Is it time for a new TNM classification in esophageal carcinoma? Ann Surg. 2008;247:633-641. [PMID: 18362626 DOI: 10.1097/sla.0b013e3181656d07]

Staging and outcome depending on surgical treatment in adenocarcinomas of the oesophagogastric junction

BACKGROUND

Owing to controversial staging and classification of adenocarcinoma of the oesophago-gastric junction (AOG) before surgery, the choice of appropriate surgical approach remains problematic. In a retrospective study, preoperative staging of AOG and the impact of preoperative misclassification on outcome were analysed.

METHODS

Data from patients with AOG were analysed from a prospectively collected database with regard to surgical treatment, preoperative and postoperative staging, and outcome.

RESULTS

One-hundred and thirty patients with Siewert types I and II AOG who did not have neoadjuvant treatment were included in the study: 41 patients with an AOG type I who underwent oesophagectomy, 51 patients with an AOG staged before surgery as type I who underwent oesophagectomy but in whom the final histology showed a type II tumour, and 38 patients whose tumours were staged as AOG type II before and after operation who underwent gastrectomy. Among patients who had an oesophagectomy, lymph node metastases (P = 0.022), tumour relapse (P = 0.009) and recurrent distant metastases (P = 0.028) were significantly more frequent in patients with AOG type II; those with AOG type II had shorter overall survival than those with type I tumours (P = 0.024). Among those with AOG type II, recurrence-free survival was significantly shorter after oesophagectomy compared with extended gastrectomy (P = 0.019). Thoracoabdominal oesophagectomy had a favourable influence on outcome compared with the transhiatal approach.

CONCLUSION

Accurate preoperative staging of AOG and appropriate surgical therapy are crucial for outcome. AOG type II is a more aggressive tumour with higher recurrence rates than AOG type I. These patients therefore benefit from more radical surgical treatment.

Long-term survival from adenocarcinoma of the esophagus after transthoracic and transhiatal esophagectomy

BACKGROUND

The effects of transthoracic or transhiatal esophagectomy on the long-term survival of patients who had adenocarcinoma of the esophagus were compared, as were factors applicable in preoperative stratification of patient treatment.

METHODS

A cohort of 147 consecutive patients with adenocarcinoma of the esophagus was evaluated for esophagectomy between 1984 and 2000. The patients were followed prospectively and observed survival rates of patients with a transthoracic or transhiatal approach to esophagectomy were compared by standardized mortality ratio (SMR) and relative mortality ratio (RMR) using the expected survival of a matched Norwegian population.

RESULTS

A R0 resection was performed by transthoracic (n = 33) or a transhiatal (n = 55) esophagectomy in 88 (60%) patients with a median age of 61 (range: 35-77) and 70 (42-88) years, respectively (P <0.001). Tumor stages and other possible risk factors were similar in the two groups. Transthoracic or transhiatal esophagectomy resulted in a median survival time of 20.5 (95% confidence interval (CI): 10.4-57.6) and 16.4 (10.6-28.7) months, respectively. The respective survival rates were 31.2% and 27.8% by 5 years, and 21.3% and 16.6% by 10 years with an overall RMR of 1.14 (P = 0.63). Median survival time in the absence or presence of lymph node metastases was 74.0 (95% CI: 17.5-166.4) and 10.7 (7.9-14.9) months. The corresponding survival rates by 10 years with non-involved or involved nodes were 48.9% and 3.8% respectively (RMR 2.22, P = 0.007). Patients with a pT1-tumor were few and the survival rate was not very different from that of the general population (SMR = 1.7, 95% CI: 0.7-4.1). The median survival time of patients with a pT2-tumor was 30.4 (95% CI: 9.0-142) months and with a pT3-tumor 14 (9.2-16.4) months. The survival rates by 10 years among patients with a pT1 tumor were 57.0% (95% CI: 14.9-78.9), pT2 33.3% (11.8-52.2), and pT3 7.1% (1.9-15.5). The relative mortality for T3 stages compared to T1 stages was statistically significant (RMR = 3.22, P = 0.024).

CONCLUSION

Transthoracic and transhiatal esophagectomy are both effective approaches for treatment of adenocarcinoma of the esophagus and survival of more than 10 years can be expected without adjuvant chemotherapy. However, increasing depth of tumor invasion and lymph node metastases reduce life expectancy.

Factors affecting the adequacy of lymph node yield in prophylactic unilateral central neck dissection for papillary thyroid carcinoma

BACKGROUND

Determinants for adequate lymph node yield (LNY) in prophylactic central neck dissection (pCND) for papillary thyroid carcinoma (PTC) remain unclear. We aimed to determine factors affecting LNY in pCND.

METHODS

Of 230 patients, 109 (47.4%) had total thyroidectomy and unilateral pCND. A specimen of ≥ 6 central lymph nodes (CLNs) was considered adequate. Factors such as patient clinicopathologic features, specimen dimensions, and pathologists' experience were compared between those with LNY  <  6 (n = 52) and LNY  ≥  6 (n  =  57). A multivariate analysis was conducted to identify independent factors for LNY ≥  6.

