Successful conservative management of a case of caustic esophagitis based on computed tomography assessment.

Case: We describe the case of a female patient who ingested approximately 100 mL of toilet bowl cleaner containing 9.5% hydrochloric acid in a suicide attempt. Upon admission for hematemesis and epigastric pain, she was alert and oriented with stable vital signs. Initial contrast-enhanced computed tomography (CT) demonstrated edematous changes with no evidence of upper gastrointestinal tract perforation. Endoscopy was not performed owing to the high risk of perforation. We managed this patient conservatively. Repeat contrast-enhanced CT revealed mediastinal emphysema on day 2, which resolved by day 6. The patient was subsequently discharged with no apparent strictures of the upper gastrointestinal tract. Outcome: Surgical interventions are frequently required following the ingestion of large amounts of highly concentrated hydrochloric acid; however, this patient was successfully managed conservatively. Conclusion: Contrast-enhanced CT is useful in the assessment of the respiratory and digestive systems and the prediction of potential complications.

Clinicopathological factors predicting R0 resection and long-term survival after esophagectomy in patients with T4 esophageal cancer undergoing induction chemotherapy or chemoradiotherapy.

PURPOSE: To identify clinicopathological factors predicting R0 resection and long-term survival after esophagectomy in patients with T4 esophageal cancer following induction chemotherapy or chemoradiotherapy. METHODS: Of 48 patients with T4 esophageal cancer who underwent induction treatment, 30 underwent R0 esophagectomy. The factors predicting R0 resection and prognostic indicators were assessed in the 48 and 30 patients, respectively, using univariate and multivariate analyses. RESULTS: In the univariate analyses, the primary tumor response, improvement of dysphagia, the post-induction therapy Glasgow Prognostic Score, an early tumor response and the post-induction therapy serum albumin and C-reactive protein levels were significantly correlated with R0 resection. Multivariate logistic regression analyses revealed that the response status and improvement of dysphagia were independent predictors of R0 resection. The univariate analyses identified a yp-T classification (yp-T0/1 vs. yp-T2/3/4), yp-nodal status and the number of pathologically positive nodes post-therapy (≤ 1 vs. ≥ 2) as significant prognostic factors. The multivariate analysis revealed that the number of pathologically positive nodes was the only significant independent prognostic indicator. CONCLUSION: Patients showing an early tumor response to induction treatment and improvement of dysphagia may be appropriate candidates for esophagectomy, and individualized postoperative management strategies should be developed for patients with initially unresectable T4 esophageal cancer who have ≥ 2 positive nodes post-treatment.

Prognostic significance of simultaneous presence of histological and immunohistochemical metastasis to lymph nodes in patients with esophageal cancer.

PURPOSE: Presence of simultaneous pathological and immunohistochemical nodal metastasis (pNM and iNM, respectively) and/or other clinical factors may be reliable prognostic predictors of survival in esophageal cancer patients who have undergone multidisciplinary treatment. METHODS: Univariate and multivariate analysis of the data collected from 77 patients who had undergone R0 esophagectomy was performed to determine the significance of presence of iNM or pNM, presence of simultaneous pNM, and other clinical factors as prognostic indicators in patients who had (n = 40) and had not (n = 37) undergone preoperative treatment. RESULTS: Presence of pNM was found to be a significant prognostic predictor in patients who had undergone preoperative treatment, presence of iNM in patients who had not undergone preoperative treatment, and presence of simultaneous pNM and iNM in both patient groups. Multivariate analysis indicated that the sole prognostic predictor for patients who had undergone preoperative treatment was presence of simultaneous pNM and iNM while that of patients who had not undergone preoperative treatment was clinical T category. CONCLUSION: Assessment of simultaneous presence of pNM and iNM may facilitate highly accurate prediction of survival in esophageal cancer patients undergoing R0 esophagectomy, regardless of whether they have undergone preoperative treatment.

Clinical and oncological effects of triplet chemotherapy followed by radical esophagectomy for resectable esophageal cancer associated with unfavorable prognostic factors.

PURPOSES: The purpose of this study was to evaluate the hypothesis that the survival of patients undergoing R0 resection after triplet chemotherapy for resectable esophageal cancer with unfavorable prognostic factors (Category 3) would be similar to that of patients undergoing esophagectomy for esophageal cancer without such factors (Category 1). METHODS: Patients with Category 3 tumors were assigned to receive triplet chemotherapy consisting of 5-fluorouracil, doxorubicin and nedaplatin (FAN) followed by radical esophagectomy. The outcomes of the bimodality treatment for Category 3 patients (n = 25) were compared with those of Category 1 patients (n = 41) in a prospective cohort study. RESULTS: Grade 3 or higher toxicity developed during chemotherapy in 32 % of the Category 3 patients, with no treatment-related deaths. No significant difference was detected in the surgery-related mortality and morbidity rates between the two groups. The recurrence-free survival was significantly worse in Category 3 than in Category 1 patients (p = 0.002), although the overall survival was not significantly different (p = 0.085) between the two groups in cases of R0 resection (5-year survival rates: 34.4 vs. 66.5 %). CONCLUSIONS: Although FAN chemotherapy followed by radical esophagectomy can be safely performed, this treatment modality may not have sufficient power to cure Category 3 disease.

Acute phlegmonous esophagitis as a rare but threatening complication of chemoradiotherapy: report of a case.

