B-mode EUS images. A total of 115 lymph nodes from 31 patients were included. RESULTS: In study 1, lymph nodes were considered malignant if 50 % or more of the node appeared blue, or if the peripheral part of the lesion was blue and the central part was red/yellow/green. The sensitivity and specificity of the elastography were 79.7 and 97.6 % with an accuracy of 93.8 %, which was significantly higher than the values for conventional B-mode imaging. In study 2, the sensitivity and specificity of the EUS elastography were 91.2 and 94.5 % with an accuracy of 93.9 %, which was also significantly higher than the values for conventional B-mode EUS imaging. CONCLUSIONS: The present study demonstrated that EUS elastography is useful for diagnosing lymph node metastasis of esophageal cancer.

Giant esophageal gastrointestinal stromal tumor: report of a case.

Gastrointestinal stromal tumors (GISTs) rarely arise in the esophagus, where carcinoma is the most common malignant neoplasm and leiomyoma is the most common benign tumor. Because of their rarity, the clinical course and treatment of esophageal GISTs are poorly understood. These lesions are generally thought to carry a poor prognosis, making the differential diagnosis of other common mesenchymal neoplasms essential, for both prognostic and therapeutic reasons. We report a case of successfully resected giant esophageal GIST, thought to be the largest resected GIST reported in Japan. The patient was a 65-year-old woman, in whom upper gastrointestinal endoscopy found a 180-mm submucosal tumor in the lower thoracic esophagus, extending just below the aortic arch. We diagnosed esophageal GIST, and the patient underwent middle and lower esophagectomy via left thoracotomy, followed by gastric tube reconstruction. The tumor was resected completely. Histopathological and immunohistochemical staining confirmed that the tumor was a high-risk lesion, and treatment with imatinib was initiated. Computed tomography showed liver metastasis 5 months later, but the patient is doing well 24 months after surgery.

The outcome of laparoscopic surgery with and without short gastric vessel division for achalasia.

Short gastric vessel division (SGVD) has been performed as a part of fundoplication for achalasia. However, whether or not SGVD is necessary is still unknown. Forty-six patients with achalasia who underwent a laparoscopic surgery with or without SGVD were analyzed. A questionnaire was administered to assess the postoperative improvement. Regarding improvement of dysphagia and postoperative reflux, there were no significant differences between SGVD (+) group and SGVD (-) group (P = 0.588 and P = 0.686, respectively). Nineteen patients (95%) in the SGVD (+) group and 24 (92%) in the SGVD (-) group answered that the surgery was satisfactory (P = 0.756). In the SGVD (+) group, the pre- and postsurgical body weight increase was +7.3%. In the SGVD (-) group, it was 8.2%. There was no significant difference of body weight increase between the 2 groups (P = 0.354). SGVD is not always required in laparoscopic surgery for achalasia.

A 3-step gradual dilation method: a new safe technique of percutaneous endoscopic gastrostomy for obstructive esophageal cancer.

Although percutaneous endoscopic gastrostomy (PEG) is the preferred method to provide enteral nutrition for a longer time period, in obstructive esophageal cancer, we cannot safely perform endoscopic access to the stomach even with the ultrathin endoscope. We experienced 1 fatal case due to esophageal perforation caused by balloon dilation, and hence, we developed a safer method. We treated 4 patients with obstructive esophageal cancer using a 3-step gradual dilation method with nasogastric tubes (from 8 to 16 Fr). After about 2 weeks of initial dilation, we could safely perform endoscopic access to the stomach with the ultrathin endoscope and PEG placement using the introducer technique. The 3-step gradual dilation method is a safe and easy procedure for endoscopic access to the stomach. It can be used to provide enteral access as a palliative treatment for patients with obstructive esophageal cancer that is not suitable for conventional PEG placement.

Is the outcome of a salvage surgery for T4 thoracic esophageal squamous cell carcinoma really poor?

