The number of metastatic lymph nodes and the ratio between metastatic and examined lymph nodes are independent prognostic factors in esophageal cancer regardless of neoadjuvant chemoradiation or lymphadenectomy extent

The impact of lymph node ratio on overall survival in patients with colorectal cancer

Background

Lymph node metastasis is a predominant prognostic indicator in colorectal cancer. Number of lymph nodes removed surgically was demonstrated to correlate with staging accuracy and oncological outcomes. However, number of lymph nodes removed depends on uncontrolled variables. Therefore, a more reliable prognostic indicator is needed. Calculation of ratio of positive lymph nodes to total number of removed lymph nodes may be an appealing solution.

Materials and Methods

We retrospectively analyzed data of 156 Stage III colorectal cancer patients whom underwent surgery between 2008 and 2015. Patients' demographic characteristics, tumor grade, location, vascular-perineural invasion status, number of removed lymph nodes, and ratio of positive lymph nodes to number of removed lymph nodes were recorded. Spearman correlation analysis was used to determine the correlation coefficient while Kaplan-Meier method and Cox proportional hazard regression model were performed for the prediction of survival and multivariate analysis, respectively.

Results

Number of removed lymph nodes did not correlate with survival, but it was inversely correlated with number of positive lymph nodes. Multivariate analysis showed that ratio of removed positive lymph nodes to the total number of lymph nodes was a significant prognostic factor for survival for a ratio equal or above 0.31 was a poor prognostic indicator (108 months vs. 34 months, hazard ratio: 4.24 [95% confidence interval: 2.15-8.34]; P < 0.019). Tumor characteristics failed to demonstrate any prognostic value.

Conclusions

This study showed that positive lymph node ratio (PLNR) is an important prognostic factor for Stage III colorectal cancer. Although 0.31 can be taken as threshold for "PLNR," prospective trials including larger patient groups are needed to validate its role as a prognostic indicator.

Is There an Optimal Definition for a Positive Circumferential Resection Margin in Locally Advanced Esophageal Cancer?

BACKGROUND

Two definitions of a positive circumferential resection margin (CRM) in esophageal cancer coexist: one by the College of American Pathologists (CAP) (CRM = 0 mm) and another by the Royal College of Pathologists (RCP) (CRM ≤ 1 mm). This study aimed to evaluate the prognostic value of both definitions in esophageal cancer and to identify a new cutoff value for the CRM to predict survival.

METHODS

Patients who underwent curative esophageal resection for locally advanced (≥ pT3) adenocarcinoma or squamous cell carcinoma were selected from 2007 to 2016. The CRM was reassessed using an ocular micrometer. Overall survival (OS) and disease-free survival were estimated with uni- and multivariate analyses.

RESULTS

The study enrolled 283 patients: 48 with a positive CRM according to the CAP definition and 171 with a positive CRM according to the RCP definition. In the multivariate analysis, a positive CRM according to both definitions was significantly associated with a poor OS (CAP: hazard ratio [HR], 2.26, p < 0.001; RCP: HR, 1.42, p = 0.035). A CRM of 0 mm was predictive of a worse OS and DFS than a CRM of 1 mm or less (p < 0.0001), whereas no significant difference was found between a CRM greater than 1 mm and a CRM of 1 mm or less, indicating that the CAP definition was more accurate for predicting prognosis and recurrence. New cutoff CRM values of 100 µm in squamous cell carcinoma and 200 µm in adenocarcinoma were optimal for predicting OS.

CONCLUSION

The CAP definition was more accurate for predicting prognosis and recurrence. The study identified a new cutoff value of CRM according to histologic type.

Near-infrared fluorescence imaging-guided lymphatic mapping in thoracic esophageal cancer surgery

PURPOSE

Identifying the lymphatic drainage pathway is important for accurate lymph node (LN) dissection in esophageal cancer (EC). This study aimed to assess lymphatic drainage mapping in thoracic EC using near-infrared fluorescent (NIRF) imaging with indocyanine green (ICG) and identify its feasibility for intraoperative LN drainage visualization and dissection.

METHODS

From November 2019 to August 2020, esophagectomy was performed using intraoperative NIRF navigation with ICG injected into the esophageal submucosa by endoscopy. All LNs were divided into four groups according to the NIRF status and presence of metastasis: NIRF⁺LN⁺, NIRF⁺LN^-, NIRF^-LN⁺, and NIRF^-LN^-.

RESULTS

Regional LNs were detected in all 84 enrolled patients with thoracic EC. A total of 2164 LNs were removed, and the mean number of dissected LNs was 25.68 ± 12.00. NIRF⁺ LNs were observed in all patients and distributed at 19 LN stations, which formed lymphatic drainage maps. The top five LN stations of NIRF⁺ probability in upper thoracic EC were No. 7, 106ecR, 107, 1, and 106recL; in middle thoracic EC, they were No. 107, 7, 110, 1, and 105; and in lower thoracic EC, they were No. 107, 7, 110, 106recR, and 1. There were no cases of ICG-related adverse events or chylothorax. The 30-day mortality rate was 0%. Major complications included anastomotic fistula (7.14%), pneumonia (4.76%), pleural effusion (13.10%), atelectasis (3.75%), hoarseness (8.33%), and arrhythmia (4.76%).

CONCLUSION

Regional LN mapping of thoracic EC was performed using ICG/NIRF imaging, which showed different preferred LN drainage stations in various anatomical locations of the thoracic esophagus. ICG/NIRF imaging is feasible for intraoperative LN drainage visualization and dissection.

CLINICAL TRIAL REGISTRATION

The clinical trial registration number is NCT04173676 ( http://www.clinicaltrials.gov/ ).

Consensus recommendations for the standardized histopathological evaluation and reporting after radical oesophago-gastrectomy (HERO consensus)

BACKGROUND

Variation in the approach, radicality, and quality of gastroesophageal surgery impacts patient outcomes. Pathological outcomes such as lymph node yield are routinely used as surrogate markers of surgical quality, but are subject to significant variations in histopathological evaluation and reporting. A multi-society consensus group was convened to develop evidence-based recommendations for the standardized assessment of gastroesophageal cancer specimens.

METHODS

A consensus group comprised of surgeons, pathologists, and oncologists was convened on behalf of the Association of Upper Gastrointestinal Surgery of Great Britain & Ireland. Literature was reviewed for 17 key questions. Draft recommendations were voted upon via an anonymous Delphi process. Consensus was considered achieved where >70% of participants were in agreement.

RESULTS

Consensus was achieved on 18 statements for all 17 questions. Twelve strong recommendations regarding preparation and assessment of lymph nodes, margins, and reporting methods were made. Importantly, there was 100% agreement that the all specimens should be reported using the Royal College of Pathologists Guidelines as the minimum acceptable dataset. In addition, two weak recommendations regarding method and duration of specimen fixation were made. Four topics lacked sufficient evidence and no recommendation was made.

CONCLUSIONS

These consensus recommendations provide explicit guidance for gastroesophageal cancer specimen preparation and assessment, to provide maximum benefit for patient care and standardize reporting to allow benchmarking and improvement of surgical quality.

The Prognostic Value of the Lymph Node in Oesophageal Adenocarcinoma; Incorporating Clinicopathological and Immunological Profiling

Simple Summary

Oesophageal cancer rates are increasing rapidly with patients often presenting at an advanced stage. The current approach to treatment involves radiotherapy, chemotherapy, or combination chemoradiotherapy with surgery; however, only a fraction of these patients will achieve meaningful responses. Therefore, there is a need to better understand the tumour and lymph node microenvironments to inform future treatment strategies. This study measured immune markers including immune checkpoint expression in tumour and lymph node tissue in oesophageal cancer patients and patient clinical outcomes, including survival time, response to treatment, and adverse events. We report herein that nodal metastases is of equal prognostic importance to clinical tumour stage and tumour regression grade in OAC and we observed a more immunosuppressive microenvironment in the tumour compared with the lymph node.

Abstract

Response rates to the current gold standards of care for treating oesophageal adenocarcinoma (OAC) remain modest with 15–25% of patients achieving meaningful pathological responses, highlighting the need for novel therapeutic strategies. This study consists of immune, angiogenic, and inflammatory profiling of the tumour microenvironment (TME) and lymph node microenvironment (LNME) in OAC. The prognostic value of nodal involvement and clinicopathological features was compared using a retrospective cohort of OAC patients (n = 702). The expression of inhibitory immune checkpoints by T cells infiltrating tumour-draining lymph nodes (TDLNs) and tumour tissue post-chemo(radio)therapy at surgical resection was assessed by flow cytometry. Nodal metastases is of equal prognostic importance to clinical tumour stage and tumour regression grade (TRG) in OAC. The TME exhibited a greater immuno-suppressive phenotype than the LNME. Our data suggests that blockade of these checkpoints may have a therapeutic rationale for boosting response rates in OAC.

Incidence and Risk Factors for Diaphragmatic Herniation following Esophagectomy for Cancer

OBJECTIVE

To evaluate the incidence and risk factors of diaphragmatic herniation following esophagectomy for cancer (DHEC), and assess the results of surgical repair.

SUMMARY BACKGROUND DATA

The current incidence of DHEC is discussed with conflicting data regarding its treatment and natural course.

METHODS

Monocentric retrospective cohort study(2009-2018). From 902 patients, 719 patients with a complete follow-up of CT-scans after transthoracic esophagectomy for cancer were reexamined to identify the occurrence of a DHEC. The incidence of DHEC was estimated using Kalbfleisch and Prentice method and risk factors of DHEC were studied using the Fine and Gray competitive risk regression model by treating death as a competing event. Survival was analyzed.

