A case of a superficial carcinoma of the esophagus with isolated
lymph node metastasis around the abdominal aorta
Tomoya Hatakeyama•Atsushi Shiozaki•Hitoshi Fujiwara•Daisuke Ichikawa•
Kazuma Okamoto•Shuhei Komatsu•Yasutoshi Murayama•Hisashi Ikoma•
Yoshiaki Kuriu•Masayoshi Nakanishi•Toshiya Ochiai•Yukihito Kokuba•
Teruhisa Sonoyama•Eigo Otsuji
Received: 17 February 2011/Accepted: 27 June 2011/Published online: 21 February 2012
? Springer 2012
isolated para-aortic lymph node metastasis is quite rare. A
56-year-old female demonstrated a type 0-IIa?IIb lesion in
the middle thoracic esophagus on endoscopic examination.
Enhanced computed tomography and positron emission
tomography demonstrated two swollen lymph nodes on the
right side of the inferior vena cava, but did not demonstrate
either a primary lesion or regional lymph node metastasis.
A retroperitoneal videoscopic lymph node biopsy was
thus performed, and the histopathological diagnosis was
metastasis of squamous cell carcinoma. Induction chemo-
therapy was administered with cisplatin/5-FU, and fol-
lowed by definitive chemoradiotherapy with cisplatin/5-FU
plus 60 Gy radiation. The patient showed satisfactory
responses in both the primary and metastatic lesions. This
is the first case report describing superficial carcinoma of
the esophagus with isolated lymph node metastasis around
the abdominal aorta. A precise histological diagnosis of the
lymph node is quite important in such cases, and an ade-
quate curative effect can be expected.
Superficial carcinoma of the esophagus with
metastasis ? Para-aortic lymph node
Superficial esophageal cancer ? Lymph node
Esophageal cancer has a higher frequency of lymph node
metastasis than other gastrointestinal tumors. Although the
preoperative diagnosis of lymph node metastasis is
important for adequate treatment, such a diagnosis is often
very difficult to make. Distant lymph node metastasis is
often found in advanced esophageal cancer patients with
M1 lymph node metastasis, along the celiac artery or left
side of the abdominal aorta. However, superficial carci-
noma of the esophagus with isolated M1 lymph node
metastasis is quite rare, and the clinicopathological char-
acteristics and treatment strategy have not been fully
evaluated. This report presents a very rare case of lymph
node metastasis from superficial esophageal cancer.