Phlegmonous infection involving the digestive tract has been reported to have a poor prognosis. However, the pathogenesis and clinical features of acute phlegmonous esophagitis have remained unclear due to the rarity of the disease. We herein report a case of acute phlegmonous esophagitis that showed a fulminant course during chemoradiotherapy for uterine cancer. The patient developed septic shock 10 h after postprandial nausea and vomiting, and a computed tomographic scan showed diffuse thickening of the esophageal wall. Severe leukopenia that was refractory to the administration of granulocyte colony-stimulating factor persisted during the first few days. The patient fortunately survived after intensive treatment. The acute phlegmonous esophagitis of the present case might have been evoked and worsened by chemoradiotherapy due to its emetic and myelosuppressive adverse effects, respectively. Although its incidence is extremely rare, acute phlegmonous esophagitis may occur as a life-threatening complication of chemoradiotherapy.

Induction chemotherapy or chemoradiotherapy followed by radical esophagectomy for T4 esophageal cancer: results of a prospective cohort study.

BACKGROUND: We hypothesized that the survival rate of patients undergoing R0 esophagectomy after induction chemotherapy or chemoradiotherapy for unresectable T4 esophageal cancer (URT4) would be similar to that of patients undergoing esophagectomy for immediately resectable esophageal cancer with no unfavorable prognostic factors (RNU). METHODS: Between April 2002 and June 2012, 87 of 283 patients with esophageal cancer who presented at the University Hospital of the Ryukyus were enrolled in this prospective cohort study. Tumors were classified as RNU and URT4 in 44 and 43 of the 87 patients, respectively. Outcomes of treatment for URT4 patients were compared with those of RNU patients. RESULTS: The R0 resection rate (61 %) and in-hospital mortality rate (20 %) of URT4 patients were significantly poorer than those of RNU patients (98 and 2.3 %, respectively), although the morbidity rate was similar in the two groups (63 and 52 %, respectively). The 5-year survival rate (35 %) of URT4 patients was significantly poorer than that of RNU patients (67 %) in the intention-to-treat analysis. However, no significant difference was noted between the two survival curves for cases of R0 resection (5-year survival rate, 60 % vs. 69 %). Multivariate analysis revealed R status as the only significant independent prognostic factor for URT4 patients (P < 0.001; hazard ratio = 8.279). CONCLUSIONS: Satisfactory survival rates can be achieved if R0 resection is performed after induction treatment in patients with T4 esophageal cancer, although secondary radical esophagectomy is associated with a higher risk of in-hospital mortality.

Radical radiotherapy for superficial esophageal cancer: impact of clinical N stage on survival.

AIM: To retrospectively analyze the results of radical radiotherapy for patients with superficial esophageal cancer (SEC). PATIENTS AND METHODS: Forty-eight patients with SEC were reviewed. The median dose of external beam radiotherapy was 66 Gy (range, 30 to 70 Gy). Intraluminal brachytherapy was used in 10 patients, and 15 patients (31%) underwent chemotherapy. The median follow-up period was 28 months (range, 4 to 116 months). RESULTS: Sixteen patients had recurrence (11 patients: in-field local recurrence; 3 patients: regional lymph node recurrence; 2 patients: distant metastasis), and the 5-year local control (LC) rate was 74.2%. The 5-year overall survival and disease-free survival (DFS) rates were 44.5% and 48.6%, respectively. Patients with clinical N1 disease (5-year DFS: 0%) had significantly poorer DFS than patients with clinical N0 disease (5-year DFS: 51%, p=0.019). CONCLUSION: Radical radiotherapy yielded relatively favorable LC rates in patients with SEC, and clinical N stage was a significant prognostic factor for DFS.

Development of gastro-lymphatic fistula during chemoradiotherapy for advanced esophageal cancer: a case report.

This is a case report of a gastro-lymphatic fistula which appeared during chemoradiotherapy for advanced esophageal cancer. A 60-year-old male was referred to the University of the Ryukyus Hospital because of a 10 kg monthly weight loss and dysphagia. Computed tomography (CT) scans indicated thickened esophageal wall at the lower thoracic esophagus and a swollen lymph node attached to the lesser curvature of the stomach. Histological analysis of the biopsy specimen revealed poorly differentiated squamous cell carcinoma and the diagnosis was of advanced esophageal cancer. A combination of chemotherapy (nedaplatin and 5-fluorouracil) and radiotherapy was initiated. After radiotherapy (20 Gy), CT scans revealed that the swollen lymph node penetrated the gastric wall resulting in a gastro-lymphatic fistula. Although gastrostomy and intestinal fistula repair were performed for gastric decompression and tube feeding, respectively, the patient's general status did not improve and he died two months after interruption of his chemoradiotherapy. The results indicate that there may be some risks of gastro-lymphatic fistula in patients treated with concurrent chemoradiotherapy for advanced esophageal cancer when there are possible signs of involvement by CT scans.

[A case of advanced gastric cancer with lung metastasis effectively treated by combination chemotherapy using S-1 and CDDP].

We report a case with gastric cancer and lung metastasis,who responded remarkably to combination chemotherapy using S-1 and weekly CDDP. A 59-year-old man was hospitalized for aphagia. Based on upper GI endoscopy and CT,type 3 gastric cancer associated with lung metastases was diagnosed. Cardiac gastrectomy, D 1 dissection, intermittented small intestine were performed. At 18 days postoperatively,the patient was administered 3 courses of S-1 (100 mg/body, on day 1-21) and CDDP (30 mg/body, on day 8, 15, 22) every 5 weeks. The treatment resulted in the metastatic tumors in the lung disappearing after 1 course. No severe adverse effects were observed. This combination chemotherapy proved useful for treating lung metastasis from gastric cancer in this patient.