RESULTS

5-year DHEC incidence was 10.3% [95%CI, 7.8%-13.2%](n = 59), asymptomatic in 54.2% of cases. In the multivariable analysis, the risk factors for DHEC were: presence of hiatal hernia on preoperative CT scan (HR = 1.72[1.01-2.94], p = 0.046), previous hiatus surgery (HR = 3.68[1.61-8.45], p = 0.002), gastroesophageal junction tumor location (HR = 3.51[1.91-6.45], p < 0.001), neoadjuvant chemoradiotherapy (HR = 4.27[1.70-10.76], p < 0.001), and minimally invasive abdominal phase (HR = 2.98[1.60-5.55], p < 0.001). A cure for DHEC was achieved in 55.9%. The postoperative mortality rate was nil, the overall morbidity rate was 12.1%, and the DHEC recurrence rate was 30.3%. Occurrence of DHEC was significantly associated with a lower hazard rate of death in a time-varying Cox's regression analysis (HR = 0.43[0.23-0.81], p = 0.010).

CONCLUSIONS

The 5-year incidence of DHEC is 10.3% and is associated with a favorable prognosis. Surgical repair of symptomatic or progressive DHEC is associated with an acceptable morbidity. However, the optimal surgical repair technique remains to be determined in view of the large number of recurrences.

Defining High-Quality Integrated Head and Neck Cancer Care Through a Composite Outcome Measure: Textbook Outcome

OBJECTIVES/HYPOTHESIS

To further improve the quality of head and neck cancer (HNC) care, we developed a composite measure defined as "textbook outcome" (TO).

METHODS

We analyzed a retrospective cohort of patients after curvative-intent primary surgery, radiotherapy (RT), or chemoradiation (CRT) for HNC between 2015 and 2018 at the Netherlands Cancer Institute. TO was defined as 1) the start of treatment within 30 days, 2a) satisfactory pathologic outcomes, without 30-day postoperative complications, for the surgically treated group, and 2b), for RT and CRT patients, no unexpected or prolonged hospitalization and toxicity after the completion of treatment as planned.

RESULTS

In total, 392 patients with HNC were included. An overall TO was achieved in 9.6% of patients after surgery, 20.6% after RT, and 2.2% after CRT. Two indicators (margins >5 mm and start treatment <30 days) reduced TO radically for both groups.

CONCLUSION

TO can aid the evaluation of the quality of care for HNC patients and guide improvement processes.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

The Lymph Node Ratio Is an Independent Prognostic Factor in Esophageal Cancer Patients Who Receive Curative Surgery

BACKGROUND/AIM

We investigated the clinical impact of the lymph node ratio (LNR) on overall survival (OS) and recurrence-free survival (RFS) in esophageal cancer patients who underwent curative surgery.

PATIENTS AND METHODS

One hundred twenty patients who underwent curative surgery for esophageal cancer between 2005 and 2017 were included in this study. The LNR was defined as the ratio of the number of metastatic lymph nodes (LNs) to the total number of harvested LNs.

RESULTS

A lymph node ratio of 10% was regarded as the optimal critical point for classification based on the overall survival rate. The 3-year and 5-year OS rates were 65.5% and 57.0%, respectively, in the LNR<10% group, and 11.8% and 0% in the LNR≥10% group; the difference was statistically significant (p<0.001). The 3-year and 5-year RFS rates were 52.6% and 44.6%, respectively, in the LNR<10% group, and 0% and 0% in the LNR>10% group; the difference was also statistically significant (p<0.001). When comparing the sites of first relapse, the incidence of distant lymph node metastasis in the LNR>10% group was significantly higher than that in the LNR<10% group.

CONCLUSION

The LNR was a risk factor for both OS and RFS in patients who underwent curative surgery for esophageal cancer.

Effect of perioperative flurbiprofen axetil on long-term survival of patients with esophageal carcinoma who underwent thoracoscopic esophagectomy: A retrospective study

Background and Objectives

Nonsteroidal anti‐inflammatory drugs (NSAIDs) have an anti‐inflammatory response, but it remains unclear whether the perioperative use of flurbiprofen axetil can influence postoperative tumor recurrence and survival in esophageal carcinoma. We aimed to explore the effect of perioperative intravenous flurbiprofen axetil on recurrence‐free survival (RFS) and overall survival (OS) in patients with esophageal carcinoma who underwent thoracoscopic esophagectomy.

Methods

This retrospective study included patients who underwent surgery for esophageal carcinoma between December 2009 and May 2015 at the Department of Thoracic Surgery, Anhui Provincial Hospital. Patients were categorized into a non‐NSAIDs group (did not receive flurbiprofen axetil), single‐dose NSAIDs group (received a single dose of flurbiprofen axetil intravenously), and multiple‐dose NSAIDs group (received multiple doses of flurbiprofen).

Results

A total of 847 eligible patients were enrolled. Univariable and multivariable analyses revealed that the intraoperative use of flurbiprofen was associated with long‐term RFS (hazard ratio [HR]: 0.56, 95% confidence interval [CI]: 0.42–0.76, p = .001) and prolonged OS (HR: 0.49, 95% CI: 0.38–0.63, p = .001).

Conclusions

Perioperative flurbiprofen axetil therapy may be associated with prolonged RFS and OS in patients with esophageal carcinoma undergoing thoracoscopic esophagectomy.

A novel nomogram with preferable capability in predicting the overall survival of patients after radical esophageal cancer resection based on accessible clinical indicators: A comparison with AJCC staging

BACKGROUND

Esophageal cancer (EC) is a malignant tumor with high mortality. Nomogram is an important tool used in clinical prognostic assessment. We aimed to establish a novel nomogram to predict the overall survival (OS) of EC patients after radical esophagectomy.

METHODS

Data pertaining to the survival, demography, and clinicopathology of 311 EC patients who underwent radical esophagectomy were retrospectively investigated. The nomogram was established based on Cox hazard regression analysis. The calibration curves and Harrell's concordance index (C-index) were used to verify the predictive accuracy and ROC curves were used to assess the efficacy of the nomogram. Kaplan-Meier curves showed the prognostic value of the related risk classification system. Pearson correlation test was performed to determine the correlation between the risk classification system and TNM staging.

RESULTS

The median OS and 5-year survival rates in the primary and validation cohorts were 44 months and 29.8%, and 52 months and 27.1%, respectively. We used six independent prognostic factors-age, Sex, AGR, PRL, N stage, and PNI-in the nomogram. The C-index of nomogram was 0.75 and 0.70 in the primary and validation cohorts, respectively. Calibration curves indicated high consistency between actual and predicted OS. ROC curves showed that nomogram has a better efficacy compared with TNM staging in both cohorts. Patients were divided into three risk groups according to the total nomogram score, the median OS in each group was significantly different in both cohorts. Furthermore, the risk classification system was strongly correlated with the T and N staging system and exhibited a better OS prediction capability.

CONCLUSIONS

We established a novel and practical nomogram with a subordinate risk classification system to predict the OS of patients after radical esophagectomy. Compared with AJCC staging, this nomogram had preferable clinical capability in terms of individual prognosis assessment.

Re-appraising the role of lymph node status in predicting survival in resected distal cholangiocarcinoma - A meta-analysis and systematic review

This systematic review and meta-analysis aimed to confirm the prognostic value of lymph node ratio (LNR), and determine an optimal LNR cut-off for overall survival (OS) in patients with distal cholangiocarcinoma (DCC) undergoing curative surgery. We additionally aimed to provide a consolidated review of current evidence regarding prognostic significance of positive lymph node count (PLNC) and total lymph node count (TLNC). A systematic search of PubMed, EMBASE and Cochrane Library was conducted from inception to October 2020. Studies were included into meta-analysis if there was histological diagnosis, curative surgery, restriction to DCC and relevant LNR results. Quality assessment was performed using the Newcastle Ottawa Scale. Findings for 1228 patients were pooled across 6 studies. Meta-analysis delineated a dose-effect gradient in which higher LNR cut-offs correlated with larger pooled hazard ratios: 0<LNR<0.2 (HR 1.54; 95% CI 1.08-2.20; p = 0.02), LNR>0.2 (HR 3.26; 95% CI 2.07-5.13; p < 0.00001) and LNR>0.4 (HR 3.59; 95% CI 2.31-5.58; p < 0.00001) when compared against a control group of LNR = 0. LNR of 0.2 (HR 2.12; 95% CI: 1.57-2.86; p < 0.0001) was found to be a significant and ideal cut-off for prognostication of poorer OS. A review of current literature reveals an ongoing debate regarding the comparative prognostic value of differing PLNC cut-offs (0/1/3 versus 0/1/4). TLNC of 10-13 is widely reported to be the minimum necessary to ensure improved long term outcomes. PLNC and LNR are strong prognostic factors for OS in DCC. An ideal LNR cut-off of 0.2 is most significantly associated with poorer OS.

Prognostic impact of lymph node metastasis along the left gastric artery in esophageal squamous cell carcinoma

BACKGROUND

Although the incidence of lymph node (LN) metastasis (LNM) along the left gastric artery is high, its relationship with the prognosis in postoperative patients with esophageal squamous cell carcinoma (ESCC) is rarely reported. This study clarified the prognostic impact of LNM along the left gastric artery in postoperative patients with ESCC.

METHODS

This study assessed data of 1521 patients with ESCC who underwent esophagectomy at the Sun Yat-sen University Cancer Center between March 1992 and March 2012. A chi-squared test and Mann-Whitney U test were used to explore the preliminary correlation between clinical factors and LNM along the left gastric artery. Univariate and multivariate Cox regression analyses were used to assess whether LNM along the left gastric artery was an independent predictor of overall survival. Kaplan-Meier analysis and the log-rank test were used to present a classifying effect based on LN status.

RESULTS

LNM was observed in 598 patients (39.3%) and was found along the branches of the left gastric artery in 256 patients (16.8%). The patients were classified into two groups based on the presence of LNM along the left gastric artery. Patients without LNM along the left gastric artery had better cancer-specific survival than those with positive LNs (P <  0.001).

CONCLUSIONS

This study indicated that LNM along the left gastric artery was an important independent prognostic factor for long-term survival among ESCC patients (P = 0.011).

Moderately differentiated esophageal squamous cell carcinoma has a poor prognosis after neoadjuvant chemoradiotherapy

Background

Neoadjuvant chemoradiotherapy (NCRT) plus surgery is the standard treatment for esophageal squamous cell carcinoma (ESCC); however, further analysis is needed to detail the histopathological characteristics of ESCC and their clinical significance after NCRT. This study aimed to present the pathological characteristics of ESCC and their association with prognosis after NCRT.

