Gen Thorac Cardiovasc Surg (2015) 63:116–119 DOI 10.1007/s11748-014-0515-6
CASE REPORT
Curative resection of esophageal cancer with a double aortic arch Norihisa Uemura • Tetsuya Abe • Ryosuke Kawai • Seiji Ito • Koji Komori Yoshiki Senda • Kazunari Misawa • Yuichi Ito • Yasuhiro Shimizu • Masayuki Shinoda
•
Received: 29 April 2014 / Accepted: 24 December 2014 / Published online: 31 December 2014 Ó The Japanese Association for Thoracic Surgery 2014
Abstract Thoracic esophageal cancer with a double aortic arch is extremely rare. We herein report the case of a 63-year-old man with a double aortic arch who underwent an esophagectomy with a three-field lymphadenectomy for cancer in the lower thoracic esophagus. In such cases, it is important to recognize the relationship between the right and left aortic arches and the bilateral recurrent laryngeal nerves (RLNs). We were able to accurately understand the anatomical position of the RLNs using a precedent cervical procedure with partial resection of the manubrium to remove the nodes along the bilateral RLNs. Keywords Esophageal cancer Double aortic arch Surgical treatment Lymphadenectomy
Introduction Thoracic esophageal cancer with a double aortic arch (DAA) is extremely rare [1]. In cases with a DAA, the ascending aorta bifurcates anteriorly to the trachea and esophagus, with one arch coursing to the left of the trachea and esophagus and the other to the right. The arches rejoin into a single descending aorta posterior to the trachea and esophagus, thereby completely encircling the two structures [2]. Dissection of the involved lymph nodes located adjacent to the recurrent laryngeal nerves (RLNs) is of special clinical significance in the treatment of thoracic
N. Uemura (&) T. Abe R. Kawai S. Ito K. Komori Y. Senda K. Misawa Y. Ito Y. Shimizu M. Shinoda Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi 464-8681, Japan e-mail: [email protected]
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esophageal cancer [3]. Therefore, in cases of thoracic esophageal cancer with a DAA, systematic dissection of the lymph nodes requires an ingenious surgical approach.
Case report A 63-year-old man presented at our department for an abnormality found by esophagography during an annual checkup. Using esophagography, an ulcerating lesion was revealed in the lower thoracic esophagus and an extrinsic compression lesion was revealed in the upper thoracic esophagus (Fig. 1a). Histological examination of biopsy specimens confirmed the presence of a squamous cell carcinoma. A CT scan showed slight thickening of the esophageal wall of the lower thoracic esophagus and two suspicious nodes along the left RLN and in the right upper mediastinum (Fig. 1b, c). The CT scan also revealed the presence of a DAA with complete vascular rings that surrounded the trachea and esophagus (Fig. 1d–f). The bilateral subclavian and carotid arteries arose directly from each arch (Fig. 1f). The esophagus was displaced forward by the distal junction of both aortic arches, and the descending aorta coursed down the right side of the lower thoracic esophagus. A PET scan revealed no hot area besides the primary lesion. The patient underwent esophagectomy with three-field lymphadenectomy following neoadjuvant chemotherapy. We first performed a cervical lymphadenectomy to ensure the anatomical position of the RLNs. We could not clearly observe the bilateral aortic arch through the transverse cervical incision. To obtain a wide operative view, the manubrium was partially resected [4]. As a result of this procedure, we were able to perform a lymphadenectomy along the RLNs to the line of the upper edge of the bilateral
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Fig. 1 a During the esophagography, an ulcerating lesion was revealed in the lower thoracic esophagus and an extrinsic compression lesion was revealed in the upper thoracic esophagus (arrow). b, c A CT scan showed two suspicious nodes along the left RLN, and in
the right upper mediastinum. (d–f) A CT scan revealed the presence of the DAA that surrounded the trachea and esophagus (arrows). The subclavian and carotid arteries arose directly from each arch
aortic arch during the cervical approach (Fig. 2). Simultaneously, we performed an abdominal lymphadenectomy with a transhiatal lower mediastinal lymphadenectomy. The descending aorta was dislocated toward the right side of the lower thoracic esophagus. Bowel continuity was reconstructed using a gastric tube through the retrosternal route. Then, we performed a mediastinal lymphadenectomy via a right thoracotomy. We first noted the beating of the right aortic arch in the right upper mediastinum, and the upper thoracic esophagus was framed by the DAA. The right vagal nerve coursed along the right side of the right aortic arch, and the right RLN came around behind the right aortic arch. The stump of the esophagus that was cut during the cervical procedure was pulled out through the vascular ring, and the left aortic arch and left RLN could be observed (Fig. 3). The cranial lymph nodes along the left RLN had already been dissected during the cervical procedure; therefore, a complete lymphadenectomy along the nerve was performed. We confirmed the presence of the bilateral RLNs during the mediastinal lymphadenectomy and were thus able to ensure their complete resection. The patient’s postoperative course was uneventful. The pathological diagnosis was pT3N1M0, and the involved lymph nodes were only observed in the perigastric nodes.
