N1 esophageal carcinoma: the importance of staging and downstaging

Lymph node micrometastasis in patients with esophageal cancer: diagnosis and a prospective study of impact on prognosis

AIM: To investigate genetically diagnostic method of lymph node micrometastasis in patients with esophageal cancer and to evaluate its prognostic significance

METHODS: Using assays of reverse transcriptase-polymerase chain reaction (RT-PCR), three hundred and sixty-six regional lymph nodes obtained from sixty-three patients with squamous cell cancer of the esophagus without invasion confirmed by routine histopathologic analysis (pN0) were studied to further detect mRNA for Mucin1 (myc1) gene and determine micrometastasis. All the patients were followed up. Survival difference was compared by x² test. Logistic regressive analysis was performed to determined independent prognostic factors.

RESULTS: Specificity of genetic diagnosis for lymph node micrometastasis was 100% (30/30); Sensitivity of genetic diagnosis for lymph node micrometastasis was 97% (27/30). myc1 mRNA was identified in thirty lymph nodes (8.2%) from twenty-two patients (34.9%). Lymph node microme-tastasis was diagnosed in these patients. Survival rate at 3-year in patients with nodal micrometastasis (54.5%) was lower than that in patients without nodal micrometastasis (80.5%) (P < 0.01). In logistic analysis nodal micrometastasis (P < 0.05, OR = 3.71) and T₃ tumor (P < 0.05, OR = 7.17) were independent prognostic factors.

CONCLUSION: Nodal micrometastasis can be genetically diagnosed by the detection of expression of myc1 mRNA in lymph node of patients with pN₀ esophageal carcinoma; Poorer prognosis after radical surgery in the patients may be correlated with nodal micrometastasis.

Benefit of postoperative adjuvant chemoradiotherapy in locoregionally advanced esophageal carcinoma

OBJECTIVE

We sought to determine whether chemoradiotherapy after esophagectomy improves survival.

METHODS

From 1994 to 2000, 31 patients with locoregionally advanced esophageal carcinoma (90% pT3, 81% pN1, and 13% pM1a) received postoperative adjuvant chemoradiotherapy. Concurrently, 52 patients with advanced carcinoma underwent esophagectomy alone and survived at least 10 weeks, the time frame for adjuvant therapy. A propensity score based on demographic, tumor, and surgical factors was used to identify matched pairs to determine the association of adjuvant therapy with outcomes.

RESULTS

For patients receiving adjuvant therapy versus esophagectomy alone, risk-unadjusted median, 1-year, and 4-year survivals were 28 versus 14 months, 68% +/- 8.4% versus 60% +/- 6.8%, and 44% +/- 9.0% versus 17% +/- 5.6%, respectively (P =.05). Similarly, risk-unadjusted median time to recurrence was 25 versus 13 months (P =.15), and median recurrence-free survival was 22 versus 11 months (P =.04). Among propensity-matched patients, median, 1-year, and 4-year survivals for those receiving adjuvant therapy versus esophagectomy were 28 versus 15 months, 60% +/- 11.0% versus 65% +/- 10.7%, and 44% +/- 11.3% versus 0% (P =.05). Median time to recurrence was 25 versus 13 months (P =.04), and recurrence-free survival was 22 versus 10 months (P =.02).

CONCLUSION

In patients with locoregionally advanced esophageal carcinoma, addition of postoperative adjuvant chemoradiotherapy to esophagectomy alone doubled survival time, time to recurrence, and recurrence-free survival. Patients with locoregionally advanced carcinoma after esophagectomy should be considered for adjuvant therapy.

Survival following intensive preoperative combined modality therapy with paclitaxel, cisplatin, 5-fluorouracil, and radiation in resectable esophageal carcinoma: A phase I report

PURPOSE

To assess the benefits of aggressive chemoradiation therapy followed by surgery in resectable esophageal carcinoma.