RESULTS

Age, sex, presentation, body mass index, tumor characteristics, TNM stages, MACIS score, and pathologist's experience were not significant determinants for LNY  ≥  6. In the univariate analysis, the length (P  =  0.021), width (P  = 0.047), thickness (P  =  0.024), and pN1a (P  =  0.042) were significant determinants but in the multivariate analysis, the length (OR  =  1.486 (95% CI: 1.053-2.097), P  =  0.024) was the only independent factor for LNY  ≥  6. Postoperative vocal cord palsy, hypoparathyroidism, stimulated thyroglobulin and recurrences were similar between LNY <6 and ≥ 6.

CONCLUSIONS

Length (or the longest measured dimension) of the fresh CLN specimen was the only factor assuring LNY ≥ 6. Surgical complications and short-term outcomes appeared similar between LNY <6 or ≥ 6.

Lymph Node Ratio is a Significant Predictor of Disease-Specific Mortality in Patients Undergoing Esophagectomy for Cancer

The seventh edition of the American Joint Committee on Cancer esophageal cancer staging system classifies nodal status by the number of malignant nodes (LNMs) found. This may be confounded by variations in lymphadenectomy and specimen review. The ratio of lymph nodes containing metastases to the total nodes excised (LNR) has been suggested as an alternative. We seek to validate the use of LNR for staging and determine the effect of the total lymph node yield (LNY) on its accuracy. A review of our prospective esophageal database identified 94 patients who underwent esophagectomy for cancer at out institution from 1992 until 2010. Univariate and multi-variate analyses were performed. The mean age of our patients was 59.4 years. Transthoracic esophagectomy was performed in all but three instances. The majority of tumors were adenocarcinoma, 76 per cent. Overall survival at 2 and 5 years was 52 and 29 per cent, respectively. LNY correlated with LNM ( r = 0.302, P = 0.001) but not LNR ( r = 0.012, P = 0.912). Using Kaplan-Meier analysis, LNR had no effect on disease-specific (DS) survival ( P = 0.803). However, a Cox proportional hazards regression model showed LNR to be a significant predictor of DS mortality (hazard ratio, 9.47; P = 0.049). The lack of correlation between LNR and LNY suggests that LNR may be a more robust staging method when LNY is low. Furthermore, LNR was found to be a significant predictor of DS mortality when controlling for other factors influencing survival. However, neither a staging system based on LNR nor its efficacy compared with the current system could be determined from these data.

An attempt at validation of the Seventh edition of the classification by the International Union Against Cancer for esophageal carcinoma

BACKGROUND

The aim of our study was to investigate the ability of the Seventh edition of the classification by the International Union Against Cancer (UICC) to identify patients at higher risk and to predict the overall survival in patients with esophageal carcinoma.

METHODS

Demographic and clinical data of 605 patients, who underwent esophagectomy for esophageal carcinoma between 1992 and 2009, were analyzed. Tumor stage and grade were classified according to the sixth and seventh editions of the UICC classification.

RESULTS

Tumor depth (T), lymph node affection (N), and metastasis (M) status according to the seventh edition of the UICC classification showed significant differences in survival of each single status. Kaplan-Meier analysis of overall survival by the seventh edition of the UICC classification showed poor discrimination between stages Ib and IIa (p=0.098), stages IIIa and IIIb (p=0.672), and stages IIIc and IV (p=0.799). Further, the estimated median survival time between stages IIa and IIb was discordant.

CONCLUSIONS

The seventh edition of the UICC TNM classification cannot satisfactorily distinguish among different risk groups of patients with resected esophageal carcinoma. The new subgroups do not unify the different TNM stages with similar survival. We strongly propose that the next revision of the UICC classification should reduce the stages to groups with similar survival, without defining complex subgroups.

Assessment of the nodal status in ampullary carcinoma: the number of positive lymph nodes versus the lymph node ratio

BACKGROUND

This study was intended to compare the prognostic power of the number of positive lymph nodes with that of the lymph node ratio in patients with ampullary carcinoma.

METHODS

A retrospective analysis was conducted of the medical records of 71 consecutive patients with ampullary carcinoma who underwent pancreaticoduodenectomy with regional lymph node dissection. A total of 2151 lymph nodes were dissected (median: 28 nodes per patient) and examined histologically. Cutoff points were determined for both the number of positive nodes and the lymph node ratio using χ(2) scores calculated with the Cox proportional hazards regression model.

RESULTS

Lymph node metastasis was found in 34 patients. The best cutoff point for the number of positive nodes was identified as three nodes, and that for the lymph node ratio was identified as 10%. Univariate analysis revealed both the number of positive nodes (0, 1-3, or ≥ 4; P < 0.0001) and the lymph node ratio (0%, 0-10%, or >10%; P < 0.0001) as significant prognostic factors. Multivariate analysis identified the number of positive nodes as an independent prognostic factor (P < 0.001), whereas the lymph node ratio failed to remain as an independent variable. The cumulative 5-year survival rates were 85% for patients with 0 positive nodes, 63% for patients with 1-3 positive nodes, and 0% for patients with ≥ 4 positive nodes (P < 0.0001).

