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The stromal part of adenocarcinomas of the oesophagus: does it conceal targets for therapy? Eur J Cancer 2010; 46:720-8. [PMID: 20044247 DOI: 10.1016/j.ejca.2009.12.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 11/26/2009] [Accepted: 12/01/2009] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To evaluate the prognostic value of the tumour stroma ratio (TSR) in resected adenocarcinoma of the oesophagus. BACKGROUND In the literature, a refinement of oesophageal cancer staging has been proposed. Recently, TSR has been identified as a histological characteristic of the tumour itself that proved to be a strong predictor for survival in colorectal cancer. METHODS In our cancer registry database, we identified 93 consecutive patients who underwent resection for oesophageal adenocarcinoma between 1990 and 2004 in two hospitals in our region. Using a predefined histopathological protocol, TSR was determined on the original haematoxylin-eosin (H&E) tissue sections of oesophagectomy specimens by two independent investigators. RESULTS With a cut-off value of 50% tumour/stroma, patients were classified as TSR high (n=60) or TSR low (n=33). There were no significant differences in patient, tumour and treatment characteristics between the two groups, except for M status (M1a) and radicality of resection. The (disease-free) survival in the TSR high group was significantly better than in the TSR low group. By multivariate analysis, TSR was identified as a highly significant prognostic factor for overall survival (HR 2.0; P=0.010), independent of depth of tumour invasion, nodal status, lymph node ratio, extracapsular involvement, TNM stage, histological grade and radicality of resection. CONCLUSION TSR is a new and practicable prognostic tumour characteristic for oesophageal adenocarcinoma that can discriminate patients with a poor outcome from those with a better outcome.
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102
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Zhang HL, Chen LQ, Liu RL, Shi YT, He M, Meng XL, Bai SX, Ping YM. The number of lymph node metastases influences survival and International Union Against Cancer tumor-node-metastasis classification for esophageal squamous cell carcinoma. Dis Esophagus 2010; 23:53-8. [PMID: 19392846 DOI: 10.1111/j.1442-2050.2009.00971.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
To study the influence of the number of metastatic lymph nodes (LNs) on survival and International Union Against Cancer tumor-node-metastasis (TNM) classification for esophageal carcinoma. The clinicopathological data on 1146 patients with esophageal squamous cell carcinoma who had undergone an esophagectomy were retrospectively studied. Survival was analyzed by the Kaplan-Meier method. By subclassifying the nodes (N) category according to the number of metastatic LNs as: N0 for no LN metastases; N1(1) for only one positive node; and N1(2) for >or=2 positive nodes. TNM staging was refined as stage IIa (T2-3N0M0), stage IIb (T1N1M0 and T2N1(1)M0), stage IIIa (T2N1(2)M0 and T3N1(1)M0), and stage IIIb (T3N1(2)M0 and T4NanyM0), and the survival was analyzed. LN metastases was found in 380 of 1146 (33.2%) treated esophageal cancer patients. In 4270 LNs harvested, metastases was detected in 807 (18.9%). The 5-year survival rates of the patients with 0, 1, and >or=2 positive nodes were 59.8, 33.4, and 9.4%, respectively. There was statistically significant difference among these three groups. The 5-year survival of the patients in stages T2N1M0 and T3N1M0 was significantly higher in the N1(1) group than in the N1(2) group (41.5 vs 24.1%, and 31.2 vs 6.8%, P<0.001). The 5-year survival rates of the patients in refined stage IIa, IIb, IIIa, and IIIb were 57.1, 42.2, 28.6, and 8.5%, with significant difference existing in each stage groups. The number of positive LNs significantly influenced survival of the patients with esophageal cancer. Three grade classification (0, 1, >or=2 positive nodes) could quite well demonstrate the effect of the number of LN metastases and the survival. The refined TNM classification based on the number of LN metastases could better reflect the prognosis of esophageal cancer. Our results offer a strong rationale for refining the International Union Against Cancer TNM classification for esophageal carcinoma.
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Affiliation(s)
- H-L Zhang
- Department of Thoracic Surgery, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China.
