Predictors of survival for esophageal cancer patients with and without celiac axis lymphadenopathy: impact of staging endosonography

Multiple management modalities in esophageal cancer: epidemiology, presentation and progression, work-up, and surgical approaches

Annually, approximately 13,200 people in the U.S. are diagnosed with esophageal cancer and 12,500 die of this malignancy. Of new cases, 9,900 occur in men and 3,300 occur in women. In part I of this two-part series, we explore the epidemiology, presentation and progression, work-up, and surgical approaches for esophageal cancer. In the 1960s, squamous cell cancers made up greater than 90% of all esophageal tumors. The incidence of esophageal adenocarcinomas has risen considerably over the past two decades, such that they are now more prevalent than squamous cell cancer in the western hemisphere. Despite advances in therapeutic modalities for this disease, half the patients are incurable at presentation, and overall survival after diagnosis is grim. Evolving knowledge regarding the etiology of esophageal carcinoma may lead to better preventive methods and treatment options for early stage superficial cancers of the esophagus. The use of endoscopic ultrasound and the developing role of positron emission tomography have led to better diagnostic accuracy in this disease. For years, the standard of care for esophageal cancer has been surgery; there are several variants of the surgical approach. We will discuss combined modality approaches in part II of this series.

Neoadjuvant therapy for oesophagogastric cancer

BACKGROUND

The prognosis after surgery for oesophagogastric cancer remains poor.

METHODS

This review clarifies current indications for neoadjuvant therapy for oesophageal and gastric cancer. A systematic literature research and evaluation of data from international cancer meetings were carried out.

RESULTS

Recently published results of large randomized phase III trials underscore the potential value of neoadjuvant treatment for oesophagogastric cancer. However, it remains uncertain which subgroups of patients should routinely undergo preoperative therapy. Metabolic response evaluation during neoadjuvant treatment is a promising tool for the selection of responding patients.

CONCLUSION

Neoadjuvant chemotherapy is a valid option for locally advanced oesophageal and gastric cancer. In the future, more effective and better tolerated treatment strategies, tailored to the specific tumour characteristics of each individual, should be possible.

Diagnosis and therapy for advanced esophageal cancer

PURPOSE OF REVIEW

The majority of esophageal cancers are advanced at presentation, rendering cure unlikely, especially by surgery alone. Consequently, much research effort has been directed towards studies of adjuvant chemotherapy and chemoradiation, particularly in defining the best regimens from the standpoint of efficacy and minimal toxicity and in an attempt to predict response.

RECENT FINDINGS

Overall results of adjuvant therapy have been conflicting, although a survival advantage has been documented in those demonstrating objective response to chemoradiation. In such circumstances, comparable survival has been demonstrated using chemoradiation alone, leading to the hypothesis that surgery may be best reserved for nonresponders. For those with stage IV disease or unfit for radical treatment, a variety of palliative modalities exist including stenting, laser photocoagulation, brachytherapy, and chemotherapy used singly or in combination, the latter providing encouraging improvement in survival over single-modality treatment.

SUMMARY

Current research is directed towards securing better results using newer chemotherapeutic agents such as taxanes and irinotecan and deploying molecular markers both to predict response to chemotherapy and to target its delivery to tumor sites.

The role of endoscopic ultrasound in the diagnosis and management of Barrett's esophagus

Although initial studies suggest a limited role for EUS in the detection of BE and the diagnosis and staging of dysplasia, a defined role in several specific situations is emerging. EUS is useful in selecting appropriate candidates for nonoperative therapies by excluding patients with submucosal cancers and those with malignant lymph nodes. EUS may also help in the selection of patients for EMR, either alone or in combination with ablative therapies.