CONCLUSIONS

The number of positive lymph nodes better predicts the outcome after resection than the lymph node ratio in patients with ampullary carcinoma.

Lymph node metastases and prognosis in oesophageal carcinoma--a systematic review

Oesophageal cancer is the 7th most common cause of cancer-related death in the developed world and the incidence of oesophageal adenocarcinoma is now the fastest growing of any gastrointestinal cancer. Lymph node involvement is the single most important prognostic factor in oesophageal cancer. Imaging to determine the extent of lymph node involvement and plan treatment often requires a combination of modalities to avoid under-staging. The 7th edition of the staging system released by the International Union Against Cancer (IUCC) has stratified lymph node involvement according to the number of lymph nodes involved and redefined its groupings for location of metastatic lymph node involvement. This review discusses the prognostic and treatment implications of these modifications and explores micrometastatic lymph node involvement, capsular infiltration and lymph node ratio as possible additions to the staging system.

Prognostic implications of lymph node metastases in carcinoma of the body and tail of the pancreas

OBJECTIVE

The current classification of pancreatic cancer is based only on anatomic location of metastatic lymph nodes (LNs). On the other hand, the number of metastatic LNs has been used in staging of colorectal, esophageal, and gastric cancers. The aim of this study was to assess the prognostic impact of the number or ratio of the metastatic LNs in pancreatic body and tail carcinoma.

METHODS

Eighty-five patients with pancreatic body and tail adenocarcinoma who underwent pancreatectomy were included. Location, number, ratio of metastatic LNs, and the survival of patients were analyzed.

RESULTS

Forty patients with LN metastasis had poor prognosis (P = 0.007). The prognoses of patients with 5 or more metastatic LNs were poorer than those with less than 5 metastatic LNs (P = 0.046), and patients with a metastatic LN ratio of 0.2 or more had the worst prognosis. Multivariate analysis revealed that 5 or more metastatic LNs and metastatic LN ratio of 0.2 or more were independent prognostic factors for survival (P = 0.0015 and P = 0.014, respectively).

CONCLUSION

These results indicate that the number and the ratio of metastatic LNs can be used to predict poor patient survival and as a staging strategy.

How radical should surgery be for early esophageal cancer?

BACKGROUND

We have compared the oncologic effectiveness of limited resection (LR) techniques such as transhiatal (TH) or limited resection of the esophagogastric junction with intestinal interposition (LREGJ) in the treatment of early esophageal carcinoma with that of the extended resection such as the classical thoracoabdominal (TA) en bloc esophagectomy.

METHODS

We performed a retrospective analysis of prospectively collected data of 113 patients with T1 esophageal cancer (57 adeno- and 56 squamous cell carcinomas) who had surgical resection with systematic lymphadenectomy. Forty-one underwent extensive (TA) and 72 limited resection (51 TH and 21 LREGJ).

RESULTS

Complete resection (R0) was achieved in all cases. Lymphatic metastases were seen in none of the mucosal but in 26.8% of the submucosal T1 cancers. The median lymph node yield was significantly higher in patients with extensive resection (24 vs. 15 lymph nodes; p=0.036), but this did not affect the overall survival (median=88 vs. 102 months, 5-year survival probability=57.8 vs. 67.7%; log rank=0.578). The median hospital stay and ICU stay were significantly shorter in the LR group (p=0.039 and p = 0.044, respectively).

CONCLUSION

Limited resection leads to lower lymph node yield but similar oncologic effectiveness as the extensive surgery. It may represent a valuable alternative in the treatment of patients with early (submucosal) esophageal carcinoma.

The N-classification for esophageal cancer staging: should it be based on number, distance, or extent of the lymph node metastasis?

BACKGROUND

The recently published AJCC-TNM staging system for esophageal carcinoma made an obvious modification on N-classification based on the number of metastatic regional lymph nodes (LN). However, this classification might ignore the site at which these LNs occur, a factor that might be even more important in reflecting patients' prognosis.

METHODS

A retrospective study of 236 patients with carcinoma of thoracic esophagus who underwent esophagectomy between 1984 and 1989 with each at least six LNs removed was conducted, with a 10-year follow-up rate of 92.4%. The proposed scheme for N-classification according to the number (0, 1-2, 3-6, ≥7; N0-3), distance (0, 1, 2, 3 stations; S0-3), or extent (0, 1, and 2 fields; F0-2) of LN involvement was evaluated by univariate and multivariate survival analysis.

RESULTS

The LN metastasis was identified in 112 patients, revealing a poorer 5-year survival in this patient group when compared to patients without node involvement. Cox regression analysis revealed that the number and distance of LN metastases and the number of metastasis fields were factors significantly influencing survival. When these factors were further analyzed by univariate log-rank test, no significant difference in survival existed between N2 and N3 patients, or among S1, S2, and S3 patients. When patients were grouped according to the extent of LN metastasis, significant differences in survival were observed overall and between each subgroup.

CONCLUSIONS

Refining the current N-classification for esophageal cancer according to the extent of LN metastasis, rather than by number alone, might be a better means of staging that could subgroup patients more effectively and result in different rates of survival.