Methods

All patients with ESCC who underwent NCRT followed by surgical resection at Sichuan Cancer Hospital (China) from January 2018 to December 2019 were included. Resection specimens of both the primary disease and lymph nodes were re-evaluated by an experienced pathologist. After NCRT, the pathological characteristics of the residual tumor were evaluated based on the Japanese residual tumor pattern, Mandard tumor regression grade (Mandard-TRG), local inflammatory infiltration classification, and lymph node status.

Results

Among the 103 patients with ESCC included in this study, the pathological complete response (pCR) rate was 34% (35/103). The pCR rate of patients with poorly differentiated tumors (31/72) was higher (43.1%) than that of patients with well or moderately differentiated tumors (P<0.05). The residual tumor rate was 66% (68/103). A positive correlation was noted between the Japanese residual tumor pattern and Mandard-TRG (Kendall’s tau-b =0.857, P<0.001). Tumor infiltration depth, lymph node positivity, moderate differentiation, and tumor recurrence were associated with poor oncological outcomes (P<0.05).

Conclusions

Patients with poorly differentiated tumors can obtain an excellent short-term response; however, they have extremely poor long-term survival. For patients with moderately differentiated tumors, both the short- and long-term outcomes are poor. Lymph node status after NCRT is a prognostic factor for ESCC treated with NCRT.

Residual lymph node disease and mortality following neoadjuvant chemoradiation and curative esophagectomy for distal esophageal adenocarcinoma

Objectives

Neoadjuvant chemoradiation has been shown to improve survival in locally advanced esophageal and gastroesophageal junction cancer. The purpose of our study was to examine the effects of posttreatment persistent lymph node (LN) disease on overall survival (OS) and recurrence in patients with esophageal adenocarcinoma after neoadjuvant chemoradiation as well as the effect of LN harvest and the potential benefit of adjuvant chemotherapy.

Methods

The records of patients who underwent esophagectomy in our hospital from January 2005 until December 2016 were analyzed. Our study group consisted of 509 patients.

Results

Patient groups were created based on pathologic staging after esophagectomy (ypT N) as 22.0% of patients were ypT0 N0, 46.2% had incomplete response only at the primary tumor level (ypT + N0), and 31.8% had at least 1 metastatic lymph node (ypTx N+). Median OS was 58.3 months. The ypTx N+ group was divided into ypTx N1 and ypTx N2 or N3 subgroups based on the number of metastatic lymph nodes. The OS between the 2 groups was not significantly different (median OS, 37.6 vs 29.8 months; P = .097). The disease-free survival did show a statistically significant difference (median disease-free survival, 27.6 vs 13.7 months; P = .007). The LN harvest was not found to be significantly associated with OS. However, administration of adjuvant chemotherapy was a significant prognosticator for increased OS (hazard ratio, 0.590; P = .043).

Conclusions

Our results demonstrate that residual LN disease after neoadjuvant chemoradiation is associated with increased mortality. Adjuvant chemotherapy, but not number of LNs resected, was correlated with increased OS in this subset of patients.

A Phase II Study Demonstrates No Feasibility of Adjuvant Treatment with Six Cycles of S-1 and Oxaliplatin in Resectable Esophageal Adenocarcinoma, with ERCC1 as Biomarker for Response to SOX

Simple Summary

Neoadjuvant chemoradiotherapy followed by surgery is currently standard of care in esophageal adenocarcinoma. However, prognosis remains dismal. The aim of our study was to assess the feasibility of administering six cycles of adjuvant S-1 and oxaliplatin following neoadjuvant chemoradiotherapy and esophagectomy. Although six cycles of adjuvant S-1 and oxaliplatin were not feasible in pretreated patients, mainly due to toxicity, efficacy results were promising compared to a propensity-score matched cohort. Exploratory biomarker analyses demonstrated potential benefit for patients with Excision repair cross-complementation group 1 (ERCC1) negative tumor expression. A proteomics biomarker model provided valuable information for prediction of survival and pharmacokinetics of 5-FU showed a correlation with treatment-related toxicity. Although it remains unclear if additional chemotherapy should be provided in the adjuvant setting, subgroups such as patients with ERCC1 negativity, could potentially benefit from this treatment option based on our exploratory biomarker research.

Abstract

We assessed the feasibility of adjuvant S-1 and oxaliplatin following neoadjuvant chemoradiotherapy (nCRT) and esophagectomy. Patients treated with nCRT (paclitaxel, carboplatin) and esophagectomy received six 21-day cycles with oxaliplatin (130 mg/m²) on day 1 and S-1 (25 mg/m² twice daily) on days 1–14. The primary endpoint was feasibility, defined as ≥50% completing treatment. We performed exploratory propensity-score matching to compare survival, ERCC1 and Thymidylate Synthase (TS) immunohistochemistry analyses, proteomics biomarker discovery and 5-FU pharmacokinetic analyses. Forty patients were enrolled and 48% completed all adjuvant cycles. Median dose intensity was 98% for S-1 and 62% for oxaliplatin. The main reason for early discontinuation was toxicity (67%). The median recurrence-free and overall survival were 28.3 months and 40.8 months, respectively (median follow-up 29.1 months). Survival was not significantly prolonged compared to a matched cohort (p = 0.09). Patients with ERCC1 negative tumor expression had significantly better survival compared to ERCC1 positivity (p = 0.01). Our protein signature model was predictive of survival [p = 0.04; Area under the curve (AUC) 0.80]. Moreover, 5-FU pharmacokinetics significantly correlated with treatment-related toxicity. To conclude, six cycles adjuvant S-1 and oxaliplatin were not feasible in pretreated esophageal adenocarcinoma. Although the question remains whether additional treatment with chemotherapy should be provided in the adjuvant setting, subgroups such as patients with ERCC1 negativity could potentially benefit from adjuvant SOX based on our exploratory biomarker research.

Variation in histopathological assessment and association with surgical quality indicators following oesophagectomy

BACKGROUND

Histopathological outcomes, such as lymph node yield and margin positivity, are used to benchmark and assess surgical centre quality, and are reported annually by the National Oesophago-Gastric Cancer Audit (NOGCA) in England and Wales. The variation in pathological specimen assessment and how this affects these outcomes is not known.

METHODS

A survey of practice was circulated to all tertiary oesophagogastric cancer centres across England and Wales. Questions captured demographic data, and information on how specimens were prepared and analysed. National performance data were retrieved from the NOGCA. Survey results were compared for tertiles of lymph node yield, and circumferential and longitudinal margins.

RESULTS

Survey responses were received from 32 of 37 units (86 per cent response rate), accounting for 93.1 per cent of the total oesophagectomy volume in England and Wales. Only 5 of 32 units met or exceeded current guidelines on specimen preparation according to the Royal College of Pathologists guidelines. There was wide variation in how centres defined positive (R1) margins, and how margins and lymph nodes were assessed. Centres with the highest nodal yield were more likely to use systematic fat blocking, and to re-examine specimens when the initial load was low. Systematic blocking of lesser curve fat resulted in significantly higher rates of patients with at least 15 lymph nodes examined (91.4 versus 86.5 per cent; P = 0.027).

CONCLUSION

Preparation and histopathological assessment of specimens varies significantly across institutions. This challenges the validity of currently used surgical quality metrics for oesophageal and other tumours.

Comparison of Up-Front Minimally Invasive Esophagectomy versus Open Esophagectomy on Quality of Life for Esophageal Squamous Cell Cancer

This study investigates whether minimally invasive esophagectomy (MIE) is a safe and effective way for patients with resectable esophageal cancer by comparing the short-term quality of life (QOL) after minimally invasive esophagectomy and open esophagectomy (OE). A total number of 104 patients who underwent esophagectomy from January 2013 to March 2014 were enrolled in this study. These patients were divided into two groups (MIE and OE group). Three scoring scales of quality of life were used to evaluate QOL before the operation and at the first, third, sixth and twelfth months after MIE or OE, which consist of Karnofshy performance scale (KPS), the European Organization for Research and Treatment questionnaire QLQC-30 (EORTC QLQC-30) and esophageal cancer supplement scale (OES-18). The MIE group was higher than the OE group in one-year survival rate (92.54% vs. 72.00%). Significant differences between the two groups were observed in intraoperative bleeding volume (158.53 ± 91.07 mL vs. 228.97 ± 109.33 mL, p = 0.001), and the incidence of postoperative pneumonia (33.33% vs. 58.62%, p = 0.018). The KPS of MIE group was significantly higher than the OE group at the first (80 vs. 70, p = 0.004 < 0.05), third (90 vs. 80, p = 0.006 < 0.05), sixth (90 vs. 80, p = 0.007 < 0.05) and twelfth months (90 vs. 80, p = 0.004 < 0.05) after surgery. The QLQC-30 score of MIE group was better than OE group at first and twelfth months after the operation. The OES-18 score of MIE group was significantly better than OE group at first, sixth and twelfth months after surgery. The short-term quality of life in MIE group was better than OE group.

The Impact of Pretreatment PET/CT Nodal Status on Esophageal Squamous Cell Carcinoma After Neoadjuvant Chemoradiation

BACKGROUND

For advanced esophageal cancer, the clinical significance of pretreatment nodal status (cN) as determined by different examinations remains unclear.

PATIENTS AND METHODS

Patients with esophageal squamous cell carcinoma who underwent neoadjuvant chemoradiation and surgery were analyzed in this study. Pretreatment cN status assessed by CT, EUS, and PET/CT and clinicopathological features were used to evaluate tumor recurrence and long-term survival.