Locally advanced esophageal cancer

Patients diagnosed with adenocarcinoma or squamous cell carcinoma of the esophagus should undergo computed tomography of the chest and abdomen and positron emission tomography to look for evidence of distant metastatic disease. In the absence of systemic metastases, locoregional staging should be performed with endoscopic ultrasonography and fine needle aspiration of accessible periesophageal lymph nodes and any detectable celiac lymph nodes. Patients found to have T3 tumors (transmural extension), T4 tumors (invasion of adjacent structures), or N1-M1a (lymph node-positive) disease do poorly when treated with surgery alone; 5-year survival is less than 20%. These patients should be considered for combined modality therapy. Patients with T4 disease are generally not deemed candidates for surgical resection; they may be considered for definitive chemoradiotherapy. Patients with T3 disease or lymph node-positive disease may be treated with neoadjuvant chemoradiotherapy followed by surgery or definitive chemoradiotherapy alone. Patients considered for trimodality therapy should be fully restaged before surgery to assess their response to neoadjuvant treatment. This should include repeat endoscopic ultrasound and fine needle aspiration of lymph nodes. Patients whose lymph node metastases do not completely respond to neoadjuvant therapy are unlikely to benefit from the addition of surgery. Patients with persistently positive celiac lymph nodes have a very poor prognosis and should not undergo surgery. Patients with persistent nodal disease who have good performance status may be considered for additional chemotherapy. Patients with locally advanced esophageal cancer who have poor performance status are not good candidates for combined modality therapy. These individuals are best managed with palliative intent. Particular attention should be given to alleviating the common problem of dysphagia, which causes significant morbidity.

Prognostic factors for the survival of patients with esophageal carcinoma in the U.S.: the importance of tumor length and lymph node status

BACKGROUND

The current TNM classification system does not consider tumor length or the number of lymph nodes in the staging and classification scheme for patients with esophageal carcinoma. Using data from the National Cancer Institute SEER Program, the authors explored the effect of tumor length and number of positive lymph nodes on survival in patients with esophageal carcinoma.

METHODS

Patients with esophageal adenocarcinoma or squamous cell carcinoma were subgrouped according to historic stage with localized, regional, or distant disease. Demographic factors (age at diagnosis, race, and gender) and tumor characteristics (morphology, histologic grade, tumor length, primary site, depth of invasion, number of positive lymph nodes, proportion of positive lymph nodes dissected, and distant metastatic sites) were examined.

RESULTS

Overall factors that were associated with an increased mortality risk included increasing age at diagnosis, black race versus white race, histologic grade, primary tumor site in the lower esophagus and abdomen versus upper regions, and increasing depth of invasion. Among patients with regional disease, the number of positive lymph nodes (>/= 5 vs. < 5) was related to an increasing risk (hazard ratio [HR], 1.29; 95% confidence interval [95%CI], 1.06-1.56). The proportion of positive lymph nodes compared with the number of lymph nodes dissected conferred an increased risk (HR, 1.63; 95%CI, 1.26-2.11). Among patients with distant disease, sites other than distant lymph nodes implied an increased mortality risk (HR, 1.37; 95%CI, 1.37-1.65). Tumor length was an independent predictor of mortality when controlling for depth of invasion in patients with localized disease (HR, 1.15; 95%CI, 1.08-1.21).

CONCLUSIONS

Tumor length, the number of involved lymph nodes, and the ratio of positive lymph nodes are important prognostic factors for survival in patients with esophageal carcinoma. A revised TNM classification system for patients with esophageal carcinoma might consider adding tumor length and number of positive lymph nodes as two important prognostic factors.

Endoscopic ultrasound

Indications and the clinical utility of endosonography have evolved as new technology, such as linear array echoendoscopes and EUS-guided fine needle aspiration, has emerged. The most noteworthy of the EUS applications are for cancer staging; including rectal, pancreatic, lung, and esophageal malignancies. There is little doubt that EUS is a powerful tool for cancer imaging, but its clinical impact in patient care and management has yet to be validated in prospective outcome studies. Other imaging modalities such as positron emission tomography (PET), dual-phased helical CT, and MR imaging technology will undoubtedly provide increasingly accurate diagnostic and staging information for gastrointestinal diseases. EUS imaging alone may assume a less significant role in relation to these noninvasive modalities in the future. EUS-guided FNA, as well as therapeutic EUS applications, will likely continue to expand in scope and play an important role in clinical medicine for many years to come.

New techniques for staging esophageal cancer

Correct staging is essential for treatment selection, discussion of prognosis, and scientific communication. The CT scan has long been the essential tool for staging esophageal cancer and still remains valuable for initial screening for distant metastases. The development of endoscopic ultrasonography (EUS), with EUS fine-needle aspiration, positron emission tomography, and minimally invasive surgical staging via thoracoscopy and laparoscopy has resulted in more precise staging. These new tools will allow better definition of patient subsets that may benefit from selected therapies and clinical investigations.