the bilateral aortic arches and RLNs. We were able to accurately understand the anatomical position of the bilateral aortic arches and RLNs in the present case during a precedent cervical lymphadenectomy with partial resection of the manubrium. Additionally, a suspicious lymph node in a vascular ring was found that was too caudal to resect using the normal cervical approach and was impossible to resect using the right thoracotomy approach. Therefore, we estimated that the manubrium needed to be resected to resect the node in the vascular ring. Generally, in cases of thoracic esophageal cancer, the involved lymph nodes are observed at a high frequency along the RLNs, so a lymphadenectomy in that region is of particular clinical significance [3]. In this regard, the present surgical procedure was an appropriate and effective approach. Although lower mediastinal lymph node resections are usually performed on the side opposite the descending thoracic aorta, we could not perform the left thoracotomy due to the presence of a significantly swollen node in the right upper mediastinum. To help cover the left side lymphadenectomy in the lower mediastinum, a transhiatal lower mediastinal lymphadenectomy was performed. During the right thoracotomy, the descending aorta that was located on the right side of the esophagus did not prevent the full dissection of the mediastinum lymph nodes, and complete resection of the suspicious nodes was, therefore, possible. This is only the third case report concerning surgery for thoracic esophageal cancer in a patient with a DAA. Matono et al. [1] reported the first case in 2011, but these
Discussion In such cases, it is important to recognize the anatomy in the upper mediastinum, especially the relationship between
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Gen Thorac Cardiovasc Surg (2015) 63:116–119
Fig. 2 Surgical findings (cervical region): The bilateral aortic arch could be observed through the cervical incision with partial resection of the manubrium
authors could not confirm either the left aortic arch or the left RLN because the esophageal bed between the trachea and the posterior junction of the aortic arches was extremely narrow. As a result, these authors could not confirm the presence of bilateral RLNs in the upper mediastinum. We were able to confirm the presence of the bilateral RLNs in the upper mediastinum by the preceding identification of these nerves during a cervical procedure that involved partial resection of the manubrium to obtain a wider operative view. When the anatomy in the upper
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mediastinum is complicated, sufficient exposure of these nerves should be provided by a cervical approach performed prior to the subsequent procedures. Kubo et al. [5] reported the second case in 2012. In this case, the authors chose to perform left posterolateral thoracotomy via the fourth intercostal space, and the lymph nodes along the right RLN were dissected through the neck without sternotomy. This surgical procedure could result in insufficient lymphadenectomy in the right upper mediastinum, especially for a patient with lymph node metastasis in that field,
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Fig. 3 Surgical findings (thoracic region): The bilateral RLNs could be identified during the right thoracotomy
such as in our case. Therefore, we believe that a surgical procedure similar to that described above should be chosen to complete a sufficient lymphadenectomy in the upper mediastinum.
Conclusion We encountered a patient with thoracic esophageal cancer with a DAA, and successfully performed an esophagectomy with three-field lymphadenectomy through right thoracotomy with partial resection of the manubrium. Thus, we were able to accurately understand the anatomical position of the RLNs as a result of the precedent cervical procedure with partial resection of the manubrium and removed the suspicious nodes along the bilateral RLNs. Conflict of interest interest exists.
References 1. Matono S, Fujita H, Tanaka T, Tanaka Y, Nagano T, Nishimura K, et al. Esophagectomy for thoracic esophageal cancer with a double aortic arch: report of a case. Surg today. 2011;41:1150–5. 2. Shah RK, Mora BN, Bacha E, Sena LM, Buonomo C, Del Nido P, et al. The presentation and management of vascular rings: an otolaryngology perspective. Int J Pediatr Otorhinolaryngol. 2007;71:57–62. 3. Tachimori Y, Nagai Y, Kanamori N, Hokamura N, Igaki H. Pattern of lymph node metastases of esophageal squamous cell carcinoma based on the anatomical lymphatic drainage system. Dis Esophagus. 2011;24:33–8. 4. Matsubara T, Ueda M, Nagao N, Takahashi T, Nakajima T, Nishi M. Cervicothoracic approach for total mesoesophageal dissection in cancer of the thoracic esophagus. J Am Coll Surg. 1988;187:238–45. 5. Kubo N, Ohira M, Yamashita Y, Sakurai K, Tanaka H, Muguruma K, et al. Successful resection of esophageal carcinoma associated with double aortic arch: a case report. Anticancer Res. 2012;32:3351–5.