RESULTS

Two hundred and twenty-two patients were identified in this study. Pretreatment PET/CT cN0 [odds ratio (OR) cN0 versus cN+, 5.316, p < 0.001] and pretreatment CT cN0 (OR 1.957, p = 0.032) both independently predicted ypN0. Pretreatment PET/CT cN0 was also associated with a lower recurrence rate and longer survival across the entire study group. Among patients with ypN0, pretreatment PET/CT cN+ indicated poor disease-free survival [hazard ratio (HR) 2.777, p = 0.001] and overall survival (HR 2.211, p = 0.034) compared with pretreatment PET/CT cN0, which predicted a favorable prognosis.

CONCLUSIONS

Data from the current study suggest that pretreatment lymph node status as assessed by PET/CT is strongly correlated with survival outcomes after neoadjuvant chemoradiation and surgery in patients with esophageal squamous cell carcinoma. ypN0 patients can achieve better survival outcomes when pretreatment cN0 is assessed by PET/CT.

A Comparison of the Current N2 Classification and a Modified N2 Categorization in TNM Staging of Esophageal Cancer Patients

Objective

To compare the effectiveness of the current N classification and a modified N2 categorization in TNM staging of esophageal cancer (EC) patients.

Methodology

A total of 2753 EC patients were enrolled in the study: 2283 EC patients from the Surveillance, Epidemiology, and End Results (SEER) database and 470 separate Chinese patients were used to verify the results of the SEER database. X-tile software was employed to determine the optimal cutoff points of the number of metastatic lymph nodes (LNs) in the N2 category. Univariate and multivariate Cox regression analyses were performed to identify the survival risk factors.

Result

Patients in the N2 category were divided into two groups based on the number of metastatic LNs. Patients with three and four metastatic LNs were categorized as N2a, while those with five and six metastatic LNs were categorized as N2b. The 3-year overall survival (OS) rate in the SEER database was 71.5%, 42.3%, 23.6%, 17.2%, and 10.7% for patients with N0, N1, N2a, N2b, and N3, respectively (P<0.001). Furthermore, a separate Chinese cohort was enrolled to validate the revised N2 category. Additionally, the 3-year OS rate was 71.5%, 42.3%, 23.6%, 17.2%, and 10.7% for patients with N0, N1, N2a, N2b, and N3, respectively (P<0.001).

Conclusion

The current N2 category should be further divided into two groups (N2a and N2b) to provide more accurate prognosis information that could further help in developing personalized therapeutic strategies.

Log odds of positive lymph nodes is a better prognostic factor for oesophageal signet ring cell carcinoma than N stage

BACKGROUND

Signet ring cell carcinoma is a rare type of oesophageal cancer, and we hypothesized that log odds of positive lymph nodes (LODDS) is a better prognostic factor for oesophageal signet ring cell carcinoma.

AIM

To explore a novel prognostic factor for oesophageal signet ring cell carcinoma by comparing two lymph node-related prognostic factors, log odds of positive LODDS and N stage.

METHODS

A total of 259 cases of oesophageal signet ring cell carcinoma after oesopha-gectomy were obtained from the Surveillance, Epidemiology, and End Results database between 2006 and 2016. The prognostic value of LODDS and N stage for oesophageal signet ring cell carcinoma was evaluated by univariate and multivariate analyses. The Akaike information criterion and Harrell’s C-index were used to assess the value of two prediction models based on lymph nodes. External validation was performed to further confirm the conclusion.

RESULTS

The 5-year cancer-specific survival (CSS) and 5-year overall survival (OS) rates of all the cases were 41.3% and 27.0%, respectively. The Kaplan-Meier method showed that LODDS had a higher score of log rank chi-squared (OS: 46.162, CSS: 41.178) than N stage (OS: 36.215, CSS: 31.583). Univariate analyses showed that insurance, race, T stage, M stage, TNM stage, radiation therapy, N stage, and LODDS were potential prognostic factors for OS (P < 0.1). The multivariate Cox regression model showed that LODDS was an significant independent prognostic factor for oesophageal signet ring carcinoma patients after surgical resection (P < 0.05), while N stage was not considered to be a significant prognostic factor (P = 0.122). Model 2 (LODDS) had a higher degree of discrimination and fit than Model 1 (N stage) (LODDS vs N stage, Harell’s C-index 0.673 vs 0.656, P < 0.001; Akaike information criterion 1688.824 vs 1697.519, P < 0.001). The results of external validation were consistent with those in the study cohort.

CONCLUSION

LODDS is a superior prognostic factor to N stage for patients with oesophageal signet ring cell carcinoma after oesophagectomy.

Impact of Lymph Node Ratio on Survival Outcome in Esophageal Squamous Cell Carcinoma After Minimally Invasive Esophagectomy

BACKGROUND

Esophageal squamous cell cancer (ESCC) is one of the deadliest cancers in the world. Esophagectomy remains the principal treatment, and minimally invasive esophagectomy (MIE) has been performed worldwide. This study aimed to clarify whether the lymph node ratio (LNR), defined as the ratio of metastatic lymph nodes (LNs) to examined, is a prognostic factor for ESCC after MIE.

METHODS

This study included 327 MIEs with the patient in the prone position at two institutions from 2010 to 2015. Cox proportional hazards regression analyses using clinicopathologic characteristics and the LNR were performed for the pN1 patients and the whole cohort.

RESULTS

In the multivariate analysis for all stages, independent prognostic factors were depth of tumor invasion (P < 0.0001), LNR (P = 0.014), operative time (P = 0.003), and pneumonia (P = 0.012). In the analysis of the pN1 subgroup, the optimum LNR cutoff level for overall survival (OS) was 9 based on receiver operation characteristic analysis. The LNR was significantly associated with depth of tumor invasion (P = 0.004) and number of metastatic LNs (P < 0.0001). The OS curve for the group with an LNR of 9 or higher was significantly worse than for the group with an LNR lower than 9 (P < 0.001). Multivariate analyses demonstrated that the LNR is a unique independent prognostic factor for the pN1 subgroup (hazard ratio, 6.811; 95% confidence interval, 2.009-23.087; P = 0.002).

CONCLUSIONS

The LNR is an independent prognostic factor in ESCC after MIE. Especially for patients with pN1 status, the LNR is more useful than the number of metastatic LNs for predicting survival outcome.

Modified nodal stage of esophageal cancer based on the evaluation of the hazard rate of the negative and positive lymph node

Background

The study aimed to propose a modified N stage of esophageal cancer (EC) on the basis of the number of positive lymph node (PLN) and the number of negative lymph node (NLN) simultaneously.

Method

Data from 13,491 patients with EC registered in the SEER database were reviewed. The parameters related to prognosis were investigated using a Cox proportional hazards regression model. A modified N stage was proposed based on the cut-off number of the re-adjusted ratio of the number of PLN (_numberPLN) to the number of NLN (_numberNLN), which were derived from the comparison of the hazard rate (HR) of _numberPLN and _numberNLN. The modified N stage was confirmed using the cross-validation method with the training and validation cohort, and it was also compared to the N stage from the American Joint Committee on Cancer (AJCC) staging system (7th edition) using Receiver Operating Characteristic (ROC) curve analysis.

Results

The _numberPLN on prognosis was 1.042, while _numberNLN was 0.968. The modified N stage was defined as follows: N1 stage: the ratio range was from 0 to 0.21; N2 stage: more than 0.21, but no more than 0.48; N3 stage: more than 0.48. The log-rank test indicated that significant survival differences were confirmed among the N1, N2 and N3 sub-groups of patients in the training population. The difference of all the patients using the modified N stage method were more significant than AJCC N stage. The result of ROC analysis indicated that the modified N stage could represent the N stage of EC more accurately.

Conclusion

The modified N stage based on the re-adjusted ratio of _numberPLN to _numberNLN can evaluate tumor stage more accurately than the traditional N stage.

A structured training pathway to implement robot-assisted minimally invasive esophagectomy: the learning curve results from a high-volume center

To ensure safe implementation of robot-assisted minimally invasive esophagectomy (RAMIE), the learning process should be optimized. This study aimed to report the results of a surgeon who implemented RAMIE in a German high-volume center by following a tailored and structured training pathway that involved proctoring. Consecutive patients who underwent RAMIE during the course of the program were included from a prospective database. A single surgeon, who had prior experience in conventional MIE, performed all RAMIE procedures. Cumulative sum (CUSUM) learning curves were plotted for the thoracic operating time and intraoperative blood loss. Perioperative outcomes were compared between patients who underwent surgery before and after a learning curve plateau occurred. Between 2017 and 2018, the adopting center adhered to the structured training pathway, and a total of 70 patients were included in the analysis. The CUSUM learning curves showed plateaus after 22 cases. In consecutive cases 23 to 70, the operating time was shorter for both the thoracic phase (median 215 vs. 249 minutes, P = 0.001) and overall procedure (median 394 vs. 440 minutes, P = 0.005), intraoperative blood loss was less (median 210 vs. 400 milliliters, P = 0.029), and lymph node yield was higher (median 32 vs. 23 nodes, P = 0.001) when compared to cases 1 to 22. No significant differences were found in terms of conversion rates, postoperative complications, length of stay, completeness of resection, or mortality. In conclusion, the structured training pathway resulted in a short and safe learning curve for RAMIE in this single center's experience. As the pathway seems effective in implementing RAMIE without compromising the early oncological outcomes and complication rates, it is advised for surgeons who are wanting to adopt this technique.

Prognostic significance of lymph node ratio after neoadjuvant chemoradiation therapy for esophageal squamous cell carcinoma

Purpose

We retrospectively evaluated the prognostic significance of lymph node ratio (LNR) in patients with esophageal squamous cell carcinoma who underwent neoadjuvant concurrent chemoradiation therapy (NCRT) followed by surgery.

Materials and Methods

In total, 270 patients who underwent NCRT followed by surgery between August 2005 and December 2015 were included. They were divided into three groups: LNR 0 (n = 196), LNR low (0 < LNR ≤ 0.1; n = 63), and LNR high (>0.1; n = 11). The primary endpoint was overall survival (OS), and the secondary endpoints were freedom from local recurrence (FFLR), distant metastasis-free survival (DMFS), and disease-free survival (DFS).