BACKGROUND: Among patients with T4 thoracic esophageal squamous cell carcinoma (TESCC), it is unclear whether the outcomes of late responders who undergo high-dose chemoradiotherapy (CRT) followed by salvage esophagectomy differs from those of early responders who undergo low-dose CRT followed by esophagectomy. METHODS: A total of 153 patients with T4 TESCC were treated with CRT. The first evaluation was performed after 40 Gy of CRT for downstaging. Of these, 28 patients could be downstaged, and underwent subsequent surgery (early responders). For the remaining patients, additional CRT was administered, and patients were re-evaluated after treatment and underwent salvage surgery. In total, 40 patients (early + late responders) were analyzed. RESULTS: The primary tumors exhibited a grade 3 response in six (21.4 %) of the early responders and two (16.7 %) of the late responders (p = 1.000). The rate of residual tumor in the primary tumor was 80 % (32/40 patients). The proportions of resected lymph nodes and positive metastatic nodes were similar between early and late responders (p = 0.406 and p = 0.859, respectively). The 5-year overall survival rates among the early and late responders were 25.9 and 36.5 %, respectively, and the median survival times were 24.8 and 24.3 months (p = 0.925), respectively. The 5-year cause-specific survival rates in the early and late responder groups were 61.5 and 72.9 % (p = 0.425), respectively. CONCLUSION: The outcomes of both early and late responders to CRT were similar, and salvage surgery for T4 TESCC outweighs the risks in patients with T4 TESCC.

Preoperative hepatic CT perfusion as an early predictor for the recurrence of esophageal squamous cell carcinoma: initial clinical results.

Reports suggest that hepatic blood flow may have an association with cancer progression. The aim of the present study was to evaluate whether the hepatic blood flow measured by CT perfusion (CTP) may identify patients at high­risk for postoperative recurrence of esophageal squamous cell carcinoma (ESCC). Prior to surgery, hepatic CTP images were obtained using a 320-row area detector CT. The data were analyzed by a commercially available software based on the dual input maximum slope method, and arterial blood flow (AF, ml/min/100 ml tissue), portal blood flow (PF, ml/min/100 ml tissue) and perfusion index [PI (%) = AF/AF + PF x 100] were measured. These parameters were compared with the pathological stage and outcome of the ESCC patients. Forty-five patients with ESCC were eligible for this study. The median follow-up period was 17 months, and recurrences were observed in 9 patients (20%). The preoperative PI values of the 9 patients with recurrence were significantly higher than those of the 36 patients without recurrence (23.9 vs. 15.9, P=0.0022). Patients were categorized into the following two groups; high PI (>20) and low PI (<20). The recurrence-free survival of the low PI group was significantly better than that of the high PI group (P<0.0001). A multivariate analysis showed that a high PI was an independent risk factor for recurrence (odds ratio, 19.1; P=0.0369).Therefore, the preoperative PI of the liver may be a useful imaging biomarker for predicting the recurrence of patients with esophageal cancer.

[Usefulness of FDG-PET for superficial esophageal squamous cell carcinoma].

We investigated the usefulness of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) for superficial esophageal squamous cell carcinoma after resection via endoscopic submucosal dissection (ESD). Our case study included 37 patients and 49 tumors resected via ESD in our hospital between January 2012 and December 2013. Histopathological diagnosis confirmed squamous cell carcinoma in all cases. Tumors located near the esophago cardiac junction were excluded. We investigated retrospectively whether the standardized uptake value (SUV) obtained by using FDG-PET could be the criterion to decide whether to perform ESD. At first, the tumor was examined via endoscopy. If tumor depth (T status)was less than cSM1, we performed ESD. When the tumor depth was less than pSM1, no infiltration of the vessel or lymph duct was observed, and the surgical margin was free; therefore, we did not perform any further therapy. On the other hand, we measured the SUV obtained via FDG-PET. The cut-off value was set as 3.0 based on the correlation between the SUV and tumor depth. We investigated if SUV<.0 could be the criterion for further therapy after ESD. In our results, the sensitivity was 95%, specificity was 67%, and accuracy was 90%. The SUV also helped to identify the malignancy of the superficial esophageal cancer and could help to decide whether ESD should be undertaken.