The authors have declared that no conflict of
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CASE REPORT
Curative resection of esophageal cancer with a double aortic arch Norihisa Uemura • Tetsuya Abe • Ryosuke Kawai • Seiji Ito • Koji Komori Yoshiki Senda • Kazunari Misawa • Yuichi Ito • Yasuhiro Shimizu • Masayuki Shinoda
•
Received: 29 April 2014 / Accepted: 24 December 2014 / Published online: 31 December 2014 Ó The Japanese Association for Thoracic Surgery 2014
Abstract Thoracic esophageal cancer with a double aortic arch is extremely rare. We herein report the case of a 63-year-old man with a double aortic arch who underwent an esophagectomy with a three-field lymphadenectomy for cancer in the lower thoracic esophagus. In such cases, it is important to recognize the relationship between the right and left aortic arches and the bilateral recurrent laryngeal nerves (RLNs). We were able to accurately understand the anatomical position of the RLNs using a precedent cervical procedure with partial resection of the manubrium to remove the nodes along the bilateral RLNs. Keywords Esophageal cancer Double aortic arch Surgical treatment Lymphadenectomy
Introduction Thoracic esophageal cancer with a double aortic arch (DAA) is extremely rare [1]. In cases with a DAA, the ascending aorta bifurcates anteriorly to the trachea and esophagus, with one arch coursing to the left of the trachea and esophagus and the other to the right. The arches rejoin into a single descending aorta posterior to the trachea and esophagus, thereby completely encircling the two structures [2]. Dissection of the involved lymph nodes located adjacent to the recurrent laryngeal nerves (RLNs) is of special clinical significance in the treatment of thoracic
N. Uemura (&) T. Abe R. Kawai S. Ito K. Komori Y. Senda K. Misawa Y. Ito Y. Shimizu M. Shinoda Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi 464-8681, Japan e-mail: [email protected]
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esophageal cancer [3]. Therefore, in cases of thoracic esophageal cancer with a DAA, systematic dissection of the lymph nodes requires an ingenious surgical approach.
Case report A 63-year-old man presented at our department for an abnormality found by esophagography during an annual checkup. Using esophagography, an ulcerating lesion was revealed in the lower thoracic esophagus and an extrinsic compression lesion was revealed in the upper thoracic esophagus (Fig. 1a). Histological examination of biopsy specimens confirmed the presence of a squamous cell carcinoma. A CT scan showed slight thickening of the esophageal wall of the lower thoracic esophagus and two suspicious nodes along the left RLN and in the right upper mediastinum (Fig. 1b, c). The CT scan also revealed the presence of a DAA with complete vascular rings that surrounded the trachea and esophagus (Fig. 1d–f). The bilateral subclavian and carotid arteries arose directly from each arch (Fig. 1f). The esophagus was displaced forward by the distal junction of both aortic arches, and the descending aorta coursed down the right side of the lower thoracic esophagus. A PET scan revealed no hot area besides the primary lesion. The patient underwent esophagectomy with three-field lymphadenectomy following neoadjuvant chemotherapy. We first performed a cervical lymphadenectomy to ensure the anatomical position of the RLNs. We could not clearly observe the bilateral aortic arch through the transverse cervical incision. To obtain a wide operative view, the manubrium was partially resected [4]. As a result of this procedure, we were able to perform a lymphadenectomy along the RLNs to the line of the upper edge of the bilateral
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Fig. 1 a During the esophagography, an ulcerating lesion was revealed in the lower thoracic esophagus and an extrinsic compression lesion was revealed in the upper thoracic esophagus (arrow). b, c A CT scan showed two suspicious nodes along the left RLN, and in
the right upper mediastinum. (d–f) A CT scan revealed the presence of the DAA that surrounded the trachea and esophagus (arrows). The subclavian and carotid arteries arose directly from each arch
aortic arch during the cervical approach (Fig. 2). Simultaneously, we performed an abdominal lymphadenectomy with a transhiatal lower mediastinal lymphadenectomy. The descending aorta was dislocated toward the right side of the lower thoracic esophagus. Bowel continuity was reconstructed using a gastric tube through the retrosternal route. Then, we performed a mediastinal lymphadenectomy via a right thoracotomy. We first noted the beating of the right aortic arch in the right upper mediastinum, and the upper thoracic esophagus was framed by the DAA. The right vagal nerve coursed along the right side of the right aortic arch, and the right RLN came around behind the right aortic arch. The stump of the esophagus that was cut during the cervical procedure was pulled out through the vascular ring, and the left aortic arch and left RLN could be observed (Fig. 3). The cranial lymph nodes along the left RLN had already been dissected during the cervical procedure; therefore, a complete lymphadenectomy along the nerve was performed. We confirmed the presence of the bilateral RLNs during the mediastinal lymphadenectomy and were thus able to ensure their complete resection. The patient’s postoperative course was uneventful. The pathological diagnosis was pT3N1M0, and the involved lymph nodes were only observed in the perigastric nodes.
