Thoracoscopic radical esophagectomy and laparoscopic transhiatal lymph node dissection for superficial esophageal cancer associated with lymph node metastases in the dorsal area of the thoracic aorta

Abstract

Esophageal cancer invading the muscularis mucosa sometimes involves regional lymph node metastases. However, lymph node metastases are rare in the dorsal area of the thoracic aorta. We describe a patient with an intramucosal esophageal cancer invading the muscularis mucosa, accompanied by lymph node metastases in the dorsal area of the thoracic aorta. These lesions were successfully resected by hand-assisted laparoscopic surgery using a transhiatal approach. A 60-year-old man was diagnosed with superficial esophageal cancer during a routine health examination. Endoscopic examination and ultrasonography revealed a superficial cancer, of diameter 6.0 cm, invading the submucosal layer and intramural metastases caudal to the primary tumor. Enhanced computed tomography and F-deoxyglucose positron emission tomography demonstrated the two metastatic lymph nodes, one in the dorsal area of the thoracic aorta and the other near the left gastric artery. Thoracoscopic radical esophagectomy with three-field lymph node dissection was performed. The metastatic lymph node in the dorsal area of the thoracic aorta was successfully removed by hand-assisted laparoscopic surgery using a transhiatal approach. Histopathological examination showed primary cancer invading the muscularis mucosa and intramural metastases in the lamina propria mucosa and submucosal layer. The pathological diagnosis according to the Japanese classification of esophageal cancer was MtLt, 47 mm, 0-IIa + IIb, pT1a-MM, ie(+), INF-b, ly3, v0, pN4(4a), pIM1, M0, and pstage IVa. The patient underwent two courses of adjuvant chemotherapy, consisting of CDDP and 5-fluorouracil. At present, 1 year and 8 months after surgery, the patient remains alive without tumor recurrence. Although the lymph node in the dorsal area of the thoracic aorta is not recognized as regional nodes of thoracic esophageal cancer, solitary mediastinal metastases from a mucosal cancer may indicate the existence of direct lymphatic flow from the thoracic esophagus to the retroaortic region. Transhiatal approach by hand-assisted laparoscopic surgery is useful to dissect the metastatic lymph node in the dorsal area of the thoracic aorta.

Assessing the outcomes of posterior thoracic para-aortic lymph node lymphadenectomy after induction chemotherapy in patients with esophageal squamous cell carcinoma

“…Past reports have demonstrated several approaches for dissecting posterior TPAN: the left thoracotomy approach, the left thoracoscopic approach, and the transhiatal approach [3][4][5][6][7]. Although the transhiatal approach is less invasive, the narrow surgical space increases the manipulation complexity.…”

“…They also reported that the patients with posterior TPAN metastasis had more advanced cN and cM stages than those with anterior TPAN, suggesting that posterior TPAN is a systemic disease. However, several case reports have shown that complete dissection improved the prognosis of patients with cStage IVB esophageal cancer who presented with solitary posterior TPAN metastasis [3][4][5][6][7].…”

Bilateral approach for thoracoscopic esophagectomy with lymph node dissection in the dorsal area of the thoracic aorta in patients with esophageal cancer: A report of two cases

“…Shiozaki et al reported that the posterior mediastinal lymph nodes, including those around the anterior area of thoracic aorta, could be dissected using the pneumomediastinum method [11] . Ninomiya et al reported on dissection of lymph nodes in the DTA performed using transhiatal mediastinoscopy [12] . During the pneumomediastinal procedure, the operating field is deep and narrow, and the mediastinoscopic view would be more limited with this procedure than with the thoracoscopic procedure.…”

Thoracic para-aortic lymph node recurrence in patients with esophageal squamous cell carcinoma: A propensity score-matching analysis

“…Lymph node metastasis is among the most crucial negative prognostic factors affecting cancer patients[ 6 ]. Thoracic para-aortic lymph node (TPLN) metastasis, a rare complication of esophageal cancer, has only been described in a few case reports[ 7 , 8 ], although in one case report, it was observed that there was a higher incidence of metastasis with recurrent disease[ 9 ]. Generally, two-field lymphadenectomy is commonly performed in Western countries and China[ 3 - 5 ], whereas extended three-field lymphadenectomy is performed in Japan[ 10 ].…”