40 40 QOL evidence-based medicine
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2 40 40 QOL evidence-based medicine
3 A B C D 1Transhiatal esophagectomy 2 3 1Neoadjuvant chemotherapy 2Neoadjuvant chemoradiotherapy 1Adjuvant chemotherapy 2Adjuvant radiotherapy
4 A B TNM 7
5 QOL EBM Evidence Based Medicine 14 12
6 1 1 EBM Evidence based 3 QOL 4 4 Informed Consent
7 m m1 m m1 m2 EMR 2 2 1m3 sm1 EMR 5,6 m3 sm1 m3 9.3sm EMR 34 EMR 3 EMR p a Endoscopic Mucosal ResectionEMR
8 1 EMR b c 2 a a b a mm b c
9 2 EMR b a b c d e c 2 2 ABC a b Endoscopic Mucosal ResectionEMR
10 4 EMR m2 a m1m2 m3 sm p301998sm2 13 sm3 8 2 b EMR c EMR ,11
11 evidence evidence 1 m1 m2 23 EMR T4 T3 downstaging 2 A 1 QOL QOL 13,14 QOL 1
12 a QOL 15,16 b c 1 2 EMR a b 106rec c 2 QOL 1 T3 17,18 2
13 rec 19, myocutaneous flapskin roll 24 B 1 T2 30mm 25 2
14 2 26,27 CTUSMRI 3 101R 34 1 Ut Ut 28, Ut 28, Mt Mt , , Lt Lt 37 1 Mt 38,39 8,40, , ,45 prospective
15 a b c 47,48 49 d e 2 50 * 51 C 1 52, RouxY 54
16 D Turner 55 Transhiatal esophagectomy poor risk T1b T3 QOL 59, VATSVideo Assisted Thoracic Surgery 61 HALSHand Assisted Laparoscopic Surgery QOL
17 1 64, X Z 67,68 69,70 controversial Alberts Toxicity Witzel 810
18 evidence over all controversial controversial downstaging downstaging in vivo Neoadjuvant chemotherapy evidence RTOGCALGBSWOGECOG 73 CDDP5FU vs CDDP5 FU 2 74 vs 73 MRC CDDP5FU vs
19 1 200 controversial 75,76 over all CDDP5FU paclitaxel 77 CDDP5FU 2 Neoadjuvant downstaging chemoradiotherapy medical oncologist radiation oncologist controversial 80 CDDP5FUVinblastine 45 Gy 50 vs CDDP5FU 2 40 Gy 55 vs CDDP 2 37 Gy 143 vs
20 JCOG CDDP5FU 2 vs controversial Gy JCOG 4 1 Adjuvant chemotherapy 87 CDDPVDS vs CDDP5FU vs vs vs CDDP5FU50 14 CDDP5FU 2 Adjuvant JCOG radiotherapy Gy24Gy 50Gy Gy 91 92
21 M1 cisplatin key drug CDDP5FU cisplatincddp5 fluorouracil5fubleomycinblmpaclitaxeltaxolmitomycin CMMC vinorelbinenvbmethotrexatemtx vindesinevdspaclitaxeltaxolmitomycin CMMCcisplatin CDDP 93 cisplatin 25 key drug CDDP5FU paclitaxel paclitaxel TaxolCDDP5FU 95 TaxolCDDP CDDPBLMVDS 5FU
22 T13N01 60Gy T1T2 p A 60Gy30 6 N1 N0 1 1 m1m2 EMR 2 m3sm2 T 3 sm3
23 4 7 cm 97 CT 5mm 98 60Gy cm 6cm 6cm CT 2T thyroid notch 3cm 23 T 3L L 34 3cm Gy5 60Gy Gy35 7 EMR m1m2 50Gy Gy30 6 m3sm2 60Gy Gy T1T2 99, Gy
24 15mm 20mm 5mm 5 mm 1 35Gy 1 5Gy Gy 12 1 m1m2 50Gy25 5 8Gy2 1 12Gy3 3 10Gy2 1 15Gy3 3 2 m3sm2 1 50Gy Gy Gy4 4 15Gy Gy Gy30 6 8Gy2 1 12Gy3 3 10Gy2 1 15Gy Gy30 6 8Gy2 2 12Gy3 2 10Gy2 1 15Gy3 3 B QOL
25 T4 T4 * CDDP5FU 50 Gy64Gy 102,103 clinical stage T13N01M01983 American Joint Committee Staging Confirmatory Study 104 Patterns of Care Study 105 CDDP5FU 5065Gy retrospective 106 prospective T4M1aUICC
26 QOL locoregional , , , ,117 QOL 118 PS
27 EMRC Gastroenterol Endosc Hanashi T, et alclinical evaluation on treatments for mucosal cancer of the esophagus. Diseases of the Esophagus , m3sm m3sm1 EMR m3sm QOL Kelly DJ, et alimpact of clinicopathologic parameters on patient survival in carcinoma of the cervical esophagus. Am J Surg , Omura K, et allarynx-preserving resection of the cervical esophagus for cervical esophageal carcinoma limited to the submucosal layer. J Surg Oncol , Saito R, et ala clinical study of surgical