Diffusion-weighted magnetic resonance imaging for predicting and detecting the early response to chemoradiotherapy of advanced esophageal squamous cell carcinoma.

BACKGROUND: The aim of this study was to investigate the utility of the apparent diffusion coefficient (ADC) value in diffusion-weighted magnetic resonance imaging (DWMRI) for prediction and early detection of treatment response in advanced esophageal squamous cell carcinoma. METHOD: DWMRI was performed in 27 patients with primary cT4 esophageal carcinoma that were undergoing chemoradiotherapy before treatment and after 20 and 40 Gy. We calculated tumor ADCs and association of the treatment effect between responders and nonresponders. RESULTS: The ADC at the time of 20 Gy was significantly higher in responders compared to nonresponders (1.13 vs. 0.93; p = 0.005). The ADC cut-off value was set at 1.00 × 10(-3) mm(2)/s and the ADC predicted the responders with a sensitivity, positive predictive value and accuracy of 79, 73 and 74%, respectively. The increased rate of the ADC at the time of 20 Gy (ΔADC20) was also significantly higher in responders compared to nonresponders (35.4 vs. 1.5%; p = 0.0007). An ADC cut-off value for ΔADC20 of 15% predicted the responders with a sensitivity, positive predictive value and accuracy of 71, 100 and 85%, respectively. CONCLUSION: The ADC values predicted the prognosis of patients with advanced esophageal squamous cell carcinoma as well as the treatment response.

S-1 monotherapy as second- or third-line chemotherapy for unresectable and recurrent esophageal squamous cell carcinoma.

PURPOSE: S-1 is widely used for various cancers. It may be useful for esophageal squamous cell carcinoma (ESCC); however, there are insufficient data. The purpose is to provide results of an analysis of S-1 monotherapy for unresectable and recurrent ESCC. PATIENTS AND METHODS: Twenty patients with histologically proven ESCC who were previously treated with other chemo(radio)therapies were treated with S-1 alone as second- or third-line chemotherapy. RESULTS: A complete response (CR) was observed in 1 case (5%). A partial response (PR), stable disease (SD), and progressive disease (PD) were seen in 4 (20.0%), 7 (35.0%), and 8 (40.0%) cases, respectively. Two cases (10%) of anemia, 1 case (5%) of leukopenia, 3 cases (15%) of fatigue, and 3 cases (15%) of diarrhea were observed as grade 3 toxicity; however, there were no cases of grade 4 toxicity. The 1-year progression-free survival (PFS) rate was 10.0%, and the median PFS was 100 days. The 1-year overall survival (OS) was 30.5%, and the median OS was 330 days. The 1-year PFS rate in CR/PR/SD and PD was 16.7 and 0%, and the median survival time was 120 and 40 days. CONCLUSION: S-1 is a promising new drug which can be used as a second- or third-line chemotherapy for ESCC.

[A case of far advanced-esophageal squamous cell carcinoma successfully treated with docetaxel].

A 65-year-old man with dysphagia and hoarseness was admitted to our hospital. The upper gastrointestinal examinations revealed a tumor in the lower esophagus while the biopsy specimens revealed squamous cell carcinoma. The clinical diagnosis was esophageal cancer(Lt, type 2, cT3N4M0, cStage IVa). The patient underwent neoadjuvant-chemotherapy(5-fluorouracil/cisplatin). After one course, computed tomography(CT)showed rapid growth of the tumor and lymph nodes, resulting in a progressive disease. It was considered unresectable because of the direct invasion of the No. 1 lymph node to the liver. Then, three courses of docetaxel were administered as second-line chemotherapy, and CT revealed the markedly reduced size of the tumor and lymph nodes, resulting in a partial response. The tumor was now thought to be resectable. Subtotal esophagectomy could be performed and the postoperative course was uneventful. Histopathological findings showed no evidence of malignancy at the primary tumor(grade 3), although there were residual atypical keratinocytes in some lymph nodes. The patient is doing well without any signs of recurrence 21 months after the surgery.