The significance of lymph node status as a prognostic factor for esophageal cancer

The revision of the TNM Classification of Malignant Tumors, 7th Edition, suggests the lymph node (LN) status to be the most significant risk factor in esophageal cancer. This article reviews the current status of LNs as indicators of prognosis. The significance of the number of metastatic LNs, the number of resected LNs, and a novel index, the "LN ratio" (metastatic LNs/removed LNs) in patients with esophageal cancer, were reviewed. The number of metastatic LNs independently predicted the prognosis of both overall survival and relapse-free survival. The number of positive LNs was also the best predictive marker of survival. Furthermore, overall survival significantly depended on the number of surgically removed LNs, and the LN ratio closely correlated with survival. The LN status is considered to be the most significant information that can be used to predict the prognosis. However, there are many issues that still need to be resolved. Better knowledge of the N-status is therefore needed to effectively utilize this information. Further research should focus on the N-status of patients with esophageal cancer.

The total number of resected lymph node is not a prognostic factor for recurrence in esophageal squamous cell carcinoma patients undergone transthoracic esophagectomy

BACKGROUND

The total number of resected lymph nodes (TLN) has been shown to predict survival in esophageal cancer, but its relationship with recurrence has been rarely reported. We aim to study the prognostic factors in esophageal squamous cell carcinoma (ESCC) patients, with a particular focus on the role of TLN.

METHODS

Two hundred sixty-eight ESCC patients who underwent transthoracic esophagectomy were selected for the study. A Cox regression model was used to identify prognostic factors.

RESULTS

Recurrence occurred in 115 of 268 patients. The median time to recurrence was 10 months (range, 1-58). The recurrence-free survival at 1, 3, and 5 years was 62.3%, 32.1%, and 28.5%, respectively. Multivariate analysis identified age (P = 0.001), N stage (N1-3 vs. N0, P = 0.001), tumor length (P = 0.019), and development of recurrence (P < 0.001) as independent prognostic factors for overall survival, whereas T (T3/4 vs. T1/2, P = 0.029) and N stage (N1-3 vs. N0, P = 0.017) were independent prognostic factors for recurrence. TLN was a significant factor only when predicting overall survival in N0 patients (HR, 0.976; 95% CI, 0.953-0.999; P = 0.042).

CONCLUSION

The TLN is not a prognostic factor for recurrence in ESCC patients undergone transthoracic esophagectomy.

CyclinD1, p53, E-cadherin, and VEGF discordant expression in paired regional metastatic lymph nodes of esophageal squamous cell carcinoma: a tissue array analysis

BACKGROUND AND OBJECTIVES

The correlation of biomarker expression between primary tumors and corresponding metastases has not yet been well reported in esophageal squamous cell carcinoma (ESCC). This study was to confirm whether primary ESCC tumors differ from their regional metastatic lymph nodes (RMLN) in CyclinD1, p53, E-cadherin, and vascular endothelial growth factor (VEGF) expression and determine prognostic value of their alteration.

METHODS

There were 134 patients with stage T3N1-3M0 ESCC recruited for the research. Expression of CyclinD1, p53, E-cadherin, and VEGF was evaluated in primary ESCC tumors and their paired RMLN assembled on tissue microarrays by immunohistochemistry (IHC). The comparison of expression in different lesion and their correlation with prognosis was analyzed.

RESULTS

E-cadherin was discordant expression in 55.2% cases and appeared to be more frequently positive in metastatic lymph nodes (P < 0.001). The VEGF expression level was significantly higher in primary tumors (P < 0.001). Combined analysis of VEGF expressions in paired lesions (P = 0.003) and its decreased expression (P = 0.006) were both predictive.

CONCLUSIONS

Biomarker expression was discordant between the primary tumor and its paired lymphatic metastasis in over 25% of patient with ESCC. VEGF discordant expression was a new prognostic factor and combined analysis of expression in paired lesions was useful to predict. Analysis of protein expression only in primary tumors would be inadequate to judge prognosis.

Ratio of metastatic lymph nodes to total number of nodes resected is prognostic for survival in esophageal carcinoma

INTRODUCTION

The role of the number of metastatic nodes in esophageal cancer surgery is of interest. We assess predictors of survival after oesophagectomy for esophageal and gastroesophageal junction malignancy.

METHODS

Prospective data of consecutive patients undergoing oesophagectomy and systematic lymphadenectomy between 1991 and 2007.

RESULTS

Of 224 patients, 148 patients (66%) had adenocarcinoma, 70 (31%) squamous cell carcinoma, and 6 (2.6%) were other tumor types. Five-year survival was 43% with hospital mortality of 3.5%. Locoregional recurrence occurred in 14%. The total number of affected nodes significantly reduced survival (four or more metastatic nodes). Further analysis of the ratio of nodes affected to the total number resected showed a significant decrease in survival as the percentage of positive nodes increased (p < 0.001).

CONCLUSIONS

Patients undergoing surgery for esophageal cancer should be staged according to a minimum total number of metastatic lymph nodes and ratios because this more accurately predicts survival than current staging systems.