treatment of patients with carcinoma of cervical esophagus extending to the thoracic esophagus. Jpn J Thorac Cardiovasc Surg , Kuwano H, et alfree jejunal pouch graft reconstruction after a resection of hypopharyngeal or cervical esophageal cancer. Hepatogastroenterology , Bottger TH, et alcarcinoma of the hypopharynx and the cervical oesophagusa surgical challenge. Eur J Surg , Triboulet JP, et alsurgical management of carcinoma of the hypopharynx and cervical esophagusanalysis of 209 cases. Arch Surg , Coleman JJ 3rd.Reconstruction of the pharynx and cervical esophagus. Semin Surg
28 Oncol , Kuwano H, et althe subepithelial extension of esophageal carcinoma for determining the resection margin during esophagectomya serial histopathologic investigation. Surgery 131S1421, Akiyama HRadical lymph node dissection for cancer of the thoracic esophagus. Ann Surg , Tsurumaru M, et aloutcomes of extensive lymph node dissection for squamous cell carcinoma of the thoracic esophagus. Ann Thorac Cardiovasc Surg , Watanabe H, et alsignificance of extended systemic lymph node dissection for thoracic esophageal carcinoma in Japan. Recent Results Cancer Res , Udagawa H, et alsurgical treatment of squamous cell cancer of the esophagus. Diseases of the Esophagus , T2T3 Ei Nishimaki T, et alevaluating the rational extent of dissection in radical esophagectomy for invasive carcinoma of the thoracic esophagus. Surg Today2738, T2T3 Ei Isono K, et alresults of nationwide study on the three-field lymph node dissection of esophageal cancer. Oncology , Akiyama H, et alsystematic lymph node dissection for esophageal cancer-effective or not? Diseases of the Esophagus 7213,
29 48Gawad KA, et alhow important is the route of reconstruction after esophagectomya prospective randomized study. Am J Gastroenterol , van Lanschot JJ, et alrandomized comparison of prevertebral and retrosternal gastric tube reconstruction after resection of oesophageal carcinoma. Br J Surg , Sugimachi KAdvances in the surgical treatment of oesophageal cancer. Br J Surg , Heitmiller FRResults of standard left thoracoabdominal esophagectomy. Semin Thorac Cardiovasc Surg , Siewert JR, et aladenocarcinoma of the esophagogastric junctionresults of surgical therapy based on anatomicaltopographic classification in 1,002 consecutive patients. Ann Surg , van de Ven C, et althree-field lymphadenectomy and pattern of lymph node spread in T3 adenocarcinoma of the distal esophagus and the gastro-esophageal junction. Eur J Cardiothorac Surg , Turner GGExcision of the thoracic esophagus for carcinoma with constriction of an extrathoracic gullet. Lancet , Akiyama H, et alimmediate pharyngogastrostomy following total esophagectomy by blunt dissection. Jpn J Surg , Law S, et althoracoscopic esophagectomy for esophageal cancer. Surgery , Akaishi T, et althoracoscopic en bloc total esophagectomy with radical mediastinal lymphadenectomy. J Thorac Cardiovasc Surg , HALS Kijima M, et alrestricted indication for an esophageal bypass operation as suggested through the authors experience and study. Med J , De Palma GP, et alplastic prosthesis versus expandable metal stents for palliation of inoperable esophageal thoracic carcinomaa controlled prospective study. Gastrointest Endosc , Sanyika C, et alpalliative treatment of esophageal carcinoma, efficacy of plastic versus selfexpandable stents. S.A.M.J , Alberts A.S. et alsevere Complication of 5Fluorouracil and Cisplatin with Concomi-