Results

The median number of retrieved lymph nodes per patient was 33. Pathologically, 74 patients had positive lymph nodes. The median follow-up duration was 36.1 months, and the median survival period was 68.4 months. There was a significant correlation between LNR and the number of positive lymph nodes (correlation coefficient = 0.763, p < 0.001). There was a substantial difference in the OS among the LNR groups, with 2-year survival rates of 79.0%, 54.0%, and 9.1% in the LNR 0, LNR low, and LNR high groups, respectively (p < 0.001). A marked decrease in FFLP, DMFS, and DFS was observed with the increasing LNR. In subgroup analysis, the survival results of patients with clinically positive lymph node were similar from those of entire cohort.

Conclusion

LNR is a significant prognostic factor in patients with esophageal squamous cell carcinoma who underwent NCRT followed by surgery. Additional treatment and closer follow-up would be necessary for patients with a high LNR.

Meta-analysis of prognostic factors of overall survival in patients undergoing oesophagectomy for oesophageal cancer

INTRODUCTION

Currently, the American Joint Commission on Cancer (AJCC) staging system is used for prognostication for oesophageal cancer. However, several prognostically important factors have been reported but not incorporated. This meta-analysis aimed to characterize the impact of preoperative, operative, and oncological factors on the prognosis of patients undergoing curative resection for oesophageal cancer.

METHODS

This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling to determine pooled univariable hazard ratios (HRs). The study was prospectively registered with the PROSPERO database (Registration: CRD42018157966).

RESULTS

One-hundred and seventy-one articles including 73,629 patients were assessed quantitatively. Of the 122 factors associated with survival, 39 were significant on pooled analysis. Of these. the strongly associated prognostic factors were 'pathological' T stage (HR: 2.07, CI95%: 1.77-2.43, P < 0.001), 'pathological' N stage (HR: 2.24, CI95%: 1.95-2.59, P < 0.001), perineural invasion (HR: 1.54, CI95%: 1.36-1.74, P < 0.001), circumferential resection margin (HR: 2.17, CI95%: 1.82-2.59, P < 0.001), poor tumor grade (HR: 1.53, CI95%: 1.34-1.74, P < 0.001), and high neutrophil:lymphocyte ratio (HR: 1.47, CI95%: 1.30-1.66, P < 0.001).

CONCLUSION

Several tumor biological variables not included in the AJCC 8th edition classification can impact on overall survival. Incorporation and validation of these factors into prognostic models and next edition of the AJCC system will enable personalized approach to prognostication and treatment.

Narrative review of the role of gastroenterologist in the diagnosis, treatment and palliation in gastric and gastroesophageal cancer

Esophageal cancer (EC) and gastric cancer (GC) carry a high mortality rate. Unfortunately, a majority of patients are asymptomatic and at the time of diagnosis, the disease may invariably be in its advanced stages with limited curative options. Thus, it is imperative to recognize certain risk factors including gastroesophageal reflux disease (GERD), male gender, pre-existing Barrett’s esophagus, smoking history, obesity, Helicobacter pylori infection, atrophic gastritis among others for both EC and GC, intervene on time with screening and surveillance modalities if indicated and optimize treatment plans. With advances in endoscopic techniques, early neoplastic lesions are increasingly managed by gastroenterologists, offering an alternative to surgery. The gold standard for diagnosis of EC and GC is high definition endoscopy with adequate targeted biopsies. Endoscopic ultrasound (EUS) is a key in the staging of early cancers dictating the pathway for treatment options. We also play a key role in palliation cases with the aim to reduce the symptoms like nausea, vomiting and even when possible, restore oral intake and improve nutrition in both advanced GC and EC. This review article discusses the risk factors, diagnostic and endoscopic treatment modalities of early EC and GC and palliation of advanced cancer where gastroenterologists play a key role.

Lymphadenectomy and Survival After Neoadjuvant Chemoradiation for Esophageal Adenocarcinoma: Is More Better?

PURPOSE

The purpose of this study was to assess the impact of number of lymph nodes examined on survival in patients with esophageal adenocarcinoma who underwent neoadjuvant chemoradiation.

METHODS

The National Cancer Database was queried for patients who underwent neoadjuvant chemoradiation followed by surgery for esophageal adenocarcinoma. Propensity scores were created predicting the odds of undergoing resection of ≥ 25 nodes. Patients were matched on propensity score. Overall survival analyses were performed using the Kaplan-Meier method. Sensitivity analyses were performed using various nodal cutoffs.

RESULTS

In total, 3953 patients who underwent neoadjuvant chemoradiation were identified. The median number of resected nodes was 14 nodes (IQR, 8-20 nodes). Resection of ≥ 15 (vs. < 15 nodes: 32 vs. 26 months; p < 0.001), ≥ 20 (vs. < 20 nodes: 36 vs. 28 months; p = 0.001), and ≥ 25 (vs. < 25 nodes: 37 vs. 29 months; p = 0.015) nodes was associated with higher median survival, but resection of ≥ 30 nodes was not (vs. < 30 nodes: 41 vs. 33 months; p = 0.367). Resection of ≥ 25 lymph nodes remained predictive for improved survival on subset analysis in patients with negative nodes and who underwent treatment at high-volume centers.

CONCLUSIONS

After neoadjuvant chemoradiation, resection of 25 or more lymph nodes was associated with longer median survival. Prospective trials are warranted to determine the optimal nodal yield after neoadjuvant chemoradiation.

Patterns of Failure After Trimodal Treatment in Esophageal Squamous Cell Carcinoma: Initial Experiences from a High-Risk Endemic Area

Recurrence is a significant problem faced in patients with esophageal cancer even after treatment with trimodal approach. We report patterns of failure in our patients of esophageal squamous cell cancer (ESCC) treated with trimodal approach. This is a single-institution retrospective analysis of 46 patients of locally advanced ESCC (treated between 2013 and 2017) managed by trimodal treatment approach. Variables were summarized using descriptive statistics. Survival statistics were estimated using Kaplan-Meier method. With a median follow-up of about 28 months, we noted an overall recurrence rate of 37% (17/46), with most of the failures being distant, with or without locoregional recurrence (4 isolated distant and 6 combined distant and locoregional). Median RFS was 34 months and median OS was yet to be reached at the last follow-up. To conclude, optimization of treatment approaches in ESCC is of utmost importance and need of the hour to further improve outcomes in these patients.

Distribution of lymph node metastases in esophageal adenocarcinoma after neoadjuvant chemoradiation therapy: a prospective study

BACKGROUND

The distribution of lymph node metastases in esophageal adenocarcinoma following neoadjuvant chemoradiation (nCRTx) is unclear, but may have consequences for radiotherapy and surgery. The aim of this study was to define the distribution of lymph node metastases and relation to the radiation field in patients following nCRTx and esophagectomy.

METHODS

Between April 2014 and August 2015 esophageal adenocarcinoma patients undergoing transthoracic esophagectomy with 2-field lymphadenectomy following nCRTx were included in this prospective observational study. Lymph node stations according to AJCC 7 were separately investigated. The location of lymph node metastases in relation to the radiation field was determined. The primary endpoint was the distribution of lymph node metastases and relation to the radiation field, the secondary endpoints were high-risk stations and risk factors for lymph node metastases and relation to survival.

RESULTS

Fifty consecutive patients were included. Lymph node metastases were found in 60% of patients and most frequently observed in paraesophageal (28%), left gastric artery (24%), and celiac trunk (18%) stations. Fifty-two percent had lymph node metastases within the radiation field. The incidence of lymph node metastases correlated significantly with ypT-stage (p = 0.002), cT-stage (p = 0.005), lymph angioinvasion (p = 0.004), and Mandard (p = 0.002). The number of lymph node metastases was associated with survival in univariable analysis (HR 1.12, 95% CI 1.068-1.173, p < 0.001).

CONCLUSIONS

Esophageal adenocarcinoma frequently metastasizes to both the mediastinal and abdominal lymph node stations. In this study, more than half of the patients had lymph node metastases within the radiation field. nCRTx is therefore not a reason to minimize lymphadenectomy in patients with esophageal adenocarcinoma.

Optimal number of harvested lymph nodes for curatively resected gallbladder adenocarcinoma based on a Bayesian network model

BACKGROUND AND OBJECTIVES

To identify the optimal range and the minimum number of lymph nodes (LNs) to be examined to maximize survival time of patients with curatively resected gallbladder adenocarcinoma (GBAC).

METHODS

Data were collected from the surveillance, epidemiology, and end results database on patients with GBAC who underwent curative resection between 2004 and 2015. A Bayesian network (BN) model was constructed to identify the optimal range of harvested LNs. Model accuracy was evaluated using the confusion matrix and receiver operating characteristic (ROC) curve.

RESULTS

A total of 1268 patients were enrolled in this study. Accuracy of the BN model was 72.82%, and the area under the curve of the ROC for the testing dataset was 78.49%. We found that at least seven LNs should be harvested to maximize survival time, and that the optimal count of harvested LNs was in the range of 7 to 10 overall, with an optimal range of 10 to 11 for N+ patients, 7 to 10 for stage T1-T2 patients, and 7 to 11 for stage T3-T4 patients.

CONCLUSIONS

According to a BN model, at least seven LNs should be retrieved for GBAC with curative resection, with an overall optimal range of 7 to 10 harvested LNs.

Critical number of lymph node involvement in esophageal and gastric cancer and its impact on long-term survival-A single-center 8-year study

BACKGROUND

Nodal disease in esophageal and gastric cancer is associated with poor survival.

OBJECTIVES

To determine the critical level of lymph node involvement where survival becomes significantly compromised.

METHODS

Survival analyses using multivariable Cox regression and receiver operator characteristics (ROC) were undertaken to determine what number of positive lymph nodes were most sensitive and specific in predicting survival.

RESULTS

A total of 317 patients underwent esophagectomy (n = 190, 59.9%) and gastrectomy (n = 127, 40.1%) for adenocarcinoma. At multivariable analyses, four nodes positivity (irrespective of T-category) was associated with nearly a fivefold increased risk of mortality when compared to node-negative patients (hazard ratio [HR], 4.9; interquartile range 2.0-11.5; P < .001). A positive ratio of up to 50.0% was not associated with worse survival than having four nodes positive (HR, 4.6; 95% confidence interval, 2.6-8.1; P < .001). ROC analysis demonstrated four lymph nodes positive to have a sensitivity of 80.5%, a specificity of 60.1%, and an accuracy of 77.8 (P < .001).