Current diagnosis and future impact of micrometastases for therapeutic strategies in adenocarcinoma of the esophagus, gastric cardia, and upper gastric third

Esophageal and gastric cancers are aggressive neoplasms with a poor prognosis. Although postoperative mortality has declined and rates of complete resection have improved considerably, 5 year survival rates are still very low. Early metastatic relapse after complete resection of an apparently localized primary lesion indicates that disseminated tumor cells, undetectable by current methods, may already have been present at the time of surgery, even in patients with seemingly early tumor stages. Occult residual tumor disease is suggested when either bone marrow or lymph nodes from which tumor relapse may originate are affected by micrometastatic lesions undetectable by conventional histopathology. The presence of single tumor cells detected by immunohistological methods is increasingly regarded as a clinically relevant prognostic factor. The use of antibodies against tumor-associated targets enables detection of individual epithelial tumor cells in lymph nodes and in bone marrow in various tumor entities. The potential role and -benefit of an antibody-based treatment as a therapeutic target would be of particular interest in tumors with a notoriously poor prognosis such as esophageal cancer and cardia cancer.

Lymph node ratio versus number of affected lymph nodes as predictors of survival for resected pancreatic adenocarcinoma

BACKGROUND

The objective of this study was to compare the prognostic significance of the lymph node ratio (LNR) with the absolute number of affected lymph nodes for resected pancreatic ductal adenocarcinoma.

METHODS

Data were collected from 84 patients who had undergone pancreatoduodenectomy for pancreatic ductal adenocarcinoma over a 10-year period. Patients were categorized into four groups according to the absolute LNR (0, 0-0.199, 0.2-0.299, > or =0.3). Kaplan-Meier and Cox proportional hazard models were used to evaluate the prognostic effect.

RESULTS

An LNR of > or =0.2 (median survival 8.1 vs. 35.7 months with LNR < 0.2; p < 0.001) and > or =0.3 (median survival 5.9 vs. 29.6 months with LNR < 0.3; p < 0.001), tumor size (p < 0.017), positive resection margin (p < 0.001), and nodal involvement (p < 0.001) were found to be significant prognostic markers following univariate analysis. Following multivariate analysis, only LNR at both levels [> or =0.2 (p = 0.05; HR 1.8) and LNR of > or =0.3 (p = 0.01; HR 2.7)] were independent predictors of a poor outcome. The number of lymph nodes examined had no effect on overall survival in either node-positive patients (p = 0.339) or node-negative patients (p = 0.473).

CONCLUSIONS

The LNR represents a stronger independent prognostic indicator than the absolute number of affected lymph nodes in patients with resected pancreatic ductal adenocarcinoma.

A critical appraisal of circumferential resection margins in esophageal carcinoma

Background

In esophageal cancer, circumferential resection margins (CRMs) are considered to be of relevant prognostic value, but a reliable definition of tumor-free CRM is still unclear. The aim of this study was to appraise the clinical prognostic value of microscopic CRM involvement and to determine the optimal limit of CRM.

Methods

To define the optimal tumor-free CRM we included 98 consecutive patients who underwent extended esophagectomy with microscopic tumor-free resection margins (R0) between 1997 and 2006. CRMs were measured in tenths of millimeters with inked lateral margins. Outcome of patients with CRM involvement was compared with a statistically comparable control group of 21 patients with microscopic positive resection margins (R1).

Results

A cutoff point of CRM at ≤1.0 mm and >1.0 mm appeared to be an adequate marker for survival and prognosis (both P < 0.001). The outcome in patients with CRMs ≤1.0 and >0 mm was equal to that in patients with CRM of 0 mm (P = 0.43). CRM involvement was an independent prognostic factor for both recurrent disease (P = 0.001) and survival (P < 0.001). Survival of patients with positive CRMs (≤1 mm) did not significantly differ from patients with an R1 resection (P = 0.12).

Conclusion

Involvement of the circumferential resection margins is an independent prognostic factor for recurrent disease and survival in esophageal cancer. The optimal limit for a positive CRM is ≤1 mm and for a free CRM is >1.0 mm. Patients with unfavorable CRM should be approached as patients with R1 resection with corresponding outcome.

Neoadjuvant chemoradiotherapy for esophageal cancer: Impact on extracapsular lymph node involvement

AIM: To assess the effects of neoadjuvant chemoradiotherapy (CRT) on the presence of extracapsular lymph node involvement (LNI) and its prognostic value in patients with resected esophageal cancer.

METHODS: Two hundred and ninety-eight patients with advanced esophageal cancer underwent esophagectomy between 1997 and 2006. One hundred and ninety patients (63.8%) were treated with neoadjuvant CRT prior to resection. A total of 986 metastatic LNs were examined. Survival of the patients was analyzed according to intra- and extra-capsular LNI.

RESULTS: Five-year survival rate was 22.5% for the entire patient population. Patients with extracapsular LNI had a 5-year survival rate of 16.7%, which was comparable to the 15.8% in patients with infiltrated nodes of the celiac trunk (pM1lymph). In contrast to patients treated with surgery alone, neoadjuvant therapy resulted in significantly (P = 0.001) more patients with pN0/M0 (51.6% vs 25.0%). In 17.6% of the patients with surgery alone vs 16.8% with neoadjuvant CRT, extracapsular LNI was detected. Neoadjuvant therapy does not reduce the occurrence of extracapsular LNI.