30 tant Radiotherapy in inoperable Non-metastatic Squamous Cell Oesophageal After IntubationEarly Termination of a Prospective Randomised Trial. Eur J Cancer 28A , Kalen DP, et alchemotherapy followed by surgery compared with surgery alone for localized esophageal cancer. N Engl J Med , Law S, et alpreoperative chemotherapy versus surgical therapy alone for squamous cell carcinoma of the esophagusa prospective randomized trial. J Thorac Cardiovasc Surg , Girling DJ, et alsurgical resection with or without preoperative chemotherapy in oesophageal cancera randomised controlled trial. Lancet , Roth JA, et alrandomized clinical trial of preoperative and postoperative adjuvant chemotherapy with cisplatin, vindesine, and bleomycin for carcinoma of the esophagus. J Thorac Cardiovasc Surg , Cisplatin5FULeucovorin Kelsen DP, et ala phase trial of paclitaxeltaxolin advanced esophageal cancer preliminary report. Semin Oncol 215 Suppl 84448, Recht A, et althe role of radiation therapy in treating patients with potentially resectable carcinoma of the esophagus. Chest S240S, Sugimachi K, et alhyperthermia combined with chemotherapy and irradiation for patients with carcinoma of the oesophagusa prospective randomized trial. Int J Hypertherm , Urba SG, et alrandomized trial of preoperative chemoradiation versus surgery alone in patients with localized esophageal carcinoma. J Clin Oncol , Walsh TN, et ala comparison of multimodal therapy and surgery for esophageal adenocarcinoma. N Engl J Med , Bosset JF, et alchemoradiotherapy followed by surgery compared with surgery alone in squamous-cell cancer of the esophagus. N Engl J Med , Stahl M, et alcombined preoperative chemotherapy and radiotherapy in patients with locally advanced esophageal cancer. Interim analysis of a phase trial. J Clin Oncol , Prise EL, et ala randomized study of chemotherapy, radiation therapy, and surgery versus surgery for localized squamous cell carcinoma of the esophagus. Cancer , Apinop C, et ala prospective study of combined therapy in esophageal cancer. Hepatogastroenterology , Heath EI, et alphase evaluation of preoperative chemoradiation and postoperative chemotherapy for squamous cell and adenocarcinoma of the esophagus. J Clin Oncol , Ando N, et ala randomized trial of surgery with and without chemotherapy for localized squamous carcinoma of the thoracic esophagusthe Japan Clinical Oncology Group Study. J Thorac Cardiovasc Surg , Ando N, et ala randomized trial of surgery alone vs. surgery plus postoperative chemotherapy with cisplatin and 5fluorouracil for localized squamous carcinoma of the thoracic esophagusthe Japan Clinical Oncology Group StudyJCOG Proc Am Soc Clin Oncol 18269a, Pouliquen X, et al5fluorouracil and cisplatin therapy after palliative surgical resection