METHOD

Twenty-nine patients with resectable carcinoma were treated with 60 Gy of radiation (2 Gy daily for 6 weeks) and concurrent chemotherapy consisting of continuous infusion of 5-fluorouracil (200-225 mg/m(2)/d), paclitaxel (25, 40, 50, or 60 mg/m(2)) weekly over 1 hour, and cisplatin (25 mg/m(2)) weekly immediately following paclitaxel throughout radiation. Patients received either 4 cycles of postoperative paclitaxel 175 mg/m(2) over 3 hours and cisplatin 75 mg/m(2) every 3 weeks or paclitaxel 175 mg/m(2) over 3 hours and cisplatin 75 mg/m(2) every 3 weeks prior to the initiation of chemoradiation. After induction therapy and restaging, esophagectomy was performed 4 to 6 weeks later.

RESULTS

Twenty-seven patients were eligible for study (26 men, 23 with adenocarcinoma). Median age was 58 years (range 30-73). The maximum tolerated dose combination was paclitaxel 50 mg/m(2) over 1 hour weekly, cisplatin 25 mg/m(2) over 1 hour weekly, 5-fluorouracil 200 mg/m(2)/d by continuous infusion throughout radiotherapy and radiation to 60 Gy. Twenty-two patients completed therapy and underwent surgical resection. Four patients had complete pathological responses and 18 had partial responses with no mortality. The commonest dose-limiting toxicity was mucositis and esophagitis (n = 7). Median follow-up of 27 patients was 150 weeks (range 7-303). At 2-year follow-up 16/27 (59%) were alive and 15/27 (56%) were free of disease. At 4-year follow-up 12/27 (44%) were alive and free of disease. Median follow-up of 22 patients undergoing esophagectomy was 205 weeks (range 26-303). At 4-year follow-up 10/22 (45%) were alive and free of disease. For the 18 patients treated at or above the maximum tolerated dose, median follow-up was 151 weeks (range 35-206) and at 3-year follow-up 9/18 (50%) were alive and free of disease.

CONCLUSION

Aggressive combined modality therapy of esophageal carcinoma was associated with excellent long-term survival in this phase I trial.

Long-term survivors of advanced esophageal cancer without surgical treatment: a multicenter questionnaire survey in Kyushu, Japan

Since the introduction of recent improvements in adjuvant therapy for esophageal cancer, some patients have demonstrated good prognosis. In the present study, we analyzed 3- and 5-year survivors of advanced esophageal cancer who did not undergo any surgical treatment. Between 1990 and 1998, 831 patients were admitted to 14 university hospitals and one cancer center associated with the membership of the Kyushu study group for adjuvant therapy of esophageal cancer. Twelve (1.4%) of the patients were 3-year survivors and 13 (1.6%) were 5-year survivors. The reasons for non-operation were refusal (eight patients), tumor-related factors (11 patients), and host-related factors (six patients). With a single exception, all patients had locally advanced tumors. Almost all long-term survivors had fewer than five lymph node metastases, in regions limited to the neck and/or mediastinum. Radiation therapy was combined with chemotherapy for 16 of the 25 patients, and chemotherapy-based cisplatin was used for 15 of these 16 patients. Fifteen of the patients remain alive; 10 died seven of them from esophageal cancer. Chemoradiation therapy was effective for some patients with locally advanced esophageal cancer, particularly in the absence of or with few lymph node metastases. To improve the prognosis of patients with advanced esophageal cancer who, for various causes, cannot undergo surgical treatment, a new protocol for adjuvant therapy is required.

Clinical benefit of chemosensitivity test for patients with regional lymph node-positive esophageal squamous cell carcinoma

BACKGROUND AND OBJECTIVES

Patients who have undergone resection for lymph node-positive esophageal squamous cell carcinoma are at high risk of recurrence and early death. The role of the postoperative adjuvant chemotherapy in this population needs to be determined. The present study was designed to determine whether the chemosensitivity test in fresh human esophageal squamous cell carcinoma, using highly purified tumor cells, correlates with the clinical response.

METHODS

A retrospective review of all patients with resected squamous cell carcinoma of the thoracic esophagus between 1993 and 2000 was performed. We determined the chemosensitivity for cisplatin (CDDP), 5-fluorouracil (5-FU), mitomycin C, and adriamycin in vitro in fresh human esophageal squamous cell carcinoma using the MTT assay. Regional lymph node-positive (N1) patients who received sequential postoperative chemotherapy were compared with lymph node positive patients who underwent surgery alone.