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103
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Hu Y, Hu C, Zhang H, Ping Y, Chen LQ. How does the number of resected lymph nodes influence TNM staging and prognosis for esophageal carcinoma? Ann Surg Oncol 2009; 17:784-90. [PMID: 19953333 DOI: 10.1245/s10434-009-0818-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Yang Hu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
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104
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Prognostic value of lymph node metastases and lymph node ratio in esophageal squamous cell carcinoma. Eur J Surg Oncol 2009; 36:155-9. [PMID: 19854606 DOI: 10.1016/j.ejso.2009.09.005] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2008] [Revised: 09/09/2009] [Accepted: 09/17/2009] [Indexed: 02/07/2023] Open
Abstract
AIMS Although the positive lymph node (LN) metastasis in patients with thoracic esophageal squamous cell carcinoma carcinoma (SCC) has been reported to be a risk factor to reduce long-term survival, only a few studies have so far evaluated the lymph node metastasis among this group of patients. The purpose of this study was to evaluate the impact of lymph node positivity and ratio on survival of esophageal SCC. METHODS All patients undergoing esophagectomy at the Forth Hospital of Hebei Medical University between January 1986 and December 2002 were reviewed. Survival curves were estimated using the Kaplan-Meier method. RESULTS Of 1,325 patients with invasive cancer, had squamous cell cancer of the esophagus. Median overall survival (OS) of the entire group was 36.7 months and 5-year OS was 39.3%. The most significant prognostic factor for overall survival was the presence of positive LN (P<0.01). Additionally, patients with zero involved LN had a 5-year survival of 49.1%, while patients with 1-3 positive LN and >3 positive LN had 5-year survival of 19.5% and 11.0%, respectively (P<0.01). Finally, an increasing ratio of positive to examined LN was linearly associated with a worsening 5-year survival, patients with <25%, 25%-50% and >50% positive LN had 5-year survival of 47.53%, 14.6% and 8.9%, respectively (P<0.01). CONCLUSION Increasing number of positive LN in patients with esophageal cancer and increasing ratio of metastatic to examine LN portend a poor prognosis. These factors should play an important role in predicting prognosis of patients.
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Twine CP, Lewis WG, Morgan MA, Chan D, Clark GWB, Havard T, Crosby TD, Roberts SA, Williams GT. The assessment of prognosis of surgically resected oesophageal cancer is dependent on the number of lymph nodes examined pathologically. Histopathology 2009; 55:46-52. [PMID: 19614766 DOI: 10.1111/j.1365-2559.2009.03332.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AIMS The prognosis in surgically resected oesophageal carcinoma (OC) is dependent on the number of regional lymph nodes (LN) involved, but no guidance exists on how many LNs should be examined histopathologically to give a reliable pN status. The aim of this study was to determine whether the number of LNs examined after OC resection has a significant effect on the assessment of prognosis. METHODS AND RESULTS Routinely generated pathology reports from 237 consecutive patients undergoing oesophagectomy for OC were examined and analysed in relation to survival. The main outcome measure was survival from date of diagnosis. Lymph node count (LNC) correlated strongly with survival; a plateau was reached after a count of 10. Median and 2-year survival was 30 months and 42%, respectively, if <10 nodes were examined (n = 88), compared with 51 months and 61% if >10 nodes were examined (P = 0.005). This effect was greatest in pN0 cases. The prognostic value of the absolute number of LN metastases (<4) and LN ratio (<0.4) was strongly dependent on a LNC of >10. CONCLUSIONS These results demonstrate the importance of careful pathological examination and lymph node retrieval after OC resection. At least 10 nodes should be examined to designate an OC as pN0.
