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Ann Thorac Surg 2005;80:1510-1512
© 2005 The Society of Thoracic Surgeons

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Case report

Esophageal Cancer Surgery in Heart Transplant Patients

^a Chirurgische Klinik und Poliklinik, Munich, Germany
^b Erste Medizinische Klinik, Munich, Germany
^c Klinik für Herz und Gefäßchirurgie, Deutsches Herzzentrum München Klinikum rechts der Isar, Technical University Munich, Munich, Germany

Accepted for publication April 20, 2004.

^_* Address reprint requests to Dr von Rahden, Department of Surgery, Technical University Munich, Chirurgische Klinik and Poliklinik, Ismaningerstr 22, Munich81675, Germany (Email: vrahden{at}nt1.chir.med.tu-muenchen.de).

	Abstract

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We herein report about 2 heart transplant patients undergoing surgical resection for esophageal cancer. Both were long-term survivors after orthotopic heart transplantation for dilated cardiomyopathy. One patient underwent a transthoracic esophagectomy and gastric pull-up for an early squamous cell carcinoma of the infracarinal esophagus. The second patient underwent a resection of the cervical esophagus and interposition of a free jejunal segment after neoadjuvant radiochemotherapy for a locally advanced squamous cell carcinoma in the cervical esophagus.

	Introduction

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Preoperative risk evaluation and patient selection led to improved outcome after esophageal cancer surgery [1]. However, impaired cardiac function remains an independent predictor of a fatal postoperative course [1]. Long-term survivors after heart transplantation are mostly in good physical status and according to a large survey by Hetzer and colleagues [2] their quality of life is comparable with the general population, and only a few of them are significantly limited in their lifestyle.

The cancer risk after transplantation is increased. Posttransplant lymphoproliferative disorders as well as nonmelanoma skin cancers are well-known. Esophageal cancers have been occasionally reported. Data from a nationwide cohort study from Sweden indicate a three-fold increased risk after solid organ transplantation [3]. The cancer risk after cardiac transplantations [4, 5] appears to be even higher than after kidney transplantation. This is regarded as a result of the higher doses of immunosuppressive drugs required.

We herein report about two cases of long-term survivors after cardiac transplantation who had surgical resection for esophageal cancer.

	Case Reports

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Patient 1
A 67-year-old male, who had orthotopic cardiac transplantation for dilated cardiomyopathy in 1990, was admitted in 1998 for treatment of an early squamous cell cancer of the infracarinal esophagus (T1 N0 M0 on preoperative staging).

The patient underwent extensive evaluation of the cardiologic risk for surgery. Electrocardiography showed sinus rhythm with mild tachycardia (heart rate 100 bpm) and regular conduction. Echocardiography demonstrated well-functioning ventricles of normal size and slightly dilated atria as common after cardiac transplantation. A normal ejection fraction (68%) was confirmed by cardiac catheter study. The coronary angiogram showed regular coronary arteries without stenosis. Transplant rejection was excluded by myocardial biopsy.

Further risk factors were a reduced renal function (compensated chronic renal failure; blood urea nitrogen, 35 mg/dL; creatinine, 1.8 mg/dL; glomerular filtration rate = 21.5 mL/min) and a moderate chronic obstructive pulmonary disease (forced expiratory volume in 1 second, 68%; peak expiratory flow, 66%) due to a long-lasting smoking history and ethyltoxic child-A liver cirrhosis with reduced hepatic function (pseudocholinesterase, 714 U/L; pathologic ¹⁴C-aminopurine-breathing test) due to long-term alcohol abuse and a noninsulin-dependent diabetes mellitus. The patient was on immunosuppressive therapy with cyclosporine A and methylprednisolone.

Despite the patient's elevated risk, a score of 21 with our composite scoring system indicated high-risk for surgery [1], a decision was still made for surgical treatment.

The patient received a standard transthoracic en-bloc-esophagectomy and gastric pull-up for reconstruction. We performed a one-stage procedure, starting with the laparotomy for creating the gastric tube, and we proceeded with a thoracotomy through the fifth intercostal space. The mediastinum was only slightly affected after cardiac transplantation. As indicated by the surgical report, the transplanted heart was anastomosed to the host's atria according to the standard technique described by Shumway and Lower [6]. A standard en-bloc-esophagectomy was performed. Gastric pull-up was performed in the original bed of the esophagus with a high intrathoracic anastomosis.

The specimen showed the small tumor (7 x 7 mm) at the level of the tracheal bifurcation. The histopathologic report described a poorly differentiated basaloid squamous cell carcinoma, classified as pT1 pN0 R0 G3 to 4.

The postoperative course was complicated. Respiratory insufficiency due to severe pneumonia developed in the patient. He temporarily required respirator ventilation and received a tracheotomy. Postoperative episodes of paroxysmal sinus tachycardia were believed to be due to pneumonia and the denervated heart; apart from this, the cardiac function was regular. One and one-half months after the esophagectomy, the patient was discharged home in rather good condition. Nevertheless, the patient's general status deteriorated together with renal and hepatic function. He developed terminal renal insufficiency, and finally died 13 months after the esophagectomy without evidence of tumor recurrence.