A 56-year-old female underwent health screening in
August 2009. A slightly elevated superficial esophageal
carcinoma with a flat center, type 0-IIa?IIb , measuring
about 5 cm in length was found in the middle thoracic
esophagus by endoscopy (Fig. 1a). Narrow band imaging
(NBI) showed obviously dilated and irregularly branched
tumor-specific vasculature, neovasculature, and complete
destruction of intrapapillary capillary loops (IPCL) similar
to immature capillaries, which strongly indicated tumor
invasion to the submucosal layer ; Fig. 1b). The histo-
pathological diagnosis of a biopsy sample was squamous
cell carcinoma (Fig. 2b). An upper gastrointestinal series
could not detect the tumor (Fig. 1c). Computed tomogra-
phy (CT) of the neck, chest, abdomen, and pelvis could
detect neither the primary lesion nor regional enlarged
lymph nodes. However, two enhanced and enlarged lymph
T. Hatakeyama ? A. Shiozaki ? H. Fujiwara (&) ?
D. Ichikawa ? K. Okamoto ? S. Komatsu ? Y. Murayama ?
H. Ikoma ? Y. Kuriu ? M. Nakanishi ? T. Ochiai ?
Y. Kokuba ? T. Sonoyama ? E. Otsuji
Division of Digestive Surgery, Department of Surgery,
Kyoto Prefectural University of Medicine, 465 Kajii-cho,
Kamigyo-ku, Kyoto 602-8566, Japan
Surg Today (2012) 42:676–680
nodes were detected on the right side of the inferior vena
cava (IVC; Fig. 1d). Both of these nodes measured 11 mm
along the short axis. F-18 fluorodeoxyglucose positron
emission tomography (FDG-PET) demonstrated high
uptakes in these lymph nodes (SUV=6.3 and 4.5, respec-
tively), but there was no abnormal uptake at either the
primary lesion or regional lymph nodes (Fig. 2a). The
possibility of lymphatic disorders, such as malignant
lymphoma had to be ruled out, because superficial carci-
noma of the esophagus with isolated lymph node metas-
tasis around the abdominal aorta is quite rare. Therefore, a
retroperitoneal videoscopic lymph node biopsy was
obtained for diagnosis of the lymphadenopathy. The
procedure was performed under endotracheal general
anesthesia with the patient in a left lateral position. A 5-cm
transverse incision was made at the midline between the tip
of 12th rib and the iliac crest along the posterior axillary
line. Balloon dilatation of retroperitoneal space was per-
formed through a 12 mm port. Two additional 5 mm ports
were then inserted through the fascia on either side of the
12 mm port as a single incision laparoscopic surgery
(SILS). The two enlarged lymph nodes were easily iden-
tified on the right side of the IVC and removed. The his-
topathological findings demonstrated the presence of
squamous cell carcinoma (Fig. 2c), and the diagnosis was
lymph node metastasis from esophageal cancer.
The patient received induction chemotherapy with 2
courses of cisplatin (CDDP; 70 mg/m2/day at the first day)
Fig. 1 a Endoscopy
demonstrated a slightly elevated
carcinoma with a flat center,
type 0-IIa?IIb lesion, in the
middle thoracic esophagus.
b Narrow band imaging (NBI)
showed the obviously dilated
and irregularly branched
neovasculature, and complete
destruction of intrapapillary
capillary loops (IPCL) similar to
immature capillaries. c An
upper gastrointestinal series
could not detect the tumor. d CT
demonstrated two enhanced and
enlarged lymph nodes on the
right side of the IVC (arrow)
Surg Today (2012) 42:676–680 677
plus 5-Fluorouracil (5-FU; 700 mg/m2/day for 5 days).
Induction chemotherapy resulted in partial reduction of the
primary lesion on follow-up endoscopy, but there were no
evaluable lesions indicating lymph node metastasis. Sub-
sequently, definitive chemoradiotherapy was administered
with 2 courses of CDDP/5-FU plus 60 Gy radiation . In
general, patients less than 80 years of age are irradiated
over an extended field, that includes the gross tumor vol-
ume plus the thoracic and abdominal esophagus and the
M1a region, where possible . The radiation field in the
current case was set to include not only the primary lesion
but also the area around the site where the metastatic
abdominal lymph nodes had been removed (Fig. 3a).
Systemic chemotherapy was administered for possible
micrometastases. Endoscopy and PET–CT after definitive
chemoradiotherapy demonstrated complete responses in
both the primary and metastatic lesions (Fig. 3b, c), and
she has remained well without recurrence 15 months after
Esophageal cancer has one of the highest malignant
potentials of any tumor. It shows a higher frequency of
lymph node metastasis than other gastrointestinal tumors.
Lymph node metastasis has been recognized as one of the
useful indicators for predicting the outcome of esophageal
cancer. Lymph node metastasis often occurs in esophageal
cancer, and the incidence of lymph node metastasis, even
in tumors with invasion to the submucosal layer, is as high
as 45% . The lymphatic flow of the esophagus is very
complex, and multidirectional lymphatic flow causes wide
spread and random patterns of lymph node metastasis from
the cervical to abdominal areas . The esophageal lym-
phatic drainage system contains abundant lymphatics,
which form a dense submucosal plexus. The flow of lymph
in the plexus runs longitudinally and nonsegmentally, thus
lymph can travel a long distance in the plexus before tra-
versing the muscle layer and entering the regional lymph
Fig. 2 a The FDG-PET
demonstrated high uptake in
two lymph nodes on the right
side of IVC (arrow). There was
no abnormal uptake in the
primary lesion or regional
b Histopathological diagnosis of
the biopsy sample of the
primary lesion was squamous
cell carcinoma. c The
histopathological diagnosis of
the resected lymph nodes was
also squamous cell carcinoma
678Surg Today (2012) 42:676–680
nodes [6, 7]. Anatomic skip metastases to the N2 or N3
region defined in the Japanese Guide Lines  are found in
50–60% of esophageal cancer . Takeuchi et al. 