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Affiliation(s)
- Christopher P Twine
- South East Wales Cancer Network, Department of General and Upper GI Surgery, University Hospital of Wales, Cardiff Cardiff, UK
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106
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Groth SS, Virnig BA, Whitson BA, DeFor TE, Li ZZ, Tuttle TM, Maddaus MA. Determination of the minimum number of lymph nodes to examine to maximize survival in patients with esophageal carcinoma: data from the Surveillance Epidemiology and End Results database. J Thorac Cardiovasc Surg 2009; 139:612-20. [PMID: 19709685 DOI: 10.1016/j.jtcvs.2009.07.017] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2008] [Revised: 05/27/2009] [Accepted: 07/06/2009] [Indexed: 01/18/2023]
Abstract
OBJECTIVE We used a population-based cancer registry to examine the association between lymph node counts and mortality to determine the minimum number of lymph nodes that should be examined as part of esophageal resection. METHODS Using the Surveillance Epidemiology and End Results database, we identified patients who had an esophagectomy for invasive esophageal carcinoma from 1988 through 2005 and who had a known number of lymph nodes examined pathologically. After stratifying patients (0, 1-11, 12-29, and 30 or more lymph nodes examined) based on a recursive partitioning analysis, we assessed the association between lymph nodes counts and mortality using the Kaplan-Meier method. To adjust for potential confounding covariates, we used a Cox proportional hazards regression model. RESULTS Of the patients in the Surveillance Epidemiology and End Results database with esophageal cancer, 4882 met our inclusion criteria. We noted a significant difference between the lymph node groups with regards to unadjusted all-cause (P < .0001) and cancer-specific mortality (P = .004). After adjusting for cancer registry, patient factors, tumor characteristics, and timing of radiation therapy, we noted a significant difference between the lymph node groups with regards to all-cause and cancer-specific mortality. Compared with patients who had no lymph node evaluation, only patients who had more than 12 lymph nodes examined had a significant improvement in mortality; patients who had 30 or more lymph nodes examined had significantly lower mortality rates than the other groups. CONCLUSION To maximize all-cause and cancer-specific survival, esophageal cancer patients should have at least 30 lymph nodes examined pathologically as part of esophageal resection.
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Affiliation(s)
- Shawn S Groth
- University of Minnesota Department of Surgery, Division of Thoracic Foregut Surgery, Minneapolis, MN 55455, USA
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107
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Peters CJ, Hardwick RH, Vowler SL, Fitzgerald RC. Generation and validation of a revised classification for oesophageal and junctional adenocarcinoma. Br J Surg 2009; 96:724-33. [PMID: 19526624 DOI: 10.1002/bjs.6584] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Oesophageal adenocarcinoma is the commonest oesophageal malignancy in the West, but is staged using a system designed for squamous cell carcinoma. The aim was to develop and validate a staging system for oesophageal and junctional adenocarcinoma. METHODS Patients with oesophageal adenocarcinoma (Siewert types I and II) undergoing oesophagectomy with curative intent were randomly assigned to generation (313 patients) and validation (131) data sets. Outcome in the generation data set was associated with histopathological features; a revised node (N) classification was derived using recursive partitioning and tested on the validation data set. RESULTS A revised N classification based on number of involved lymph nodes (N0, none; N1, one to five; N2, six or more) was prognostically significant (P < 0.001). Patients with involved nodes on both sides of the diaphragm, regardless of number, had the same outcome as the N2 group. When applied to the validation data set, the revised classification (including nodal number and location) provided greater discrimination between node-positive patients than the existing system (P < 0.001). CONCLUSION A revised N classification based on number and location of involved lymph nodes provides improved prognostic power and incorporates features that may be useful before surgery in clinical management decisions.
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Affiliation(s)
- C J Peters
- Medical Research Council (MRC) Cancer Cell Unit, Hutchison/MRC Research Centre, Cambridge, UK
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108
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van Meerten E, van der Gaast A, Tilanus H, Poley J, Muller K, van Dekken H. Pathological analysis after neoadjuvant chemoradiotherapy for esophageal carcinoma: The rotterdam experience. J Surg Oncol 2009; 100:32-7. [DOI: 10.1002/jso.21295] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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109
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Xing Y, Badgwell BD, Ross MI, Gershenwald JE, Lee JE, Mansfield PF, Lucci A, Cormier JN. Lymph node ratio predicts disease-specific survival in melanoma patients. Cancer 2009; 115:2505-13. [PMID: 19309746 PMCID: PMC2755291 DOI: 10.1002/cncr.24290] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND The objectives of this analysis were to compare various measures associated with lymph node (LN) dissection and to identify threshold values associated with disease-specific survival (DSS) outcomes in patients with melanoma. METHODS Patients with lymph node-positive melanoma who underwent therapeutic LN dissection of the neck, axilla, and inguinal region were identified from the SEER database (1988-2005). We performed Cox multivariate analyses to determine the impact of the total number of LNs removed, number of negative LNs removed, and LN ratio on DSS. Multivariate cut-point analyses were conducted for each anatomic region to identify the threshold values associated with the largest improvement in DSS. RESULTS The LN ratio was significantly associated with DSS for all LN regions. The LN ratio thresholds resulting in the greatest difference in 5-year DSS were .07, .13, and .18 for neck, axillary, and inguinal regions, respectively, corresponding to 15, 8, and 6 LNs removed per positive lymph node. After adjustment for other clinicopathologic factors, the hazard ratios (HRs) were .53 (95% confidence interval [CI], .40 to .71) in the neck, .52 (95% CI, .42 to .65) in the axillary, and .47 (95% CI, .36 to .61) in the inguinal regions for patients who met the LN ratio threshold. CONCLUSIONS Among the prognostic factors examined, LN ratio was the best indicator of the extent of LN dissection, regardless of anatomic nodal region. These data provide evidence-based guidelines for defining adequate LN dissections in melanoma patients.