31 of squamous cell carcinoma of the esophagus. A multicenter randomized trial. French Associations for Surgical Research. Ann Surg , Iizuka T, et alpreoperative radioactive therapy for esophageal carcinoma. Randomized evaluation trial in eight institutions. Chest , Teniere P, et alpostoperative radiation therapy does not increase survival after curative resection for squamous cell carcinoma of the middle and lower esophagus as shown by a multicenter controlled trial. Surg Gynecol Obstet , Fok M, et alpostoperative radiotherapy for carcinoma of the esophagusa prospective, randomized controlled trial. Surgery , Ajani JACurrent status of new drugs and multidisciplinary approaches in patients with carcinoma of the esophagus. Chest 1131 suppl112s119s, Iizuka T, et alphase evaluation of cisplatin and 5fluorouracil in advanced squamous cell carcinoma of the esophagusa Japanese Esophageal Oncology Group Trial. Jpn J Clin Oncol , Ilson DH, et alphase trial of paclitaxel, fluorouracil and cisplatin in patients with advanced carcinoma of esophagus. J Clin Oncol , Kelsen DP, et ala phase trial of paclitaxel and cisplatin in patients with locally advanced metastatic esophageal cancera preliminary report. Semin Oncol 24Suppl , M0 J Jpn Soc Cancer Ther Mizowaki T, et aloptimal size criteria of malignant lymph nodes in the treatment planning of radiotherapy for esophageal cancerevaluation by CT and MRI. Int J Radiat Oncol Biol Phys , Okawa T, et almulti-institutional randomized trial of external radiotherapy with and without intraluminal brachytherapy for esophageal cancer in Japan. Japanese Society of Therapeutic Radiology and OncologyJASTROStudy Group. Int J Radiat Oncol Biol Phys , Ir Herskovic A, et alcombined chemotherapy and radiotherapy compared with radiotherapy alone in patients with cancer of the esophagus. N Engl J Med , AlSarraf M, et alprogress report of combined chemoradiotherapy versus radiotherapy alone in patients with esophageal canceran intergroup study. J Clin Oncol , Cooper JS, et alchemoradiotherapy of locally advanced esophageal cancerlong-term follow-up of a prospective randomized trialrtog JAMA , Coia LR, Minsky BD, Berkey BA, et aloutcomes of patients receiving radiation for cancer of the esophagusresults of the patterns of care study. J Clin Oncol , Chan A, Wong AIs combined chemotherapy and radiation therapy equally effective as surgical resection in locarized esophageal carcinoma? Int J Radiat Oncol Biol Phys , Ohtsu A, et aldefinitive chemoradiotherapy for T4 andor M1 lymph node squamous
32 cell carcinoma of the esophagus. J Clin Oncol , Morita M, et alcharacteristics and sequence of the recurrent patterns after curative esophagectomy for squamous cell carcinoma. Surgery 11617, Matsubara T, et allocation of recurrent disease after extended lymph node dissection for carcinoma of the thoracic esophagus. J Am Coll Surg , Kato H, et alrecurrent esophageal carcinoma after esophagectomy with three-field lymph node dissection. J Surg Oncol , Fujita H, et allymph node metastasis and recurrence in patients with a carcinoma of the thoracic esophagus who underwent three-field dissection. World J Surg , Nemoto K, et alradiation therapy for loco-regionally recurrent esophageal cancer after surgery. Radiother Oncol , Zhang DW, et alsurgical treatment of recurrent symptoms after curative radiotherapy for esophageal carcinoma. Chin Med J , Swisher SG, et alsalvage esophagectomy for recurrent tumors after definitive chemotherapy and radiotherapy. J Thorac Cardiovasc Surg , Ng TM, et almanagement of strictures after radiotherapy for esophageal cancer. Gastrointest Endosc , 1986