reported a study of radio-guided sentinel lymph node
navigation in esophageal cancer, and found that more than
85% of thoracic esophageal cancer patients show at least 1
sentinel lymph node located in the N2 or N3 region as
defined in the Japanese Guide Lines . However, there
are no sentinel lymph nodes in the N4 region (e.g., para-
aortic lymph node) . Solitary lymph node metastasis of
esophageal cancer to the right side of IVC is rare. One of
the most likely metastatic routes is via the left gastric artery
and celiac artery . Although the possibility that there
were some micrometastases to regional lymph nodes could
not be denied, the malignant cells may have skipped the
regional lymph nodes and reached distant lymph nodes.
The metastatic pathway from the middle thoracic esopha-
gus to the right side of the IVC in the current case could not
be explained clearly. Although lymph node metastasis to
the right side of the IVC from superficial esophageal cancer
is quite rare. The present case is the first report of super-
ficial carcinoma of the esophagus with isolated para-aortic
lymph node metastasis found in the literature.
FDG-PET is a noninvasive diagnostic modality with a
high specificity rate in the demonstration of metabolically
active tumor tissue throughout the entire body. It is
therefore recommended to be a useful tool to determine the
initial staging of esophageal cancer because of its high
specificity in comparison to that of conventional modalities
such as CT, which is inaccurate in the evaluation of small
metastatic lymph nodes. Several studies have demonstrated
the superiority of FDG-PET in the staging of esophageal
cancer based on accurate diagnosis of both distant nodal
and hematogenous metastases [10, 11]. FDG-PET is the
main modality used for staging and planning treatment for
esophageal cancer in patients being considered for resec-
tion . The current patient underwent PET–CT to screen
for lymph nodes and organ metastasis and the scan suc-
cessfully detected a very rare isolated distant lymph node
metastasis. This case suggests that a PET–CT is effective
for the early detection of metastases that are not antici-
pated, and that patients are thus able to undergo intensive
treatment, thereby prolonging their survival.
Abdominal M1 lymph node metastasis from thoracic
esophageal cancer is usually found around the celiac artery
or left side of the abdominal aorta , while isolated lymph
node metastasis around the abdominal aorta is quite rare.
Therefore, it is necessary to rule out the presence of any
lymphatic disorders, such as malignant lymphoma. A ret-
roperitoneal videoscopic biopsy was performed for a pre-
cise diagnosis and the findings revealed lymph node
metastasis of squamous cell carcinoma. The use of diag-
nostic staging laparoscopy was recently introduced to
complement other staging modalities and histopathologi-
cally document metastatic disease. Diagnostic laparoscopy
is an acceptable and safe technique with a low risk of
Fig. 3 a The field of radiation therapy targeting the primary lesion
and lymph nodes on the right side of the IVC is shown. b Endoscopy
after definitive chemoradiotherapy demonstrated complete response.
c PET–CT scan after completion of definitive chemoradiotherapy did
not demonstrate any uptake on the right side of the IVC
Surg Today (2012) 42:676–680 679
complications [12, 13]. A retroperitoneal videoscopic
lymph node biopsy was performed to make a precise
diagnosis of lymphadenopathy, and this made it possible to
reduce the degree of surgical stress and also enables the
patient to avoid postoperative complications.