CONCLUSION

The absolute number of nodes positive for cancer is more important than the proportion of positive nodes in predicting survival in esophageal/gastric cancer. Four positive lymph nodes are associated with a fivefold increase in mortality. Beyond this, increasing numbers of positive lymph nodes make no appreciable difference to survival.

Analysis of a registry database for esophageal cancer from high-volume centers in China

Esophageal cancer has a high incidence among malignancies in China, but a comprehensive picture of the status of its surgical management in China has hitherto not been available. A nationwide database has recently been established to address this issue.

METHOD

A National Database was setup through a network platform, and data was collected from 70 high-volume centers (>100 esophagectomies/per year) across China. Data was entered between January 2009 and December 2014, and was analyzed in June 2015 after a minimal follow-up of 6 months for all patients. 8181 patients with complete data who received surgery for primary esophageal cancer on the Database were included in the analysis.

RESULT

In this series, there were 6052 males and 2129 females, with a mean age of 60.5 years (range: 22-90 years). The pathology in 95.5% of patients was squamous cell carcinoma. The pathological stage distribution was 1.2% in stage 0, 2.5% in Ia, 11.5% in Ib, 14.8% in IIa, 36.1% in IIb, 19.3% in IIIa, 8.3% in IIIb, 6.2% in IIIc. 1800 patients (22.0%) with locally advanced disease received preoperative neoadjuvant therapy and 3592 patients (43.9%) underwent postoperative adjuvant chemotherapy and/or radiotherapy. The esophagectomies were performed through left thoracotomy approach in 5870 cases (72.6%), through right chest approach in 2215 cases (27.4%) including right thoracotomy (21.3%) and VATS (6.1%). The 30-day postoperative mortality rate was 0.6% (43 patients), and the overall postoperative complication rate was 11.6% (951 patients). The 1-, 3-, and 5-year overall survival rates were 82.6%, 61.6%, and 52.9%, respectively.

CONCLUSION

This National Registry Database from high-volume centers provides a comprehensive picture of surgical management for esophageal cancer in China for the first time. Squamous cell carcinoma predominates, but there is heterogeneity with respect to the surgical approach and perioperative oncologic management. Overall, surgical mortality and morbidity rates are low, and good survival rates have been achieved due to improvement of surgical treatment technology in recent years.

Does the lymph node yield affect survival in patients with esophageal cancer receiving neoadjuvant therapy plus esophagectomy? A systematic review and updated meta-analysis

BACKGROUND

Conflicting data have been reported on the prognostic impact of the extent of lymphadenectomy during esophagectomy for esophageal cancer (EC) after neoadjuvant therapy, especially after neoadjuvant chemoradiotherapy (nCRT).

METHODS

A comprehensive online search was performed to explore the association between increased lymph node yield (LNY) and survival of patients with EC, in which the overall survival (OS) was set as the primary outcome. In addition to analysis of the entire cohort, subgroup analyses of different induction therapy and different populations were also performed.

FINDINGS

A total of 19528 patients from twelve studies were included in our study. The pooled data revealed that more lymph node harvested was associated with better OS (HR = 0·87; 95% CI: 0·79-0·95, p < 0·001). Notably, a higher LNY was associated with better OS if the threshold was less than 18. However, more thorough lymphadenectomy might not bring additional survival benefits when it came to a cutoff value more than 18. The subgroup analysis further revealed that a higher LNY after nCRT was associated favorable survival. In terms of subset analysis of different populations, increased LNY was associated with longer OS in Western populations but not in Eastern.

INTERPRETATION

Increased LNY during esophagectomy after neoadjuvant therapy, especially after nCRT, might be associated with improved OS. More studies are warranted to assess the survival benefits of a higher LNY receiving neoadjuvant therapy plus esophagectomy, especially in Eastern populations.

FUNDING

Supported by the projects from Suzhou Key Laboratory of Thoracic Oncology (SZS201907), Suzhou Key Discipline for Medicine (SZXK201803), the Science and Technology Research Foundation of Suzhou Municipality (SYS2018063, SYS2018064), Municipal Program of People's Livelihood Science and Technology in Suzhou (SS2019061) and Major Project for Social Development, Jiangsu Provincial Department of Science and Technology (SBE2020750085).

Distribution of Lymph Node Metastases in Esophageal Carcinoma Patients Undergoing Upfront Surgery: A Systematic Review

Metastatic lymphatic mapping in esophageal cancer is important to determine the optimal extent of the radiation field in case of neoadjuvant chemoradiotherapy and lymphadenectomy when esophagectomy is indicated. The objective of this review is to identify the distribution pattern of metastatic lymphatic spread in relation to histology, tumor location, and T-stage in patients with esophageal cancer. Embase and Medline databases were searched by two independent researchers. Studies were included if published before July 2019 and if a transthoracic esophagectomy with a complete 2- or 3-field lymphadenectomy was performed without neoadjuvant therapy. The prevalence of lymph node metastases was described per histologic subtype and primary tumor location. Fourteen studies were included in this review with a total of 8952 patients. We found that both squamous cell carcinoma and adenocarcinoma metastasize to cervical, thoracic, and abdominal lymph node stations, regardless of the primary tumor location. In patients with an upper, middle, and lower thoracic squamous cell carcinoma, the lymph nodes along the right recurrent nerve are often affected (34%, 24% and 10%, respectively). Few studies describe the metastatic pattern of adenocarcinoma. The current literature is heterogeneous in the classification and reporting of lymph node metastases. This complicates evidence-based strategies in neoadjuvant and surgical treatment.

Lymph Node Ratio in HPV-Associated Oropharyngeal Cancer: Identification of a Prognostic Threshold

OBJECTIVE

To evaluate the utility of lymph node ratio (LNR) as a prognostic factor for survival and recurrence in surgically treated patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC).

STUDY DESIGN

Retrospective cohort study.

METHODS

In this retrospective cohort study of a tertiary healthcare system in a major metropolitan area, we reviewed 169 consecutive patients with HPV-related OPSCC treated using transoral robotic surgery. Univariable and multivariable Cox proportional hazards regression analysis with stratified models were used to compare LNR with other traditional clinicopathologic risk factors forrecurrence and survival. An LNR cutoff was found using the minimal P approach.

RESULTS

Multivariable Cox regression models showed that each additional percentage increase in LNR corresponded to an adjusted hazard ratio (HR) of 1.04 (confidence interval [CI] 1.02-1.07). LNR was more significant when adjusted for adequate lymph node yield of ≥ 18 nodes (HR 5.05, 95% confidence interval [CI] 1.38-18.47). The minimal P generated cutoff point at LNR ≥ 17% demonstrated a HR 4.34 (95% CI 1.24-15.2) for disease-free survival.

CONCLUSION

For HPV-related OPSCC, continuous LNR and an LNR threshold of 17% could be helpful in identifying recurrent disease in addition to measures such as lymph node number alone.

LEVEL OF EVIDENCE

4.

Combined CT texture analysis and nodal axial ratio for detection of nodal metastasis in esophageal cancer

OBJECTIVE

To assess the accuracy of a combination of CT texture analysis (CTTA) and nodal axial ratio to detect metastatic lymph nodes (LNs) in esophageal squamous cell carcinoma (ESCC).

METHODS

The contrast-enhanced chest CT images of 78 LNs (40 metastasis, 38 benign) from 38 patients with ESCC were retrospectively analyzed. Nodal axial ratios (short-axis/long-axis diameter) were calculated. CCTA parameters (kurtosis, entropy, skewness) were extracted using commercial software (TexRAD) with fine, medium, and coarse spatial filters. Combinations of significant texture features and nodal axial ratios were entered as predictors in logistic regression models to differentiate metastatic from benign LNs, and the performance of the logistic regression models was analyzed using the area under the receiver operating characteristic curve (AUROC).

RESULTS

The mean axial ratio of metastatic LNs was significantly higher than that of benign LNs (0.81 ± 0.2 vs 0.71 ± 0.1, p = 0.005; sensitivity 82.5%, specificity 47.4%); namely, significantly more round than benign. The mean values of the entropy (all filters) and kurtosis (fine and medium) of metastatic LNs were significantly higher than those of benign LNs (all, p < 0.05). Medium entropy showed the best performance in the AUROC analysis with 0.802 (p < 0.001; sensitivity 85.0%, specificity 63.2%). A binary logistic regression analysis combining the nodal axial ratio, fine entropy, and fine kurtosis identified metastatic LNs with 87.5% sensitivity and 65.8% specificity (AUROC = 0.855, p < 0.001).

CONCLUSION

The combination of CTTA features and the axial ratio of LNs has the potential to differentiate metastatic from benign LNs and improves the sensitivity for detection of LN metastases in ESCC.

ADVANCES IN KNOWLEDGE

The combination of CTTA and nodal axial ratio has improved CT sensitivity (up to 87.5%) for the diagnosis of metastatic LNs in esophageal cancer.

Log odds of positive lymph nodes predicts survival in patients treated with neoadjuvant therapy followed by esophagectomy

BACKGROUND AND OBJECTIVES

We aimed to evaluate the efficacy of the log odds of positive lymph nodes (LODDS) in survival prediction of patients with esophageal carcinoma receiving neoadjuvant therapy, compared with N descriptor and positive lymph node ratio (LNR).

METHODS

Patients with esophageal carcinoma receiving neoadjuvant therapy from 2004 to 2015 were reviewed in Surveillance, Epidemiology, and End Results database. The receiver operating characteristics curve and area under the curve (AUC) were used to compare discriminatory power among N descriptor, LNR, and LODDS. The goodness of fit was measured using the -2 log-likelihood ratio (-2LLR).

