Surgery for resectable esophageal cancer in Japan.

In Japan over 10,000 new cases of esophageal cancer and a little less than 10,000 deaths occur annually. Carcinoma of the esophagus occurs six times more frequently in males than females, and is the sixth most common carcinoma in males. Although adenocarcinoma is the most common form (more than 50%) in North America and many western European countries, approximately 90% of esophageal carcinoma is squamous cell carcinoma in Japan. Approximately 50% develop in the middle thoracic and about 20% occur in the lower thoracic esophagus, so it is evident that 75% of esophageal cancers occur in these middle and lower parts of the esophagus. One-quarter of the invasive tumors diagnosed are at the T1 level and one-half at the T2 and T3 levels. Sixty percent to 70% of patients are in need of surgery since the cancer is classified as submucosal to T3 levels. In fact, esophagectomy is performed for 60% of total cases, and the extended threefield lymphadenectomy is the general procedure in Japan. Endoscopic mucosal resection (EMR) is increasingly performed for mucosal cancer, and has proved to be a safe and curative procedure that has provided a good quality of life (QOL) following resection. Chemoradiation therapy or chemotherapy are performed, if possible, for cases with many lymph node metastases or T4 tumors. If downstaging is achieved, surgical treatment is reviewed. Thoracic esophageal cancer often involves not only mediastinal lymph nodes but also cervical and abdominal lymph nodes. Adequate dissection of mediastinal lymph nodes should be performed (especially along the recurrent laryngeal nerve), under right-sided thoracotomy and all of the thoracoabdominal esophagus needs to be resected. Since lymph node metastasis along the lesser curvature of the stomach occurs frequently, this part of Surgery for Resectable Esophageal Cancer in Japan