Primary esophageal adenocarcinoma arising from heterotopic gastric mucosa: report of a case.

Adenocarcinoma arising from heterotopic gastric mucosa (HGM) is exceedingly rare. This report presents the case of a 57-year-old male who presented with the chief complaint of dysphagia. Endoscopy and computed tomography revealed a locally advanced tumor of the cervical esophagus and swollen mediastinal lymph nodes. He underwent chemoradiotherapy followed by esophagectomy with three-field lymph node dissection. The resected tumor was a circumferentially scarred lesion located 1.5 cm from the proximal margin. The tumor was identified to be a well-differentiated adenocarcinoma arising from HGM with invasion to the muscularis propria. Postoperative chemoradiotherapy was performed because positive surgical margins were observed in the resected tissue. The patient has remained alive for more than 4 years after surgery, without any evidence of recurrence.

The overall prevalence of metastasis in T1 esophageal squamous cell carcinoma: a retrospective analysis of 295 patients.

OBJECTIVES: T1 esophageal squamous cell carcinoma (ESCC) has a low, but still present, risk of lymph node (LN) metastasis. Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is often applied for T1 ESCC. To achieve successful treatment by EMR/ESD, the risk of LN metastases, LN recurrence, and hematological recurrence need to be better understood. The aim of this study was to determine the precise risk for metastasis in T1 ESCC. METHODS: We divided 295 patients with T1 ESCC who underwent surgery and/or ESD/EMR into 6 categories (m1, m2, m3, sm1, sm2, and sm3). Their risks of LN metastasis, LN recurrence, hematological recurrence, and the outcome were determined. RESULTS: The rates of LN metastasis and LN recurrence were 0% in m1 and m2, 9% in m3, 16% in sm1, 35% in sm2, and 62% in sm3 cases. The incidence of hematological recurrence was 0% in m1, m2, m3, and sm1 cases; 9% in sm2 cases; and 13% in sm3 cases. The overall risk of metastasis was 9% in m3, 16% in sm1, 38% in sm2, and 64% in sm3 patients. The 5-year disease-specific survival rates were 100% in m1, m2, and m3; 90.9% in sm1; 78.8% in sm2; and 68.6% in sm3 patients. Statistically, both lymphatic and venous invasion were selected as predictive markers for metastasis. In m3 patients, positivity for either of these had an odds ratio for metastasis of 7.333 (P = 0.093). CONCLUSIONS: Our study provides a precise assessment of the comprehensive risk of metastasis and feasible predictive markers for T1 ESCC.

[Evaluation of tumor heterogeneity for esophageal squamous cell cancer by dynamic FDG-PET].

The aim of this study is to assess the tumor heterogeneity of esophageal squamous cell cancer by dynamic FDG-PET (dPET). Thirty patients were enrolled in this study. Images were obtained after intravenous injection of 370 MBq of 18F-FDG for 1 h. The time-density curve of the standardized uptake value( SUV) was evaluated quantitatively by fractal analysis. Tumor fractal dimension (FD) maps were acquired, and the FD of the tumor was measured. There was a significant correlation between FD and the clinical response to adjuvant therapy. The FD reduction rates of adjuvant therapy were 23.23% in the responder group and 5.83% in the nonresponder group. FD may be a valid imaging biomarker for assessing the response to neoadjuvant therapy.

[Evaluation of false-negative lymph nodes diagnosed by fludeoxy glucose-positron emission tomography in cases of metastatic esophageal squamous cell carcinoma].

We have encountered many cases wherein the metastatic nest of esophageal squamous cell carcinoma occupied only a small space in the lymph nodes because of which computed tomography( CT) and fludeoxy glucose( FDG)-positron emission tomography( PET) could not detect the lymph node metastasis satisfactorily. The false-negative lymph nodes that were not detected by FDG-PET before surgery were smaller in diameter, rate of occupation, and area of occupation than the true-positive lymph nodes. The smallest area of the cancer nest in the true-positive group was 7.5 mm2, and therefore, it was reasonable to consider a 5-mm diameter area as the criteria for correct diagnosis by FDG-PET. Most of the false-negative lymph nodes with a large area of carcinoma were attached to the primary tumor; therefore, they could not be precisely identified. The detection of false-negative lymph nodes by FDG-PET was not precise because of increases in the quantity of stroma-like cells in poorly differentiated carcinomas and in fibrosis caused by neoadjuvant therapy in the lymph nodes.