RESULTS

A total of 50 patients were reviewed, and chemosensitivity tests were successfully performed in 46 patients: 20 patients received surgery alone (S group), and 26 patients received surgery plus postoperative chemotherapy (SC group) according to results of MTT assay using highly purified tumor cells. When the SC group was divided into an SC-low group (inhibition rate of CDDP + 5-FU was below 85%, n = 15) and an SC-high group (over 85%, n = 11), the SC-high group showed more significant survival prolongation than the S group or the SC-low group (P < 0.01).

CONCLUSIONS

Our results suggest that the results of the conventional MTT assay may be useful in evaluating the optimum adjuvant chemotherapy for patients with regional lymph node positive (pN1) esophageal squamous cell carcinoma.

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.

Role of clinically determined depth of tumor invasion in the treatment of esophageal carcinoma

OBJECTIVE

We sought to evaluate the effectiveness of clinical staging of depth of tumor invasion (cT), the relationship of cT to survival, the benefits of downstaging cT, and the role of cT in treatment decisions.

METHODS

The accuracy of determining T by means of endoscopic ultrasonography and the relationship of cT to survival were assessed in 209 patients undergoing esophagectomy alone for esophageal carcinoma. The benefit of downstaging cT was assessed in 128 patients undergoing induction therapy and esophagectomy. The role of cT in treatment decisions was determined by integrating these results with the results of previous work.

RESULTS

Compared with pathologic T (pT), cT was 87% accurate, 82% sensitive, 91% specific, 89% positively predictive, and 86% negatively predictive of tumors confined to (< or =T2) or invading beyond (>T2) the esophageal wall. In cN0, increasing cT was predictive of progressively poorer survival. For each category of pT N0, cT accurately predicted survival, except for pT3, which was underestimated (P <.0001). In cN0, downstaging by induction therapy was beneficial only if tumors invaded beyond the wall (> or =cT3, P =.0003). In cN1, it was beneficial only when downstaging was synchronous in cT3/T4 (P <.001).

CONCLUSIONS

cT should be the principal determinant of treatment in cN0. In cN0, if endoscopic ultrasonography identifies tumors of greater than cT2, multimodality therapy should be considered. However, only when cT3/T4 tumors are downstaged to pT2 or less will patients benefit, but their survival will not equal that of patients with tumors of cT2 or less having esophagectomy alone. If endoscopic ultrasonography identifies tumors of cT2 or less, esophagectomy alone should be used because induction therapy might adversely affect survival.

Refining esophageal cancer staging

OBJECTIVE

Cancer staging is dynamic, reflecting accrual of knowledge and experience in treatment. The objectives of this study were to assess current esophageal cancer staging and to determine whether refinements of classification and stage grouping are necessary.

METHODS

From 1983 through November 2000, 480 patients underwent esophagectomy without induction therapy. Depth of tumor invasion (T), regional lymph node status (N), distant status (M), number of metastatic regional lymph nodes, and histopathologic type and grade were subjected to survival-tree analysis, multivariable Cox and hazard function analysis, and residual misclassification risk analysis.

RESULTS

Inhomogenity of survival was found within and lack of distinction was found between current American Joint Committee on Cancer staging groups, supporting the need for refinement. T1 and N1 were redefined on the basis of survival differences. T1a is intramucosal cancer, T1b is submucosal cancer (P =.008), N1 is 1 or 2 metastatic regional lymph nodes, and N2 is 3 or more metastatic regional lymph nodes (P =.01). Current subclassification of M1 is not warranted (P =.9). Histopathologic type (P =.17) and grade (P =.3) minimally refined staging. Reassignment of staging groups constrained by American Joint Committee on Cancer definitions of stages 0 and IV produced less monotonic, distinctive, and homogeneous survival than free assignment of staging groups.

CONCLUSIONS

Current American Joint Committee on Cancer staging of esophageal cancer is inadequate. Refinement requires redefinition of T1, N1, and M1 classifications. Stage grouping within the constraints of American Joint Committee on Cancer definitions produces less accurate prognosis than free assignment based on survival data.