33 1 Cecervical esophagus Tethoracic esophagus Utupper thoracic esophagus Mtmiddle thoracic esophagus 2 Ltlower thoracic esophagus 2 Aeabdominal esophagus Ph EGJ 3 4 E G 2 3 EG EGGE 5 EGJ EGJH
34 図 1 占居部位 O 食道入口部 esophageal orifice S 胸骨上縁 upper margin of the sternum B 気管分岐部下縁 tracheal bifurcation D 横隔膜 diaphragm EGJ 食道胃接合部 esophagogastric junction H 食道裂孔 esophageal hiatus 図 2 食道胃接合部癌
35 TX T0 Tis EP 3 T1a LPMMMLPM MM 3 T1b SM T2 MP T3 Ad 4 T4 Adj 5 1 pt1b pt1b lyt2 2 RaChRaChEMR RapT1bT4 RapT0T3 3 Tis T1a M 4 T3 5 T4 T3 108 N1108T4
36 spf 100sm 100tr 100ac up 102mid rec L R 106pre 106tb L R 107 superficial cervical nodes of neck superficial cervical lymph nodes submandibular lymph nodes cervical pretracheal lymph nodes accessory nerve lymph nodes cervical paraesophageal lymph nodes deep cervical lymph nodes upper deep cervical lymph nodes middle deep cervical lymph nodes peripharyngeal lymph nodes supraclavicular lymph nodes upper thoracic paraesophageal lymph nodes thoracic paratracheal lymph nodes recurrent nerve lymph nodes pretracheal lymph nodes tracheobronchial lymph nodes bifurcational lymph nodes 6 7 Ce 7 No.100sm No.102up No.104 No.102 NNo.101 No.101 NNo. 102mid Ut No.101 No.109
37 ao 112pul middle thoracic paraesophageal lymph nodes main bronchus lymph nodes lower thoracic paraesophageal lymph nodes supradiaphragmatic lymph nodes posterior mediastinal lymph nodes thoracic paraaortic lymph nodes pulmonary ligament lymph nodes ligamentum arteriosum lymph nodes anterior mediastinal lymph nodes Mt No.107 pulmonal hilar lymph nodes Lt diaphragmatic lymph nodes * * * Botallo right cardiac lymph nodes left cardiac lymph nodes lesser curvature lymph nodes greater curvature lymph nodes suprapyloric lymph nodes subpyloric lymph nodes left gastric artery lymph nodes common hepatic artery lymph nodes celiac artery lymph nodes splenic hilar lymph nodes splenic artery lymph nodes A 14V hepatoduodenal ligament lymph nodes posterior pancreatico-duodenal lymph nodes mesenteric lymph nodes superior mesenteric artery lymph nodes superior mesenteric vein lymph nodes middle colic artery lymph nodes abdominal paraaortic lymph nodes anterior pancreatico-duodenal lymph nodes infrapancreatic lymph nodes infradiaphragmatic lymph nodes esophageal hiatus lymph nodes
38 Number of regional lymph nodes
39 N1 N2 N3 N4 Ce rec tbL pre106tbR Te Ut Mt Lt rec rec tbL tbL rec mid106pre 106tbR tbL up pre 106tbR pre106tbR Ae EG EG GE N1 N2 N3 N4
40 TNM Stage Stage N0 N1 N2 N3 N4 M1 Tis T1a 0 T1b T2 a b T3 T4 T2N2M0Stage T3N1M1Stage b pstage pn0 pn1 pn2 pn3 pn4 pm1 ptis pt1a 0 pt1b pt2 a b pt3 pt4 pt2n2m0pstage pt3n2m1pstage b
41 0 Tis N0 M0 T1 N0 M0 A T2 T3 N0 N0 M0 M0 B T1 T2 N1 N1 M0 M0 T3 T4 N1 N M0 M0 TN M1 A TN M1a B TN M1b T TX T0 Tis T1 T2 T3 T4 UICC International Union Against Cancer N NX N0 N1 M MX M0 M1 M1a M1b M1a M1b M1a M1b
42 Tis, T1a, N T1a, N T1b, N T1b, N T2, T3 T4 N4, M EMR EMR
43 F A X TELFAX
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