Patient 2
The second patient, a 63-year-old human, having undergone orthotopic cardiac transplantation for dilated cardiomyopathy in 1992, was admitted with a locally advanced squamous cell carcinoma of the cervical esophagus (T3 N+ M0 on preoperative therapeutic staging). An extensive cardiologic workup for the evaluation of transplant function and assessment of cardiac risk for surgery was performed. An electrocardiogram showed atrial flutter with 1:2 conduction. A beta blocker was administered for frequency control, and IV heparin was given perioperatively for anticoagulation. Transesophageal echocardiography showed a normal left-ventricular diameter and function, but a dilated atria. There was a low-volume left-to-right shunt through the interatrial septum. The patient received a standard triple immunosuppressive regimen with cyclosporine A (100 mg-0 to 125 mg), azathioprine (1–0–0), and methylprednisolone (2.5 mg). Pulmonary, renal, and hepatic function and the patient's general condition were fine. The patient scored 18 points in the preoperative risk evaluation, indicating an intermediate risk for esophagectomy [1[.

Because of the advanced tumor stage (T3 N+), preoperative radiochemotherapy (40 Gy plus 5-fluorouracil for 4 weeks) was performed in an attempt to increase the chances for subsequent complete tumor resection. This was tolerated well by the patient. Re-staging demonstrated a good response. Resection was performed by a partial cervical esophageal sleeve resection through a cervical incision and partial proximal re-sternotomy. A jejunal loop was used for reconstruction of the digestive tract continuity with microvascular anastomosis to cervical vessels. The arterial anastomosis was performed with the inferior thyroid artery, and two cervical veins were used for venous drainage by using a microsurgical technique. The venous microvascular anastomosis had to be redone 5 hours postoperatively because of thrombosis.

The patient initially recovered well and was discharged from the intensive care unit on postoperative day 6; the patient was fully mobilized and eating soft diets. Histopathologic examination of the specimen revealed a complete response to the neoadjuvant therapy with no residual tumor tissue. Classification according to the UICC was ypT0, N0, R0 (ie, a complete response to neoadjuvant radiochemotherapy).

Two months postoperatively, the patient had neurologic symptoms develop due to spinal stenosis (level Th 3/4). These symptoms were caused by an intraspinal hemangioblastoma, which was removed by the neurosurgeon with a microsurgical technique. This was further complicated by sepsis, due to severe pneumonia and an abscess formation near the spinal chord that required neurosurgical reintervention.

After further deterioration, the patient had multiorgan failure develop with respiratory, cardiovascular, and renal insufficiency. Despite extensive therapeutic attempts (hemofiltration, respirator ventilation, and catecholamine therapy) the patient died 5 months after esophagectomy. Before multiorgan failure, the function of the heart transplant had not caused severe problems, apart from a few episodes of atrial flutter, which was successfully treated with amiodarone.

	Comment

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Major esophageal surgery in heart transplantation patients is mainly a pathophysiologic challenge. In our experience, the operative field in transthoracic esophagectomy was not severely altered by scarring or adhesions, presumably due to the technique of anastomosis according to the technique of Lower and Shumway [6]. A larger amount of adhesions may have to be expected in heart transplant patients with bi-caval anastomosis [7]. Nevertheless, we would not perform transhiatal esophagectomy in patients with any form of previous heart transplantation.

Cardiac function is recognized as a main predictor of the postoperative course [1]. In the special case of the transplanted heart, a meticulous evaluation of its function is considered mandatory, as well as continuing the immunomodulatory therapy.

We experienced episodic tachycardia as a common problem of the denervated heart [8] in both of our cases. The first patient experienced sinus tachycardia due to postoperative stress, volume deficit, and catecholamine therapy. The second patient had atrial flutter that was managed with intravenous amiodarone and heparin.

A retrospective review of both cases demands a critical reappraisal of the indications for surgery. In the first case, a decision to operate on a multi-morbid patient was based on the otherwise good and general condition, the good chances for cure in the early tumor stage, and the patient's strong desire to receive curative treatment. The second patient may have gained more benefit from a definitive radiochemotherapy, especially in light of the complete response to a neoadjuvant regimen demonstrated by the histopathology report. Nevertheless, both cases show that major esophageal surgery is possible even after heart transplantation.

	References

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1. Bartels H, Stein HJ, Siewert JR. Preoperative risk analysis and postoperative mortality of oesophagectomy for resectable oesophageal cancer Br J Surg 1998;85:840-844.[Medline]
2. Hetzer R, Albert W, Hummel M, et al. Status of patients presently living 9 to 13 years after orthotopic heart transplantation Ann Thorac Surg 1997;64:1661-1668.[Abstract/Free Full Text]
3. Adami J, Gabel H, Lindelof B, et al. Cancer risk following organ transplantationa nationwide cohort study in Sweden. Br J Cancer 2003;89:1221-1227.[Medline]
4. Gjersvik P, Hansen S, Moller B, et al. Are heart transplant recipients more likely to develop skin cancer than kidney transplant recipients? Transpl Int 2000;13(Suppl 1):S380-S381.
5. Mihalov ML, Gattuso P, Abraham K, et al. Incidence of post-transplant malignancy among 674 solid-organ-transplant recipients at a single center Clin Transplant 1996:248-255.
6. Shumway NE, Lower R, Stofer RC. Transplantation of the heart Adv Surg 1966;2:265-284.[Medline]
7. Grande AM, Rinaldi M, D'Armini AM, et al. Orthotopic heart transplantationstandard versus bicaval technique. Am J Cardiol 2000;85:1329-1333.[Medline]
8. Scott CD, Dark JH, McComb JM. Arrhythmias after cardiac transplantation Am J Cardiol 1992;70:1061-1063.[Medline]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Matthias Overbeck Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by von Rahden, B. H.A. Articles by Siewert, J. R. Search for Related Content PubMed PubMed Citation Articles by von Rahden, B. H.A. Articles by Siewert, J. R.