Jpn J Clin Oncol 2001;31(5)203–208
Comparison of Surgical Management of Thoracic Esophageal Carcinoma Between Two Referral Centers in Japan and China Wentao Fang1, Hoichi Kato2, Wenhu Chen1, Yuji Tachimori2, Hiroyasu Igaki2 and Hiroshi Sato2 1Department
of Thoracic Surgery, Shanghai Chest Hospital, Shanghai, China and 2Department of Surgery, National Cancer Center Hospital, Tokyo, Japan Received October 10, 2000; accepted February 5, 2001
Background: Comparison was made between two referral centers, the National Cancer Center Hospital (NCCH) in Japan and Shanghai Chest Hospital (SCH) in China. The aim was to detect the possible differences between surgical management of thoracic esophageal carcinoma in these two countries and to shed some light on how to improve the therapeutic outcomes at similar institutions. Methods: A total of 98 patients (50 from NCCH and 48 from SCH) with squamous cell carcinoma of the thoracic esophagus treated by a single surgeon at either center during January 1997 to July 1999 were retrospectively reviewed. Results: Lugol staining and endoscopic ultrasonography were applied routinely at NCCH only. More early diseases, multiple lesions and synchronous tumors of the digestive tract were detected in the NCCH group than in the SCH group. Significantly more stations of lymph nodes were dissected and higher metastatic rates to certain stations were found after more extensive lymphadenectomy in the NCCH group. Operation time was prolonged with significantly more postoperative complication but amount of blood loss or in-hospital mortality was not increased. There was a tendency toward better survival in the NCCH group at 2-year follow-up (70.9% NCCH vs. 56.2% SCH, p = 0.052). Conclusions: Lugol staining is useful in detecting early diseases or multiple lesions and endoscopic ultrasonography in increasing the knowledge of preoperative evaluation and thus should be recommended. Attention should be paid to more thorough lymph node dissection, especially those lymph node stations with high metastatic rates within the chest and the abdomen and meanwhile avoiding major postoperative complications, so as to improve further the accuracy of tumor staging and therapeutic outcome. Key words: thoracic esophageal carcinoma – extended lymphadenectomy – endoscopic ultrasonography – Lugol staining
INTRODUCTION Compared with other parts of the world, both Japan and China have relatively higher occurrences of esophageal cancers. Both consist mainly of squamous cell carcinomas located mostly in the thoracic esophagus, while adenocarcinoma in the distal part of the esophagus has increasingly become the major pathological type found in Europe and North America. In the past two decades, with widespread application of Lugol staining and endoscopic ultrasonography (EUS) and the introduction of extended lymph node dissection, better results have been reported by Japanese surgeons (1–6), compared either with
historical data or with those from other countries. In China, as in most Western countries, esophagectomy with lymph node sampling or limited dissection still remains the mainstay of treatment and the therapeutic outcomes are similar (7,8). We present here a comparison of data from two major referral centers, the National Cancer Center Hospital (NCCH) in Japan and Shanghai Chest Hospital (SCH) in China. Our aim was to elucidate the possible differences between surgical management of thoracic esophageal carcinoma in these two countries and to shed some light on how to improve the therapeutic outcomes at institutions sharing similar concern around the world.
PATIENTS AND METHODS For reprints and all correspondence: Hoichi Kato, Department of Surgery, National Cancer Center Hospital, 1–1 Tsukiji 5-chome, Chuo-ku, Tokyo 1040045, Japan. E-mail:
[email protected]
Patients treated for thoracic esophageal carcinoma by a single surgeon (H.K. at NCCH and W.C. at SCH) during January © 2001 Foundation for Promotion of Cancer Research
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Esophageal carcinoma in Japan and China
1997 to July 1999 were retrospectively reviewed. Only cases with a pathological type of squamous cell carcinoma and those operated on with curative intention met the selection criteria. Thus, a total of 98 cases (48 from SCH and 50 from NCCH) were included in this study. All patients underwent preoperative evaluation with esophagram, endoscopy and CT scans of the chest and abdomen. Preoperative staging was made according to the UICC (1997) classification (9). However, Lugol staining under endoscopy was carried out only in the NCCH group. Moreover, ultrasonography and CT scan of the neck and EUS were routinely performed in the Japanese group. The operative procedures at both centers were subtotal esophagectomy, with the upper digestive tract reconstructed with stomach tube through the retrosternal route. In the case of patients whose stomach was not available, reconstruction was made with colon through the subcutaneous route. All anastomoses were located in the neck. The major difference between the two centers lay in the extent of lymph node dissection. An extended cervical, mediastinal and abdominal (three-field) dissection, as described previously (1), was carried out routinely at NCCH. At SCH, however, this was limited to the mediastinum and the abdomen. Also, lymph nodes at the cervicothoracic junction and those along the celiac trunk, the common hepatic and the splenic artery were not dissected unless clearly visible or palpable (two-field dissection). At both centers, radiotherapy was given to patients with residual tumor after palliative resection. Some patients were also offered chemotherapy or chemoradiotherapy according to on-going clinical trials. All patients that survived operation were under follow-up. Results from the two groups were processed statistically, using the ?2 test for frequencies and grouped t-test for continuous data. Survival curves were calculated by the Kaplan–Meier method and the difference between the groups was examined with a log-rank test. A p value