CONCLUSION: Extracapsular LNI is an independent negative prognostic factor not influenced by neoadjuvant CRT. In a revised staging system for esophageal cancer, extracapsular LNI should be considered.

Comparison of the 6th and 7th editions of the American Joint Committee on Cancer tumor-node-metastasis staging system in patients with resected esophageal carcinoma

BACKGROUND

The 7th edition American Joint Committee on Cancer tumor-nodes-metastasis (AJCC TNM) staging system was published recently. We aim to evaluate its predictive ability and to compare the performance of the 6th and 7th editions of the AJCC TNM staging systems in esophageal cancer.

METHODS

A total of 392 esophageal squamous cell carcinoma patients receiving primary surgical resection between 1995 and 2006 were included. Patients were staged using the 6th and 7th edition staging systems. Survival analysis was performed with a Cox regression model. The homogeneity, discriminatory ability, and monotonicity of gradients of two staging systems were compared using linear trend chi2, likelihood ratio chi2 statistics, and Akaike information criterion calculation.

RESULTS

The overall five-year survival rate for the entire cohort was 27.1%. Female gender, "T," "N," and "M" classifications according to the 7th edition staging system definition were independent prognostic factors in multivariate analysis. But histology grade and cancer location had no significant influence on patient survival. The 7th edition staging system has the highest linear trend chi2 and likelihood ratio chi2 scores. Compared with the 6th edition, the 7th edition staging system also has a smaller Akaike information criterion value, which represented the optimum prognostic stratification.

CONCLUSIONS

The strength of the 7th edition AJCC TNM staging system is the new descriptors for "N" and "M" classifications. However, we did not find histologic grade and cancer location to be significant prognostic factors in our cohort. Overall, the 7th edition AJCC TNM staging system has better performance than the previous edition.

An evaluation of the number of lymph nodes examined and survival for node-negative esophageal carcinoma: data from China

BACKGROUND

The current American Joint Committee on Cancer (AJCC) staging system for esophageal cancer does not define the minimum number of lymph nodes (LNs) necessary for accurate nodal staging. This study aimed to seek the minimum number of LNs examined for adequate nodal staging of patients with node-negative esophageal cancer.

METHODS

We conducted a retrospective review of 592 patients undergoing R0 resection with node-negative esophageal carcinoma between December 1996 and December 2004. The relationship between the total number of examined LNs and death from esophageal cancer was investigated by means of a scatterplot of this variable versus Martingale residuals from a Cox proportional hazard regression model without the variable of interest. A smoothed line fit of the scatterplot was applied to detect the reasonable cutoff point.

RESULTS

The patients were classified into four categories according to the number of examined LNs: < or =5, 6 to 9, 10 to 17, and > or =18. A reduced hazard ratio of death was observed with an increasing number of LNs examined. The 5-year cancer-specific survival rate was 42.8% among patients with < or =5 LNs examined, compared with 52.6, 56.8, and 75% for those with 6-9 LNs, 10-17 LNs, and > or =18 LNs, respectively. Multivariate Cox regression analysis suggested that female sex, lower grade of cell differentiation, lower T category and increasing number of examined LNs were independent factors favoring cancer-specific survival.

CONCLUSIONS

At least 18 LNs should be resected for accurate staging of operable esophageal carcinoma. However, a validation from other institute is warranted.

Optimum lymphadenectomy for esophageal cancer

OBJECTIVE

Using Worldwide Esophageal Cancer Collaboration data, we sought to (1) characterize the relationship between survival and extent of lymphadenectomy, and (2) from this, define optimum lymphadenectomy.

SUMMARY BACKGROUND DATA

What constitutes optimum lymphadenectomy to maximize survival is controversial because of variable goals, analytic methodology, and generalizability of the underpinning data.

METHODS

A total of 4627 patients who had esophagectomy alone for esophageal cancer were identified from the Worldwide Esophageal Cancer Collaboration database. Patient-specific risk-adjusted survival was estimated using random survival forests. Risk-adjusted 5-year survival was averaged for each number of lymph nodes resected and its relation to cancer characteristics explored. Optimum number of nodes that should be resected to maximize 5-year survival was determined by random forest multivariable regression.

RESULTS

For pN0M0 moderately and poorly differentiated cancers, and all node-positive (pN+) cancers, 5-year survival improved with increasing extent of lymphadenectomy. In pN0M0 cancers, no optimum lymphadenectomy was defined for pTis; optimum lymphadenectomy was 10 to 12 nodes for pT1, 15 to 22 for pT2, and 31 to 42 for pT3/T4, depending on histopathologic cell type. In pN+M0 cancers and 1 to 6 nodes positive, optimum lymphadenectomy was 10 for pT1, 15 for pT2, and 29 to 50 for pT3/T4.

CONCLUSIONS

Greater extent of lymphadenectomy was associated with increased survival for all patients with esophageal cancer except at the extremes (TisN0M0 and >or=7 regional lymph nodes positive for cancer) and well-differentiated pN0M0 cancer. Maximum 5-year survival is modulated by T classification: resecting 10 nodes for pT1, 20 for pT2, and >or=30 for pT3/T4 is recommended.