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Affiliation(s)
- Yan Xing
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030-4009, USA
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110
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Abdominal lymph node metastasis in patients with mid thoracic esophageal squamous cell carcinoma. World J Surg 2009; 33:278-83. [PMID: 19067038 DOI: 10.1007/s00268-008-9849-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND There are few reports about abdominal lymph node metastasis of mid thoracic esophageal carcinoma. This study was designed to explore the pattern of abdominal lymph node metastasis in patients with mid thoracic esophageal squamous cell carcinoma and to evaluate the prognostic factors. METHODS The complete data of 368 patients with mid thoracic esophageal squamous cell carcinoma, who underwent modified Ivor-Lewis esophagectomy with two-field lymphadenectomy from January 1998 to January 2003, were reviewed. Survival rate was calculated by Kaplan-Meier method. Cox regression analysis was performed to identify risk prognostic factors. RESULTS Abdominal lymph node metastasis occurred in 58 (15.8%) patients: 34.5% (20/58) of them were stage T1 and T2. Skipping abdominal node metastasis was recognized in 13.8% (8/58) patients: all were stage T1 and T2. The overall 5-year survival rate of patients with abdominal lymph node metastasis (10.3%) was lower than that of those with thoracic node metastasis (18.3%). The prognosis of patients with distant abdominal lymph node metastasis was poor, and no one could survive more than 5 years. Cox regression analysis showed that five or more positive nodes and distant abdominal node metastasis were independent risk factors of patients with abdominal lymph node metastasis. CONCLUSIONS Abdominal lymph node metastasis in patients with mid thoracic esophageal squamous cell carcinoma occurred frequently, and the surgery favorable for extensive abdominal lymph node dissection should be selected. The prognosis of patients with abdominal lymph node metastasis was poor, especially those with more positive nodes and distant abdominal node metastasis.
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111
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Impact of tumor length on long-term survival of pT1 esophageal adenocarcinoma. J Thorac Cardiovasc Surg 2009; 138:831-6. [PMID: 19660349 DOI: 10.1016/j.jtcvs.2009.02.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Revised: 01/16/2009] [Accepted: 02/02/2009] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The impact of esophageal tumor length on pT1 esophageal adenocarcinoma has not been well evaluated. METHODS Case histories of all patients (n = 133) undergoing esophageal resection from 1979 to 2007 with pT1 adenocarcinoma of the esophagus were reviewed. Univariate and multivariate analyses of esophageal tumor length and other standard prognostic factors were performed. RESULTS Patients with early-stage pT1 esophageal adenocarcinoma with tumors less than 3 cm demonstrate decreased long-term survival (3 years: >3 cm = 46% vs 93%; P < .001) and higher risk of lymph node involvement (lymph node positive: >3 cm = 47% vs 10%; P < .001). Multivariable analysis shows that esophageal tumor length (>3 cm) is an independent risk factor for survival in patients with pT1 early-stage esophageal cancer (hazard ratio: 4.8, 95% confidence intervals: 1.4-16.5; P < .001) even when controlled for submucosal involvement, lymph node involvement, and lymphatic/vascular invasion status. In combination with submucosal involvement, esophageal tumor length (>3 cm) identifies a high-risk population of pT1 esophageal adenocarcinoma (3 years: group 1 [0 risk factors] = 100%, group 2 [1 risk factor] = 87%, and group 3 [2 risk factors] = 33%; P < .001). CONCLUSIONS This study demonstrates that esophageal tumor length (>3 cm) is a risk factor for long-term survival and lymph node involvement in early-stage pT1 esophageal adenocarcinoma. Esophageal tumor length (>3 cm) in combination with submucosal involvement may help to identify a high-risk group of patients with pT1 esophageal adenocarcinoma.