Utility of arterial phase of dynamic CT for detection of intestinal ischemia associated with strangulation ileus.

AIM: To clarify the usefulness of arterial phase scans in contrast computed tomography (CT) imaging of strangulation ileus in order to make an early diagnosis. METHODS: A comparative examination was carried out with respect to the CT value of the intestinal tract wall in each scanning phase, the CT value of the content in the intestinal tract, and the CT value of ascites fluid in the portal vein phase for a group in which ischemia was observed (Group I) and a group in which ischemia was not observed (Group N) based on the pathological findings or intra-surgical findings. Moreover, a comparative examination was carried out in Group I subjects for each scanning phase with respect to average differences in the CT values of the intestinal tract wall where ischemia was suspected and in the intestinal tract wall in non-ischemic areas. RESULTS: There were 15 subjects in Group I and 30 subjects in Group N. The CT value of the intestinal tract wall was 41.8 ± 11.2 Hounsfield Unit (HU) in Group I and 69.6 ± 18.4 HU in Group N in the arterial phase, with the CT value of the ischemic bowel wall being significantly lower in Group I. In the portal vein phase, the CT value of the ischemic bowel wall was 60.6 ± 14.6 HU in Group I and 80.7 ± 17.7 HU in Group N, with the CT value of the ischemic bowel wall being significantly lower in Group I; however, no significant differences were observed in the equilibrium phase. The CT value of the solution in the intestine was 18.6 ± 9.5 HU in Group I and 10.4 ± 5.1 HU in Group N, being significantly higher in Group I. No significant differences were observed in the CT value of the accumulation of ascites fluid. The average difference in the CT values between the ischemic bowel wall and the non-ischemic bowel wall for each subject in Group I was 33.7 ± 20.1 HU in the arterial phase, being significantly larger compared to the other two phases. CONCLUSION: This is a retrospective study using a small number of subjects; however, it suggests that there is a possibility that CT scanning in the arterial phase is useful for the early diagnosis of strangulation ileus.

Are additional trace elements necessary in total parenteral nutrition for patients with esophageal cancer receiving cisplatin-based chemotherapy?

It is known that cisplatin induces the excretion of zinc from the urine and thereby reduces its serum concentration. However, the fluctuation of these trace elements during or after cisplatin-based chemotherapy has not been evaluated. To answer this question, we performed a clinical study in esophageal cancer patients undergoing cisplatin-based chemotherapy. Eighteen patients with esophageal cancer who were not able to swallow food or water orally due to complete stenosis of the esophagus were evaluated. The patients were divided into a control group [total parenteral nutrition (TPN) alone for 28 days, ten cases] and an intervention group (TPN with additional trace elements for 28 days, eight cases). The serum concentrations of zinc, iron, copper, manganese, triiodothyronin (T3), and thyroxin (T4), as alternative indicators of iodine, were measured on days 0, 14, and 28 of treatment, and statistically analyzed on day 28. In the control group, the serum concentration of copper was significantly decreased from 135.4 (day 0) to 122.1 µg/ml (day 14), and finally to 110.6 µg/ml (day 28, p = 0.015). The concentration of manganese was also significantly decreased from 1.34 (day 0) to 1.17 µg/ml (day 14) and finally to 1.20 (day 28, p = 0.049). The levels of zinc, iron, T3, and T4 were not significantly changed. In the intervention group, the supplementation with trace elements successfully prevented these decreases in their concentrations. TPN with supplementary trace elements is preferable and recommended for patients who are undergoing chemotherapy in order to maintain the patients' nutrient homeostasis.