Multimodality therapy for esophageal cancer

Esophageal cancer is undergoing a major shift in its epidemiology. Its incidence is dramatically growing and it more commonly affects younger and healthier patients. Based on the published data, there is no strong evidence to recommend routine preoperative chemotherapy for the treatment of surgically resectable esophageal carcinoma. It might be that a large-scale randomized study-which will be published in the near future-will shed some different light on this subject. The role of preoperative CRT remains undetermined. To settle this issue, larger, clinical, controlled trials are needed. Improvement in the preoperative regimen and use of new drugs should be evaluated. Concomitant CRT should be considered for potential benefit in survival and local control in patients who have localized disease and are candidates for radical non-surgical treatment. Patients with pCR following neoadjuvant therapy have a consistent, substantial survival benefit. Biologic markers can be used to predict response to therapy and might allow designation of treatment based on the individual tumor. Pretreatment staging is necessary for standardization of patients undergoing treatment protocols and for outcome evaluation. Pretreatment staging will be even more important in the future for adjusting treatment to individual patient. Video-assisted thoracoscopy and laparoscopy have been found to be the most accurate lymph node staging techniques.

Esophageal cancer

Despite advances in our knowledge of esophageal cancer, 50% of patients present with incurable disease, and the overall survival after diagnosis is poor. The incidence of esophageal adenocarcinoma of the distal esophagus is rising at a rapid rate in developed countries. Recent advances in the epidemiology of esophageal cancer offer insights into preventive strategies in patients who are at risk. New developments in diagnosis may help detect the disease at an early stage. New diagnostic modalities permit more accurate staging procedures and allow appropriate selection of therapy. New studies provide more information on multimodality therapy for esophageal cancer, and new endoscopic techniques allow resection of small lesions without surgery. New stent designs provide better palliation by providing tumor ingrowth. These developments in the treatment of esophageal cancer are the focus of this review.

Interventional endoscopy in the diagnosis and staging of upper gastrointestinal malignancy

Increased population longevity as well as an emphasis on earlier diagnosis and more effective treatment of cancer have created an environment for new technologies and techniques to flourish. Some of the endoscopic entities discussed in this article have not been fully validated in clinical practice. Innovative spectroscopic modalities hold a great deal of promise, but are years away from general applicability. In contrast, many interventional endoscopic techniques are currently available and confer heightened levels of diagnostic and staging accuracy for gastric and esophageal malignancies. Earlier diagnosis can identify patients who may be eligible for less-invasive treatment options such as EMR. Minimally invasive treatment options and maximum staging accuracy are more important for patients who are marginal surgical candidates and for accurate comparison of clinical trials studying treatment options. Our challenge for the future is to properly integrate these technologic advances with the science of good medical practice.

The utility of EUS and EUS-guided fine needle aspiration in detecting celiac lymph node metastasis in patients with esophageal cancer: a single-center experience

BACKGROUND

The aims of this study were to determine the utility of EUS and EUS-guided fine needle aspiration (EUS-FNA) in the detection and confirmation of celiac lymph node metastasis in patients with esophageal cancer and to define EUS features predictive of celiac lymph node metastasis in these patients.

METHODS

The records of 211 patients with esophageal cancer who underwent EUS staging were reviewed. The operating characteristics of EUS were determined in patients where either surgery, EUS-FNA of a celiac lymph node, or both were performed (n = 102). The association between selected variables and the presence of celiac lymph node metastasis was evaluated by univariate and multivariable analyses.

RESULTS

EUS in 48 patients provided a true-positive diagnosis of celiac lymph node involvement, a false-positive and false-negative result, respectively, in 6 and 14 patients, and a true-negative diagnosis in 34 patients. The sensitivity of EUS in detecting celiac lymph node was 77% (95% CI [67, 88]), specificity 85% (95% CI [74, 96]), negative predictive value 71% (95% CI [58, 84]), and the positive predictive value 89% (95% CI [81, 97]). EUS-FNA was performed in 94% (51/54) of patients with celiac lymph nodes. The accuracy of EUS-FNA in detecting malignant celiac lymph nodes was 98% (95% CI [90, 100]). Advanced T-stage, the need for dilation, detection of peritumoral lymph nodes, and black race were associated with celiac lymph node involvement. In multivariable analysis, advanced T-stage was the strongest predictor of celiac lymph node involvement.

CONCLUSION

EUS and EUS-FNA are highly accurate in detecting and confirming celiac lymph nodes metastasis. Depth of tumor invasion as assessed by EUS is a strong predictor of celiac lymph node metastasis in patients with esophageal cancer.