the bilateral aortic arches and RLNs. We were able to accurately understand the anatomical position of the bilateral aortic arches and RLNs in the present case during a precedent cervical lymphadenectomy with partial resection of the manubrium. Additionally, a suspicious lymph node in a vascular ring was found that was too caudal to resect using the normal cervical approach and was impossible to resect using the right thoracotomy approach. Therefore, we estimated that the manubrium needed to be resected to resect the node in the vascular ring. Generally, in cases of thoracic esophageal cancer, the involved lymph nodes are observed at a high frequency along the RLNs, so a lymphadenectomy in that region is of particular clinical significance [3]. In this regard, the present surgical procedure was an appropriate and effective approach. Although lower mediastinal lymph node resections are usually performed on the side opposite the descending thoracic aorta, we could not perform the left thoracotomy due to the presence of a significantly swollen node in the right upper mediastinum. To help cover the left side lymphadenectomy in the lower mediastinum, a transhiatal lower mediastinal lymphadenectomy was performed. During the right thoracotomy, the descending aorta that was located on the right side of the esophagus did not prevent the full dissection of the mediastinum lymph nodes, and complete resection of the suspicious nodes was, therefore, possible. This is only the third case report concerning surgery for thoracic esophageal cancer in a patient with a DAA. Matono et al. [1] reported the first case in 2011, but these
Discussion In such cases, it is important to recognize the anatomy in the upper mediastinum, especially the relationship between
123
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Gen Thorac Cardiovasc Surg (2015) 63:116–119
Fig. 2 Surgical findings (cervical region): The bilateral aortic arch could be observed through the cervical incision with partial resection of the manubrium
authors could not confirm either the left aortic arch or the left RLN because the esophageal bed between the trachea and the posterior junction of the aortic arches was extremely narrow. As a result, these authors could not confirm the presence of bilateral RLNs in the upper mediastinum. We were able to confirm the presence of the bilateral RLNs in the upper mediastinum by the preceding identification of these nerves during a cervical procedure that involved partial resection of the manubrium to obtain a wider operative view. When the anatomy in the upper
123
mediastinum is complicated, sufficient exposure of these nerves should be provided by a cervical approach performed prior to the subsequent procedures. Kubo et al. [5] reported the second case in 2012. In this case, the authors chose to perform left posterolateral thoracotomy via the fourth intercostal space, and the lymph nodes along the right RLN were dissected through the neck without sternotomy. This surgical procedure could result in insufficient lymphadenectomy in the right upper mediastinum, especially for a patient with lymph node metastasis in that field,
Gen Thorac Cardiovasc Surg (2015) 63:116–119
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Fig. 3 Surgical findings (thoracic region): The bilateral RLNs could be identified during the right thoracotomy
such as in our case. Therefore, we believe that a surgical procedure similar to that described above should be chosen to complete a sufficient lymphadenectomy in the upper mediastinum.
Conclusion We encountered a patient with thoracic esophageal cancer with a DAA, and successfully performed an esophagectomy with three-field lymphadenectomy through right thoracotomy with partial resection of the manubrium. Thus, we were able to accurately understand the anatomical position of the RLNs as a result of the precedent cervical procedure with partial resection of the manubrium and removed the suspicious nodes along the bilateral RLNs. Conflict of interest interest exists.
References 1. Matono S, Fujita H, Tanaka T, Tanaka Y, Nagano T, Nishimura K, et al. Esophagectomy for thoracic esophageal cancer with a double aortic arch: report of a case. Surg today. 2011;41:1150–5. 2. Shah RK, Mora BN, Bacha E, Sena LM, Buonomo C, Del Nido P, et al. The presentation and management of vascular rings: an otolaryngology perspective. Int J Pediatr Otorhinolaryngol. 2007;71:57–62. 3. Tachimori Y, Nagai Y, Kanamori N, Hokamura N, Igaki H. Pattern of lymph node metastases of esophageal squamous cell carcinoma based on the anatomical lymphatic drainage system. Dis Esophagus. 2011;24:33–8. 4. Matsubara T, Ueda M, Nagao N, Takahashi T, Nakajima T, Nishi M. Cervicothoracic approach for total mesoesophageal dissection in cancer of the thoracic esophagus. J Am Coll Surg. 1988;187:238–45. 5. Kubo N, Ohira M, Yamashita Y, Sakurai K, Tanaka H, Muguruma K, et al. Successful resection of esophageal carcinoma associated with double aortic arch: a case report. Anticancer Res. 2012;32:3351–5.
The authors have declared that no conflict of
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