Various strategies have been considered as therapy in
such rare cases. A new strategy recommends cisplatin-
based neoadjuvant chemotherapy before definitive local
treatment by either surgery or radiotherapy. The high
response rates led to the consideration that systemic che-
motherapy might improve locoregional control as well as
decrease the risk of distant metastases . The current
patient initially received cisplatin-base induction chemo-
therapy to evaluate the effectiveness and to control possible
micrometastases. Subsequently, definitive chemoradio-
therapy was performed. Radiation therapy was performed
to cure the primary tumor and prevent the local recurrence
of para-aortic lymph node metastases, therefore, the radi-
ation fields were separated from each other to decrease the
side effects of the radiation therapy while achieving a
maximum treatment effect. A complete response was
therefore successfully obtained. In conclusion, this is the
first report of a case of superficial esophageal cancer with
isolated lymph node metastasis around the abdominal
aorta, thus suggesting the importance of making a precise
histological diagnosis of the lymph node with a high
probability of obtaining an adequate curative effect.
1. Japanese Society for Esophageal Disease. Guide lines for the
clinical and pathologic studies on carcinoma of the esophagus,
10th ed.; 2008.
2. Kumagai Y, Toi M, Kawada K, kawano T. Angiogenesis
in superficial esophageal squamous cell carcinoma: magnifying
endoscopic observation and molecular analysis. Dig Endosc.
3. Kato H, Sato A, Fukuda H, Kagami Y, Udagawa H, Togo A, et al.
A phase II trial of chemoradiotherapy for stage I esophageal
squamous cell carcinoma: Japan Clinical Oncology Group
Study(JCOG9708). Jpn J Clin Oncol. 2009;39:638–43.
4. Wakui R, Yamashita H, Okuma K, Kobayashi S, Shiraishi K,
Terahara A, et al. Esophageal cancer: definitive chemoradio-
therapy for elderly patients. Dis Esophagus. 2010;23:572–9.
5. Ando N, Ozawa S, Kitagawa Y, Shinozawa Y, Kitajima M.
Improvement in the results of surgical treatment of advanced
squamous esophageal carcinoma during 15 consecutive years.
Ann Surg. 2000;232:225–32.
6. Prenzel KL, Bollshweiler E, Schro ¨der W, Mo ¨nig SP, Drebber U,
Vallboehmer D, et al. Prognostic relevance of skip metastases in
esophageal cancer. Ann Thorac Surg. 2010;90:1662–80.
7. Patti MG, Gantert W, Way LW. Surgery of the esophagus.
Anatomy and physiology. Surg Clin N Am. 1997;77:959–70.
8. Takeuchi H, Fujii H, Ando N, Ozawa S, Saikawa Y, Suda K,
et al. Validation study of radio-guided sentinel lymph node
navigation in esophageal cancer. Ann Surg. 2009;249:757–63.
9. Nishimura T, Sayama J, Ueda H, Sugawara K, Takano R, Sagawa
J, et al. Lymph flow and lymph node metastasis in esophageal
cancer. Surg Today. 1995;25:307–17.
10. Kato H, Kuwano H, Nakajima M, Miyazaki T, Yoshikawa M,
Ojima H, et al. Comparison between positron emission tomog-
raphy and computed tomography in the use of the assessment of
esophageal carcinoma. Cancer. 2002;94:921–8.
11. Flamen P, Lerut A, Van Cutsem E, De Wever W, Peeters M,
Stroobants S, et al. Utility of positron emission tomography for
the staging of patients with potentially operable esophageal car-
cinoma. J Clin Oncol. 2000;181(8):3202–10.
12. van Neiveen Dijkum EJ, de Wit LT, van Delden OM, Rauws
EAJ, van Lanschot JJB, Obertop H, et al. The efficacy of lapa-
roscopic staging in patients with upper gastrointestinal tumors.
13. Takeno A, Takiguchi S, Yamasaki M, Miyata H, Kawabata R,
Nushijima Y, et al. A suspected [18F]fluorodeoxyglucose positron
emission tomography negative metastatic lymph node success-
fully diagnosed by laparoscopic staging in esophageal cancer:
report of two cases. Surg Today. 2009;39:888–91.
14. Shitara K, Muro K. Chemoradiotherapy for treatment of esoph-
ageal cancer in japan: current status and perspectives. Gastroin-
test Cancer Res. 2009;3:66–72.
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