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112
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Yendamuri S, Swisher SG, Correa AM, Hofstetter W, Ajani JA, Francis A, Maru D, Mehran RJ, Rice DC, Roth JA, Walsh GL, Vaporciyan AA. Esophageal tumor length is independently associated with long-term survival. Cancer 2009; 115:508-16. [PMID: 19117343 DOI: 10.1002/cncr.24062] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Esophageal cancer staging uses tumor depth as the sole criterion for assessment of the primary tumor (pT). To the authors' knowledge the impact of esophageal tumor length on long-term outcome and the esophageal cancer staging system has not been fully evaluated in the current era. METHODS All esophageal cancer patients (n = 209) undergoing surgery from 1995 to 2005 who did not receive preoperative chemotherapy or radiotherapy were reviewed. Maximum esophageal tumor length along a craniocaudal axis was determined pathologically after surgical resection. Univariate and multivariate analyses were used to assess the impact of esophageal tumor length (< or = 3 cm vs >3 cm) on long-term survival. RESULTS Esophageal tumor length was closely associated with long-term survival (hazards ratio [HR] of 6.14 [95% confidence interval (95% CI), 4.1-9.25]; 5-year survival: < or = 3 cm = 68%, >3 cm = 10% [P < .001]). Multivariate Cox regression analyses demonstrated tumor length (HR of 2.13 [95% CI, 1.26-3.63]) was found to be a significant independent predictor of long-term survival even when controlled for sex, age, tumor location, histology, margin positivity, surgical procedure, and current pTNM criteria. The incorporation of tumor length in pTNM staging significantly improves the ability to predict the long-term survival of patients (5-year survival for patients with tumors < or = 3 cm and stages I, IIA, IIB, and III disease = 86%, 62%, 49%, and 22%, respectively; survival for patients with tumors measuring >3 cm and stages I, IIA, IIB, and III disease = 27%, 22%, 0%, and 8%, respectively [P < .1]). CONCLUSIONS Esophageal tumor length is an independent predictor of long-term survival in the current era and should be considered for incorporation into the current esophageal cancer staging system to better predict long-term survival and identify high-risk patients for postoperative therapy.
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Affiliation(s)
- Sai Yendamuri
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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Saha AK, Sutton C, Rotimi O, Dexter S, Sue-Ling H, Sarela AI. Neoadjuvant Chemotherapy and Surgery for Esophageal Adenocarcinoma: Prognostic Value of Circumferential Resection Margin and Stratification of N1 Category. Ann Surg Oncol 2009; 16:1364-70. [DOI: 10.1245/s10434-009-0396-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 01/24/2009] [Accepted: 01/25/2009] [Indexed: 02/06/2023]
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Abstract
Primary treatment of carcinoma of the esophagus and cardia rests on surgical resection. Although recent advances have shown the suitability of endoscopic treatment in selected patients with very early cancers, and preliminary studies have suggested that responders to primary chemoradiation may be equivalent to resection in selected patients with squamous cell carcinoma, surgical resection remains the mainstay of therapy, as it has for the past 50 years. Various changes support highly individualized treatment decisions, in which each patient receives the treatment with the best chance of eliminating all disease.
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116
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Metzger R, Drebber U, Baldus SE, Mönig SP, Hölscher AH, Bollschweiler E. Extracapsular Lymph Node Involvement Differs Between Squamous Cell and Adenocarcinoma of the Esophagus. Ann Surg Oncol 2008; 16:447-53. [DOI: 10.1245/s10434-008-0248-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Revised: 11/01/2008] [Accepted: 11/02/2008] [Indexed: 12/15/2022]
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117
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Jamieson GG, Thompson SK. Detection of lymph node metastases in oesophageal cancer. Br J Surg 2008; 96:21-5. [DOI: 10.1002/bjs.6411] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
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.