RESULTS

About 2239 patients with a 22 months median follow-up and a 37.8% 5-year overall survival rate were included. LODDS had the best discriminatory power and goodness of fit (LODDS vs N descriptor, AUC 0.666 vs 0.626, -2LLR 15 680.402 vs 15 746.162; LODDS vs LNR, AUC 0.666 vs 0.635, -2LLR 15 680.402 vs 15 712.379; all P < .001). LODDS was the best for fewer than 15 lymph nodes retrieved (LODDS vs N descriptor, AUC 0.652 vs 0.618, P < .001; LODDS vs LNR, AUC 0.652 vs 0.625, P = .005). The prognosis of patients without metastatic nodes could be discriminated by LODDS.

CONCLUSIONS

LODDS could better predict survival of patients with esophageal carcinoma receiving neoadjuvant therapy.

Does chemoradiotherapy benefit elderly patients with esophageal squamous cell cancer? A propensity-score matched analysis on multicenter data (3JECROG R-03A)

Background

The aim of the present study was to assess the efficacy of concurrent chemoradiotherapy (CRT) or radiotherapy alone (RT-alone) in elderly patients with esophageal squamous cell carcinoma (ESCC).

Methods

The clinical data of patients with ESCC treated with RT-alone or CRT were collected and retrospectively reviewed. The 1-, 3- and 5-year overall survival (OS) rates and the clinical characteristics correlated with survival were analyzed statistically. Propensity score matching (PSM) analyses were used to compensate for differences in baseline characteristics between the CRT and RT-alone groups to confirm the survival difference.

Results

A total of 729 patients fulfilling the inclusion criteria were reviewed. Diabetes, primary tumor volume (pTV), primary tumor location (pTLo), clinical T stage,(cT) clinical N stage (cN), clinical M stage (cM) and short-term response to RT were independent factors influencing OS (P = 0.002–0.044). The 5-year OS rate was 26.6, 26.0 and 30.1% in the whole cohort, RT-alone and CRT groups, respectively. The survival difference between RT alone and CRT was not significant before or following PSM. Compared with the corresponding subgroups treated with RT alone, CRT significantly benefited patients with diabetes (P = 0.003), cT4 (P = 0.030) and cN0 (P = 0.049), whereas no benefit was identified between CRT and RT alone in the other subgroups, including cT1–3, cN1, cM, pTLo, pTV, age and gender.

Conclusions

CRT with the current chemotherapy regimens may not improve the survival of elderly ESCC patients compared to RT-alone, except in patients with cT4 stage, cN0 stage or diabetes. However, due to the limitation of the retrospective nature of the current study, further clinical trials are required for confirmation.

Genome-wide Discovery of a Novel Gene-expression Signature for the Identification of Lymph Node Metastasis in Esophageal Squamous Cell Carcinoma

OBJECTIVE

This study aimed to develop a gene-expression signature for identification of lymph node (LN) metastasis in esophageal squamous cell carcinoma (ESCC) patients.

SUMMARY OF BACKGROUND DATA

LN metastasis is recognized as the most important independent risk factor for therapeutic decision-making of ESCC patients.

METHODS

A bioinformatic approach was used to analyze RNA sequencing profiles of ESCC patients, and to develop a gene-expression signature for identifying LN metastasis. The robustness of this panel was assessed in 2 independent patient cohorts (n = 56 and 224).

RESULTS

We initially prioritized a 16-gene signature out of the total 20,531 mRNAs. The model estimated by these 16 genes discriminated LN status with an area under the curve (AUC) of 0.77 [95% confidence interval (95% CI), 0.68-0.87, 5-fold cross-validation]. Subsequently, a reduced and optimized 5-gene panel was trained in a clinical cohort, which effectively distinguished ESCC patients with LN metastasis (cohort-1: AUC, 0.74; 95% CI, 0.58-0.89; cohort-2, T1-T2: AUC, 0.74; 95% CI, 0.63-0.86), and was significantly superior to preoperative computed tomography (AUC, 0.61; 95% CI, 0.50-0.72). Furthermore, a combination signature comprising of the 5-gene panel together with the lymphatic vessel invasion (LVI) and venous invasion (VI) demonstrated a significantly improved diagnostic performance compared with individual clinical variables, in both cohorts (cohort-1: AUC, 0.87; 95% CI, 0.78-0.96; cohort-2: AUC, 0.76; 95% CI, 0.65-0.88).

CONCLUSION

Our novel 5-gene panel is a robust diagnostic tool for LN metastasis, especially in early-T stage ESCC patients, with a promising clinical potential.

Proposal of the minimal number of retrieved regional lymph nodes for accurate staging of distal bile duct cancer and clinical validation of the three-tier lymph node staging system (AJCC 8th edition)

BACKGROUND

The minimal required number of retrieved lymph nodes (MNRLNs) to enable accurate staging of distal bile duct (DBD) adenocarcinoma remains unclear. The three-tier 8th N staging system of the American Joint Committee on Cancer (AJCC) for DBD adenocarcinoma has been recently released. The present study is aimed at proposing the MNRLNs for accurate staging and validating the 8th N stage.

METHODS

Between 1991 and 2015, patients with pathologically confirmed DBD adenocarcinoma who underwent pancreatoduodenectomy were enrolled. MNRLN was calculated via a log-rank test based on cut-off values. The concordance index (C-index) was utilized to compare the discrimination capability of the two- and three-tier N stages.

RESULTS

A total of 780 patients were enrolled. Lymph node (LN) positivity and 5-year overall survival (5-YOS) rates stabilized and significant survival differences between node-negative and -positive patients were observed when ≥12 LNs were retrieved. 5-YOS rates between each 8th N stage significantly differ (N0 vs. N1, P = 0.037; N1 vs. N2, P = 0.003). The C-index of the 8th N stage was higher than that of the 7th (0.59 vs. 0.57).

CONCLUSIONS

For accurate staging, at least 12 LNs should be retrieved. The three-tier N staging system is valid for clinical practice and has a more accurate prognostic predictability than the two-tier system.

Prognostic Value of Lymph Node Yield on Overall Survival in Esophageal Cancer Patients: A Systematic Review and Meta-analysis

OBJECTIVE

This meta-analysis determines whether increased lymph node yield improves survival in patients with esophageal cancer undergoing esophagectomy with or without neoadjuvant therapy.

BACKGROUND

Esophagectomy involves resection of the esophagus and surrounding lymph nodes, which are commonly the first stations of cancer spread. The extent of lymphadenectomy during esophagectomy remains controversial, with several studies publishing conflicting results, especially in the era of neoadjuvant therapy.

METHODS

An electronic literature search was undertaken using Embase, Medline, and the Cochrane library databases (2000 to 2017). Articles with esophageal cancer patients undergoing esophagectomy with lymphadenectomy and investigating the effects of low and high lymph node yield on overall survival and disease-free survival were included. Meta-analysis of data was conducted using a random effects model. If the study divided the cohort into multiple groups based on lymph node yield, survival was compared between the lowest and highest lymph node yield groups. In addition to analysis of the entire cohort, subset analysis of only those patients receiving neoadjuvant therapy was also performed.

RESULTS

A total of 26 studies were included in this meta-analysis with a follow-up ranging from 15 to 94 months. For the analysis of overall survival, 23 studies were included. A meta-analysis showed that overall survival significantly improved in the high lymph node yield group [hazard ratio (HR) = 0.81; 95% confidence interval (95% CI) = 0.74-0.87; P < 0.01]. In the 10 studies describing disease-free survival, this was significantly improved in the high lymph node yield group (HR = 0.72; 95% CI = 0.62-0.84; P < 0.01). Subset analysis of neoadjuvant-treated patients demonstrated a survival benefit of high lymph node yield on overall survival (HR = 0.82; 95% CI = 0.73-0.92; P < 0.01).

CONCLUSION

This meta-analysis demonstrates the benefit of an increased lymph node yield from esophagectomy on overall and disease-free survival. In addition, a survival benefit of a high lymph node yield was demonstrated in patients receiving neoadjuvant therapy followed by esophagectomy.

How Many Nodes Need to be Removed to Make Esophagectomy an Adequate Cancer Operation, and Does the Number Change When a Patient has Chemoradiotherapy Before Surgery?

INTRODUCTION AND DESIGN

Node dissection during esophagectomy is an important aspect of esophageal cancer staging. Controversy remains as to how many nodes need to be resected in order to properly stage a patient and whether the removal of more nodes carries a stage-independent survival benefit. A review of the literature performed by a group of experts in the subject may help define a minimum accepted number of lymph nodes to be resected in both primary surgery and post-induction therapy scenarios.

RESULTS AND CONCLUSIONS

The existing evidence generally supports the goal of obtaining a minimum of 15 lymph nodes for pathological examination in both primary surgery and post-induction therapy scenarios.

A phase I study evaluating combined nimotuzumab and neoadjuvant chemoradiotherapy followed by surgery in locally advanced esophageal cancer

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of combined nimotuzumab and neoadjuvant chemoradiotherapy followed by surgery in locally advanced esophageal cancer.

METHODS

Patients with clinically resectable, locally advanced esophageal cancer treated with neoadjuvant chemoradiotherapy plus nimotuzumab were eligible for study participation. Radiotherapy was administered in 1.8 Gy once daily for 5 days per week up to a total dose of 41.4 Gy. Weekly nimotuzumab (200 mg/week) was administered following paclitaxel and carboplatin on the same day for 5 weeks. The primary end-point was the pathological complete response (pCR) rate and the secondary end-point was the safety, progression-free survival (PFS) and overall survival (OS).

RESULTS

A total of 64 patients with a median age of 58 years were enrolled in this study. pCR was observed in 51.6% patients. Grade 3 acute toxicities were observed in 6 patients (9.4%), shown as bone marrow suppression. 7 patients experienced grade 1 transient skin rash during nimotuzumab treatment. The median PFS time and OS time were 64.6 and 68.2 months.

CONCLUSIONS

Combined nimotuzumab and neoadjuvant chemoradiotherapy for clinically resectable, locally advanced esophageal cancer showed a significant anticancer effect with tolerable toxicities.