Prognostic significance of perigastric lymph nodes metastases on survival in patients with thoracic esophageal cancer

Several publications have showed that the number of metastatic lymph node (LN) should be taken into consideration in nodal category of esophageal cancer, but seldom considered extent of involved regional LNs. The aim of this study is to evaluate the significance of the extent of regional LN metastasis on survival in patients with esophageal cancer. A total of 245 thoracic esophageal cancer patients underwent transthoracic esophagectomy with standard lymphadenectomy between January 2000 and December 2006 were included in the study. Data including demographic factors, pathologic findings, LN parameters and survival outcomes were collected. The survival experience was depicted using Kaplan-Meier method. A multivariate Cox proportional hazard model was used to screen the significant prognostic factors. The univariate analysis to further explore the significant prognostic factor was done by log-rank test. After a median follow-up of 53.2 months, the 5-year survival rate was 46.3% for the entire cohort. Cox model regression indicated that the LN status and perigastric nodal status, aside from residual tumor status, histological tumor type and depth of invasion, were the independent prognostic factors. Patients without LN metastasis had better 5-year survival than those with positive nodes (64.2% vs. 18.9%, X2=35.875, P<0.001). However, For those patients with nodal involvement, there was no difference in 5-year survival between patients with involved nodes<3 and >or=3 (27.8% vs. 0%, X2=0.925, P=0.336). When considering the location of LN metastasis, patients could be further stratified according to whether the perigastric nodes were involved or not (37.5% vs. 10.0%, X2=4.295, P=0.038). In conclusion, involved LN number had no prognostic implication in nodal involved patients based on our data. Whereas, perigastric nodal involvement should be used to refine the N category (N0, no nodal metastasis, N1, non-perigastric node metastasis, N2, perigastric node metastasis) for the future esophageal cancer staging criteria.

How does the number of resected lymph nodes influence TNM staging and prognosis for esophageal carcinoma?

BACKGROUND

It is proposed by International Union Against Cancer (UICC) and American Joint Committee on Cancer (AJCC) that at least 6 lymph nodes (LN) should be removed during resection of esophageal cancer for an accurate N classification. However, large series evidence is needed. The aim of this study is to assess the impact of total number of removed LNs during esophagectomy on UICC-TNM staging and long-term survival.

MATERIALS AND METHODS

The clinicopathological data and follow-up results of 1098 patients with advanced esophageal carcinoma who underwent an esophagectomy were analyzed.

RESULTS

The survival experience of group A (removed LNs <6) was worse than that of group B (removed LNs > or = 6). With the stratification analysis according to N and TNM stage, for patients with pN0 cancers, the survival in group A was worse than that in group B (P = .003), while in patients with 1 and > or = 2 positive LNs, the survival experience was similar (P = .919 and .182, respectively). A significant difference in survival in patients at stage IIa was observed between group A and group B (P = .005). However, the survival in patients at stage IIb and stage III was not different between the two groups (P = .302 and 0.108, respectively).

CONCLUSIONS

For advanced esophageal carcinoma, if the number of resected LNs per operation is less than 6, an occult positive regional LN might be missed, resulting in an inaccurate N classification. The minimum of 6 LNs removed for esophageal cancer recommended by UICC and AJCC is rational and should be complied with.

The metastatic lymph node number and ratio are independent prognostic factors in esophageal cancer

OBJECTIVE

The current American Joint Committee on Cancer staging system for esophageal cancer is based on lymph node location, irrespective of the number of involved and examined lymph nodes.

METHODS

We enrolled 488 patients receiving primary curative resection without neoadjuvant therapy for esophageal cancer between 1995 and 2006. The importance of total resected lymph node number (TLN) and metastatic lymph node number (MLN) and ratio (MLR) on patient survival was investigated.

RESULTS

The overall 3-year survival rate was 35.4%. The 3-year survival rate was equivalent among patients in N1 (23.3%), M1a (22.0%), and nonregional lymph node metastasis-related M1b (18.5%, p = 0.321). No survival difference was noted between patients with TLN < 15 or > or =15 (p = 0.249). Both MLN and MLR significantly predicted patient survival. The 3-year survival rate was 52.3%, 29.2%, and 8.0% for patients with MLN = 0, 1-3, and > or =4, respectively (p < 0.001). For patients with MLR = 0-0.2 or >0.2, the 3-year survival rate was 28.7% and 9.8%, respectively (p < 0.001). However, survival rate differences were more evident when TLN was more than 15.

CONCLUSIONS

We recommend designating both regional and nonregional lymph nodes as N nodes. MLN and MLR, but not TLN, are prognostic factors in esophageal cancer.

The lymph node ratio is the strongest prognostic factor after resection of pancreatic cancer

INTRODUCTION

Survival after surgery of pancreatic cancer is still poor, even after curative resection. Some prognostic factors like the status of the resection margin, lymph node (LN) status, or tumor grading have been identified. However, only few data have been published regarding the prognostic influence of the LN ratio (number of LN involved to number of examined LN). We, therefore, evaluated potential prognostic factors in 182 patients after resection of pancreatic cancer including assessment of LN ratio.

