Challenges During Esophagectomy in Presence of Thoracic Anatomical Anomalies: A Report of Three Cases

BACKGROUND/AIM: Esophagectomy for esophageal cancer is a complex surgical procedure with predefined surgical steps. Anatomical anomalies can offer additional challenges in case of surgical treatment. We present three cases of esophageal carcinoma with thoracic anatomical anomalies affecting the treatment strategy. The aim was to address the anatomical challenges of the anomalies and their impact on surgery as well as elaborate on possible solutions. CASE REPORT: We present three patient cases with anomalies of the thoracic anatomy. The first patient had a tumor with suspected ingrowth in an arteria lusoria. Restaging after definitive chemoradiotherapy showed progression of disease but without previously noted signs of vascular wall invasion and salvage robot-assisted minimally invasive esophagectomy (RAMIE) was performed. The second patient had an azygos lobe of the lung and underwent RAMIE after neoadjuvant chemoradiotherapy. The azygos vein was clipped, and paratracheal lymph node dissection was performed, however with limited extent at the right side due to the anatomical situation. The third patient was diagnosed with a right aortic arch, where the aortic arch transverses over the right bronchus instead of the left and descends to the right of and posterior to the esophagus and trachea. Treatment included definitive chemoradiotherapy (dCRT) without surgery, given the anatomical situation and a complete clinical response to dCRT of a squamous cell carcinoma. CONCLUSION: Thoracic anatomical anomalies are rare entities, which can be asymptomatic. Clinical implications can arise in combination with diagnosis of esophageal cancer and the need for surgical treatment. Therefore, detailed information regarding possible anomalies must be obtained prior to surgery and potential challenges have to be taken into consideration. Resection of related structures with tumor ingrowth can be considered in selected cases to achieve a radical resection.