The impact of the nodal status on the overall survival of non-surgical patients with esophageal squamous cell carcinoma

BACKGROUND

The prognosis of N categories for patients with non-surgical esophageal carcinoma based on the number of metastatic lymph nodes is controversial. The present study analyzes prognostic implications of the number, extent, and size of metastatic lymph nodes for patients with esophageal squamous cell carcinoma (ESCC) treated with definitive (chemo-)radiotherapy to provide more information on treatment strategy.

METHODS

We reviewed 357 ESCC patients treated with definitive radiotherapy between January 2013 and March 2016 retrospectively. We assessed potential associations between the involved extent (N0, 1 region, 2 regions, and 3 regions), number (N0, 1-2, 3-6, and ≥ 7), and size (N0, ≤2 cm, and > 2 cm) of metastatic lymph nodes and overall survival. Multivariate analyses of the clinicopathological factors were performed using the Cox proportional hazard model.

RESULTS

5-year survival rates were 43.6% for patients in the N0 group and 29.3% in the N+ group (p = 0.001). Kaplan-Meier analyses for all cases revealed that there were significant differences in survival based on the extent (the OS rates at 3 years were 53.3% for patients in the N0 group, 45.7% in the 1 region-involved group, 28.0% in the 2 regions-involved group, and 13.3% in the 3 regions-involved group, P < 0.001), number (the OS rates at 3 years were 49.0% for patients in the 1-2 LNs group, 27.8% in the 3-6 LNs group, 0 in the ≥7LNs group, P < 0.001), and size (the OS rates at 3 years were 41.6% for patients in the LNs ≤2 cm group and 20.7% in the LNs > 2 cm group, P = 0.001) of metastatic LNs. One hundred seventy-two patients (48.2%) had experienced GTV failure, 157 (43.1%) had distant failure, 49 (13.7%) had out-of-GTV nodal failure, and 70 patients (19.6%) had no evidence of disease at the last follow-up. Nodal status correlated statistically with GTV failure. Patients with LN metastases in the abdominal region had worse survival rates than those with metastases in the other regions. The extent and number of metastatic LNs, T category, Primary tumor location, and chemotherapy were independent prognostic factors of OS in multivariate analyses.

CONCLUSIONS

For patients with ESCC who received definitive (chemo-)radiotherapy, the number, extent, and size of metastatic LNs were prognostic factors, particularly of the T2/3 disease. Patients with LN metastases in the abdominal region had worse survival.

Comparison of Ivor Lewis esophagectomy and Sweet esophagectomy for the treatment of middle-lower esophageal squamous cell carcinoma

Background

For cancer of the middle and/or lower segment of thoracic esophagus, the Ivor Lewis esophagectomy is the mainstream standard surgery, whereas the Sweet procedure is widely used in China. As no consensus has been reached about the choice of different thoracic approaches, we designed this retrospective study to investigate and compare oncological benefits of the two surgical approaches.

Methods

After propensity score matching, 150 patients who underwent the Sweet or Ivor Lewis esophagectomy from August 2003 to December 2009 in the Beijing Cancer Hospital were reviewed. We compared the postoperative recovery, nutritional parameters, and survival of the two different surgical approaches.

Results

The 5-year overall survival (OS) rate for the whole group was 48.5%, and the 10-year OS rate was 35.6%. The Ivor Lewis group had a longer operation time, longer duration of chest tube drainage, and a larger volume of total thoracic drainage. No significant differences were found between the two groups in terms of the duration of systemic inflammatory response syndrome (SIRS), length of postoperative hospital stay, duration of postoperative nasogastric tube use, incidence of major complications, and nutritional status after the esophagectomy. The OS rates were similar in both groups.

Conclusions

The Sweet and Ivor Lewis esophagectomy are both safe and effective. A change of the surgical incision may not be the best way to increase survival, and the choice of surgical procedure should depend on the preference of the thoracic surgeon to secure the safety of the operation.

Prognostic significance and role of thoracic lymph node metastasis based on Chinese expert consensus in esophageal cancer

Background

The Chinese expert consensus on thoracic lymph node (LN) dissection in radical esophagectomy (Chinese Criteria, 2017 edition) was newly promoted. This study examined the prognostic significance and role of thoracic LN metastasis based on the Chinese Criteria for esophageal cancer.

Methods

Data of patients with thoracic esophageal squamous cell carcinoma (ESCC) who underwent curative esophagectomy in the West China Hospital from May 2005 to May 2015 were retrospectively analyzed. Patients' prognosis and clinicopathological features were compared to determine the role of Chinese Criteria and their relationship with Union for International Cancer Control (UICC)/American Joint Committee on Cancer (AJCC) 8th TNM staging.

Results

Overall, 2,285 qualified patients were divided into the no (n=1,148), skip (n=156), local (n=665), and mediastinal (n=316) metastasis groups according to the Chinese Criteria. Significant prognostic differences occurred among the four groups in all the thoracic and lower mediastinal ESCC patients (both P<0.001). The Chinese Criteria grouping was an independent prognostic factor for all thoracic [P<0.001; hazard ratio (HR) =1.261, 95% confidence interval (CI): 1.103-1.441], upper (P<0.001; HR =1.391, 95% CI: 1.264-1.530), lower mediastinal thoracic ESCC patients (P<0.001; HR =1.312, 95% CI: 1.257-1.370) and all thoracic ESCC after adjuvant therapy (P<0.001; HR =1.303, 95% CI: 1.221-1.390). Significant prognostic differences among Chinese Criteria groups occurred with N1 (P=0.014) and N2 (P=0.018) stages only. Significant differences in survival among N stages were found in local (P<0.001) and mediastinal (P=0.009) metastasis groups.

Conclusions

Our study was the first to report the Chinese Criteria in measuring the degree of thoracic LN metastasis. Similar to N-stage, the Chinese Criteria were confirmed as an independent prognostic factor for thoracic ESCC. Further confirmation of our findings is warranted.

Lymph Node Ratio Versus TNM System As Prognostic Factor in Colorectal Cancer Staging. a Single Center Experience

Objective

This study aims to establish the actual validity of the lymph node ratio (LNR) as a prognostic factor for colorectal cancer patients, and to verify differences of survival and disease-free interval.

Methods

Patients referred with colorectal cancer who underwent potentially curative surgery between January 1997 and December 2011 were included. Lymph node ratio, TNM staging and survival were extracted from surgical, histological and follow-up records.

Results

Two hundred eigthy six patients with different stages of colorectal cancer underwent surgery, with comparison of survival prediction based on lymph node ratio and TNM staging. The overall survival rate was 78.3%, the recurrence rate was 11.9% and the mortality rate was estimated as 21.7%. Univariate analysis in relation to survival was significant for the following variables: serum level of CEA, CA 19.9 value, degree of histological differentiation, and tumor growth. There weren’t any statistically significant differences for the LNR (LNR </ ≥0.16: p = 0.116). The TNM system was effective both in discriminating between survival stages (Stage II vs. Stage III: p = 0.05) and in differentiating sub-groups (p = 0.05).

Conclusions

LNR alone could not be considered a better prognostic factor than the TNM system. However, future studies are needed in a larger number of patients with a standardized surgical, pathological and medical protocol.

Discrepancy Between the Clinical and Final Pathological Findings of Lymph Node Metastasis in Superficial Esophageal Cancer

BACKGROUND

Recent advances in endoscopic examinations have resulted in the detection of a larger number of early esophageal cancers; however, there have been many cases with clinically negative but pathologically positive lymph node metastasis (LNM). In this study, we aimed to evaluate the discrepancy between the clinical and pathological diagnoses of LNM in patients with cT1a-MM/cT1b N0M0 esophageal cancer, and assess LNM size in these patients to clarify the presence of LNM that cannot be detected with current modalities.

METHODS

This study included 50 patients who underwent surgery for cT1a-MM/cT1b N0M0 thoracic esophageal squamous cell carcinoma between January 2012 and November 2016 at our institution. The maximum size of involved LNs and metastatic nests were measured, and the distribution of LNM was investigated.

RESULTS

Of the 50 patients, 13 (26%) had LNM on pathological examination. Lymphatic invasion was significantly more frequent in the LNM-positive group than in the LNM-negative group (p = 0.005). The median sizes of 28 involved LNs and metastatic nests were 3 and 1.6 mm, respectively. Of these LNs, 20 (71%) were classified as micrometastases (≤ 2 mm). The involved nodes were distributed across three fields.

CONCLUSIONS

There was a discrepancy between the clinical and final pathological findings of LNM in patients with cT1a-MM/cT1b N0M0 esophageal cancer. The detection of involved nodes with current modalities in these patients was difficult because of the small size of LNM. Therefore, continued strong consideration for extended LN dissection is necessary in these patients to ensure appropriate diagnosis and treatment.

Prognostic value of lymphovascular invasion in patients with esophageal squamous cell carcinoma

Background

Whether lymphovascular invasion (LVI) in esophageal squamous cell carcinoma (ESCC) should be considered an independent prognostic factor for survival is controversial. The aim of this report was to investigate the prognostic value of LVI for patients with ESCC.

Methods

Between October 2010 and July 2011, 152 ESCC patients were retrospectively reviewed. All of the patients underwent curative resection as their primary treatment. Clinicopathological features and overall survival (OS) rate were investigated. Kaplan-Meier curves were used to calculate the OS rate, and the prognostic factors were identified by Cox regression model.

Results

Positive LVI was found in 49 (32.2%) patients. Patients with negative LVI had a significantly better 5-year OS rate than those with positive LVI (52.9% vs. 28.8%; P=0.000). The age, T stage, N stage, tumor differentiation, and LVI were demonstrated to be significant prognostic factors for OS through univariate analyses. LVI was confirmed as an independent prognostic factor for OS through multivariate survival analyses. Subgroup analyses revealed that LVI was associated with a decreased OS in node-negative patients, and no significant difference was observed in node-positive cases.

Conclusions

Our study highlighted that LVI is an independent prognostic factor in patients with resectable ESCC. LVI may facilitate the stratification of patients with poor survival.