METHODS

Since 1994, 204 patients underwent pancreatic resection for ductal pancreatic adenocarcinoma. Survival was evaluated in 182 patients with complete follow-up evaluations. Of those 182 patients, 88% had cancer of the pancreatic head, 5% of the body, and 7% of the pancreatic tail. Patients underwent pancreatoduodenectomy (85%), distal resection (12%), or total pancreatectomy (3%). Survival was analyzed by the Kaplan-Meier and Cox methods.

RESULTS

In all 204 resected patients, operative mortality was 3.9% (n = 8). In the 182 patients with follow-up, 70% had free resection margins, 62% had G1- or G2-classified tumors, and 70% positive LN. Median tumor size was 30 (7-80) mm. The median number of examined LN was 16 and median number of involved LN 1 (range 0-22). Median LN ratio was 0.1 (0-0.79). Cumulative 5-year survival (5-year SV) in all patients was 15%. In univariate analysis, a LN ratio > or = 0.2 (5-year SV 6% vs. 19% with LN ratio < 0.2; p = 0.003), LN ratio > or = 0.3 (5-year SV 0% vs. 18% with LN ratio < 0.3; p < 0.001), a positive resection margin (p < 0.01) and poor differentiation (G3/G4; p < 0.03) were associated with poorer survival. In multivariate analysis, a LN ratio > or = 0.2 (p < 0.02; relative risk RR 1.6), LN ratio > or = 0.3 (p < 0.001; RR 2.2), positive margins (p < 0.02; RR 1.7), and poor differentiation (p < 0.03; RR 1.5) were independent factors predicting a poorer outcome. The conventional nodal status or the number of examined nodes (in all patients and in the subgroups of node positive or negative patients) had no significant influence on survival. Patients with one metastatic LN had the same outcome as patients with negative nodes, but prognosis decreased significantly in patients with two or more LN involved.

CONCLUSIONS

Not the lymph node involvement per se but especially the LN ratio is an independent prognostic factor after resection of pancreatic cancers. In our series, the LN ratio was even the strongest predictor of survival. The routine estimation of the LN ratio may be helpful not only for the individual prediction of prognosis but also for the indication of adjuvant therapy and herein related outcome and therapy studies.

Pharmacokinetics and pharmacogenomics in esophageal cancer chemoradiotherapy

Esophageal cancer is one of the most lethal malignancies. Surgical resection of the tumor from the primary site has been the standard treatment, especially for localized squamous cell carcinoma, but considerable clinical efforts during the last decade have resulted in novel courses of treatment. These options include chemoradiotherapy, consisting of a continuous infusion of 5-fluorouracil (5-FU), cisplatin (CDDP), and concurrent radiation. Given the substantial inter- and/or intra-individual variation in clinical outcome, future improvements will likely require the incorporation of a novel anticancer drug, pharmacokinetically guided administration of CDDP or 5-FU, and identification of potential responders by patient genetic profiling prior to treatment. In this review, the latest information on incidence, risk factors, biomarkers, therapeutic strategies, and the pharmacokinetically guided or genotype-guided administration of CDDP and 5-FU is summarized for future individualization of esophageal cancer treatment.

Detection of lymph node metastases in oesophageal cancer

Background

The importance of lymph node status in oesophageal cancer cannot be disputed. It is therefore surprising that no standardization exists in either terminology or methodology in lymph node analysis.

Methods

All online databases were searched to identify articles published from 1970 onwards. This was supplemented by hand searching references of retrieved articles.

Results and conclusion

Without accurate identification of lymph node metastases, patients cannot be staged properly, nor can best practice for the treatment of oesophageal cancer be determined. This review outlines the problem and proposes recommendations for standardization in terminology and methodology for the detection of lymph node metastases in oesophageal cancer.

Outcomes of esophagectomy according to surgeon's training: general vs. thoracic

INTRODUCTION

Esophagectomy is performed by general and thoracic surgeons with the type of operation often dictated by the surgeons' training. The objective was to investigate outcomes of esophagectomy to determine if they varied according to surgeon's training.

METHODS

Clinical data of patients who underwent partial or total esophagectomy for esophageal cancer from 2003 through 2007 were obtained from the University HealthSystem Consortium database. Data were examined between general versus thoracic surgeon and were reviewed for number and type of operations performed, demographics, length of stay, and postoperative morbidity and mortality.

RESULTS

During the 54-month period, 2,657 esophagectomies were performed; 1,079 (41%) by general surgeons and 1,578 (59%) by thoracic surgeons. More blunt transhiatal esophagectomies were performed by general surgeons compared to thoracic surgeons (56% vs. 37%, p < 0.01) while more Ivor Lewis resections were performed by thoracic surgeons (63% vs. 44%, p < 0.01). Thoracic surgery certification did not significantly affected outcomes with regards to mean hospital and ICU stay, complications, observed mortality, and mortality index.

CONCLUSIONS

In academic centers, the majority of esophagectomies for carcinoma are performed by thoracic surgeons who favor the Ivor Lewis approach, while general surgeons favor the blunt transhiatal approach. Despite these differences, specialty training does not appear an important factor affecting outcome.