Endoscopic ultrasound and upper gastrointestinal disorders

Endoscopic ultrasound (EUS) plays a vital role in management of upper gastrointestinal disorders, particularly cancer of the esophagus, pancreas, stomach, lung (via transesophageal mediastinal staging), and bile duct. Endoscopic ultrasound has also been valuable in detection of early chronic pancreatitis (CP). In cancer of the esophagus, the primary role of EUS is to determine whether disease is localized (T1-2, N0) and appropriate for surgery, locally advanced (T3-4, N1, M1a) (which may benefit from chemoradiation with or without surgery), or metastatic. Pancreatic and bile duct cancers are more complex given the controversy over portal vein resection. In centers that resect tumors invading the portal venous system, the role of EUS is limited to tissue confirmation or identification of metastases to the liver or distant lymph nodes. In centers that do not resect the portal vein invasion, EUS plays an important role in local staging. In lung cancer, EUS is emerging as an accurate, nonsurgical alternative to staging the mediastinum through EUS fine-needle aspiration. Endoscopic ultrasound has an important role in diagnosing CP because of its high degree of sensitivity. This has also led to controversy over whether EUS can overdiagnose CP. For these reasons, we recommend the use of a high threshold for EUS and that CP be diagnosed in conjunction with other standard tests (endoscopic retrograde cholangiopancreatography, pancreatic function tests).

Prognostic significance of the size of cancer nests in metastatic lymph nodes in human esophageal cancers

BACKGROUND

Postoperative survival of patients with esophageal cancers after curative surgery is strongly affected by the presence of lymph node metastasis. The number and location of lymph node metastases have been evaluated and graded, but the clinical significance of their size has not been well investigated.

METHODS

Of 322 esophageal cancer patients who underwent curative operations with radical lymph node dissection, 170 (53%) had lymph node metastasis. A total of 784 metastatic lymph nodes were obtained, and the area of the cancer nests was measured microscopically in the cross section. The data from each patient included the area of the largest cancer nest in the positive nodes (Nmax), classified as Na (<4 mm2), Nb (4-25 mm2), Nc (25-100 mm2), or Nd (>100 mm2).

RESULTS

The 170 patients were classified according to the Nmax value: Na, 31 (18.2%); Nb, 35 (20.5%); Nc, 49 (28.8%); and Nd, 55 (32.4%). The 5-year survival rate was 77.7% in patients without lymph node metastasis and 35.4% in those with lymph node metastasis. When classified by Nmax, the 5-year survival rate was 77.8% for Na, 63.9% for Nb, 18.8% for Nc, and 12.8% for Nd. There was no significant difference in the survival rate between Na patients and those without lymph node metastasis. Nmax showed significant correlation with the primary tumor size, depth of tumor invasion, and number and location of metastatic lymph nodes, but not with histologic type or primary tumor location. In multivariate analysis, the Nmax value, the number of lymph node metastases and depth of tumor invasion were independent prognostic factors, while the location of the lymph node metastases was not statistically significant.

CONCLUSIONS

The area of the largest cancer nest in the lymph nodes was one of the most significant prognostic factors for esophageal cancers. This estimation is objective and reproducible and may be of great importance when deciding the therapeutic modality for patients with esophageal cancers.

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.

Esophageal carcinoma: surgery, radiotherapy, and chemotherapy

Several new developments in the potentially curative therapy of esophageal cancer have drawn attention over the past year. There is a potential benefit of centralization of esophagectomies in dedicated centers. Early mucosal lesions are increasingly treated by local ablative therapy. Tumors invading the submucosa are preferably treated by surgical resection. There is ongoing controversy about the optimal surgical approach. Positron emission tomography scanning is a promising tool in the preoperative work-up but needs critical evaluation. The question of whether chemoradiation with voice preservation (followed by salvage surgery in case of tumor recurrence) can replace pharyngolaryngectomy in patients with cervical esophageal cancer is still unanswered. A review of eight randomized trials demonstrated that chemoradiation as primary treatment of esophageal cancer provides an absolute reduction of mortality. The addition of new drugs like paclitaxel and irinotecan into induction regimens for the treatment of advanced disease results in higher response rates but also in increased toxicity. Preoperative radiotherapy as single modality treatment does not improve overall survival, whereas the benefit of preoperative chemotherapy and chemoradiation has not been proven unequivocally. Several retrospective studies with a small number of patients suggest that local response parameters like pathologic complete response and downstaging of regional lymph node (N) status are correlated with longer survival.