Long-term pharyngeal dysphagia after esophagectomy for esophageal cancer-an investigation using videofluoroscopic swallow studies.

Dysphagia is a common symptom of esophageal cancer (EC). Esophagectomy should relieve the presenting dysphagia as the mechanical obstruction caused by the tumor is removed. However, the new onset oropharyngeal dysphagia develops after esophagectomy and the deficit may persist increasing the risk of aspiration pneumonia and mortality as well as adversely affecting quality of life (QOL). This study investigates the persistent swallowing deficits in long-term postesophagectomy patients and explores the factors associated with dysphagia severity, penetration, and aspiration. A better understanding of the swallowing function can aid future management of the condition. A total of 29 patients who were more than six months postesophagectomy for EC, had no history of disease that would likely affect swallowing function or vocal cord palsy underwent detailed videofluoroscopic swallow studies and completed the European Organisation for Research and Treatment of Cancer QLQ-C30 and OES18 QOL questionnaires. Swallowing deficits were analyzed and rated using the videofluoroscopic dysphagia scale (VDS) and the penetration-aspiration scale (PAS). These variables were correlated with the clinical and QOL parameters to determine which factors would affect swallowing function. Our cohort consisted of 27 males and 2 females. The mean duration after esophagectomy when the swallowing study was performed was 3.2 years (range: 0.5-18.4 years). Swallowing deficits were mainly found in the pharyngeal phase of swallowing. The mean total VDS score was 36.1 (SD = 15.2, range: 11.0-69.5) out of a possible 100. The mean PAS score was 4.1 (SD = 2.5, range: 1-8) and 1.5 (SD = 0.9, range: 1-4) for thin and semisolids, respectively. Dysphagia was significantly more severe in males, those of more advanced age at esophagectomy and at swallowing assessment. Increasing pathological N stage significantly correlated with worse PAS score for thin fluid. Self-reports of more pain and less troubles with coughing were also associated with less penetration and aspiration. This study demonstrated that a mild to moderate pharyngeal dysphagia is present late after esophagectomy even in patients without VC palsy or anastomotic stricture. The long-term aspiration rate is comparable to the figures in the literature for those early after esophagectomy. It is suggested that damage to the intercostal nerves and the pulmonary vagus may affect oropharyngeal swallowing function in this population.

Post-esophagectomy gastric conduit cancers: treatment experiences and literature review.

Esophagectomy remains the mainstay of treatment for esophageal cancer. The stomach is the commonest organ used to restore intestinal continuity after esophagectomy. Metachronous gastric cancer in the gastric conduit after esophagectomy is rare; the etiology remains unclear. Possible risk factors include Helicobacter pylori infection, biliary or pancreatic reflux and prior radiotherapy. Prognosis of these patients remains poor. Treatment of this particular entity poses unique challenges to the surgeon and oncologist. Early diagnosis by endoscopy may allow endoscopic excision such as endoscopic mucosal resection or endoscopic submucosal dissection. In more advanced cancers, surgery is difficult, reconstruction is complicated, and further radiation may not be feasible because of previous neoadjuvant therapy. In this report, four patients who developed gastric conduit cancers are presented. They were treated with either surgery alone or combined with chemoradiotherapy. All four patients were still alive after at least 21 months, with three patients currently still alive (21-48 months). The literature is also reviewed, in particular addressing the incidence, possible underlying causes, prognosis and options of treatment for this specific clinical scenario.

Short and long-term advantages of transhiatal and transthoracic oesophageal cancer resection.

Two major surgical strategies to improve survival rates after oesophagectomy for oesophageal cancer have emerged during the past decades; (limited) transhiatal oesophagectomy and (extended) transthoracic oesophagectomy with two-field lymphadenectomy. This overview describes short and long-term advantages of these two strategies. In the short term, transhiatal oesophagectomy is accompanied by less morbidity. In the long term, this strategy is only preferable for patients with tumours located at the gastro-oesophageal junction, without involved lymph nodes in the proximal compartment of the chest. For patients with tumours located in the oesophagus, the transthoracic route with extended lymphadenectomy is probably preferred, because of improved long-term survival.

Id-1 and Id-2 are markers for metastasis and prognosis in oesophageal squamous cell carcinoma.

Id protein family consists of four members namely Id-1 to Id-4. Different from other basic helix-loop-helix transcription factors, they lack the DNA binding domain. Id proteins have been shown to be dysregulated in many different cancer types and their prognostic value has also been demonstrated. Recently, Id-1 has been shown to be upregulated in oesophageal squamous cell carcinoma (ESCC). However, the prognostic implications of Id proteins in ESCC have not been reported. We examined the expression of the Id proteins in ESCC cell lines and clinical ESCC specimens and found that Id protein expressions were dysregulated in both the ESCC cell lines and specimens. By correlating the expression levels of Id proteins and the clinicopathological data of our patient cohort, we found that M1 stage tumours had significantly higher nuclear Id-1 expression (P=0.012) while high nuclear Id-1 expression could predict development of distant metastasis within 1 year of oesophagectomy (P=0.005). In addition, high levels of Id-2 expression in both cytoplasmic and nuclear regions predicted longer patient survival (P=0.041). Multivariate analysis showed that high-level expression of Id-2 in both cytoplasmic and nuclear regions and lower level of nuclear Id-1 expression were independent favourable predictors of survival in our ESCC patients. Our results suggest that Id-1 may promote distant metastasis in ESCC, and both Id-1 and Id-2 may be used for prognostication for ESCC patients.