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Affiliation(s)
- G G Jamieson
- Department of Surgery, University of Adelaide, Adelaide, South Australia, Australia
| | - S K Thompson
- Department of Surgery, University of Adelaide, Adelaide, South Australia, Australia
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118
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Thompson SK, Ruszkiewicz AR, Jamieson GG, Esterman A, Watson DI, Wijnhoven BPL, Lamb PJ, Devitt PG. Improving the Accuracy of TNM Staging in Esophageal Cancer: A Pathological Review of Resected Specimens. Ann Surg Oncol 2008; 15:3447-58. [DOI: 10.1245/s10434-008-0155-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2008] [Revised: 08/14/2008] [Accepted: 08/14/2008] [Indexed: 12/20/2022]
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Schwer AL, Ballonoff A, McCammon R, Rusthoven K, D'Agostino RB, Schefter TE. Survival effect of neoadjuvant radiotherapy before esophagectomy for patients with esophageal cancer: a surveillance, epidemiology, and end-results study. Int J Radiat Oncol Biol Phys 2008; 73:449-55. [PMID: 18538500 DOI: 10.1016/j.ijrobp.2008.04.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2008] [Revised: 04/21/2008] [Accepted: 04/21/2008] [Indexed: 11/17/2022]
Abstract
PURPOSE The role of neoadjuvant radiotherapy (NeoRT) before definitive surgery for esophageal cancer remains controversial. This study used a large population-based database to assess the effect of NeoRT on survival for patients treated with definitive surgery. METHODS AND MATERIALS The overall survival (OS) and cause-specific survival for patients with Stage T2-T4, any N, M0 (cT2-T4M0) esophageal cancer who had undergone definitive surgery between 1998 and 2004 were analyzed by querying the Surveillance, Epidemiology, and End-Results database. Kaplan-Meier survival curves were generated and univariate comparisons were made using the log-rank test. Cox proportional hazards survival regression multivariate analysis was performed with NeoRT, T stage (T2 vs. T3-T4), pathologic nodal status (pN0 vs. pN1), number of nodes dissected (>10 vs. </=10), histologic type (adenocarcinoma vs. squamous cell carcinoma), age (<65 vs. >/=65 years), and gender as covariates. RESULTS A total of 1,033 patients were identified. Of these, 441 patients received NeoRT and 592 underwent esophagectomy alone; 77% were men, 67% had adenocarcinoma, and 72% had Stage T3-T4 disease. The median OS and cause-specific survival were both significantly greater for patients who received NeoRT compared with esophagectomy alone (27 vs. 18 months and 35 vs. 21 months, respectively, p <0.0001). The 3-year OS rate was also significantly greater in the NeoRT group (43% vs. 30%). On multivariate analysis, NeoRT, age <65 years, adenocarcinoma histologic type, female gender, pN0 status, >10 nodes dissected, and Stage T2 disease were all independently correlated with increased OS. CONCLUSION These results support the use of NeoRT for patients with esophageal cancer. Prospective studies are needed to confirm these results.
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Affiliation(s)
- Amanda L Schwer
- Department of Radiation Oncology, University of Colorado Health Sciences Center, Aurora, Colorado, USA
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Greenstein AJ, Litle VR, Swanson SJ, Divino CM, Packer S, Wisnivesky JP. Effect of the number of lymph nodes sampled on postoperative survival of lymph node-negative esophageal cancer. Cancer 2008; 112:1239-46. [PMID: 18224663 DOI: 10.1002/cncr.23309] [Citation(s) in RCA: 169] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The presence of lymph node (LN) metastases in esophageal cancer has important prognostic and treatment implications. However, the optimal number of LNs that should be examined for accurate staging is controversial. In the current study, the association between survival and the number of LNs evaluated was examined in patients who underwent resection of lymph node-negative (American Joint Committee on Cancer [AJCC] TNM stage I-IIA) esophageal cancer. METHODS All patients were identified who underwent surgery for lymph node-negative esophageal cancer between 1988 and 2003 from the Surveillance, Epidemiology, and End Results cancer registry. Patients were classified into 3 groups by the number of negative LNs sampled during surgery (<or=10 LNs, 11-17 LNs, and>or=18 LNs). Esophageal cancer-specific survival was compared among these LN groups using Kaplan-Meier curves. Stratified and Cox regression analyses were used to evaluate the association between survival and the number of negative LNs after adjusting for potential confounders. RESULTS A total of 972 patients were included in the study. Disease-specific survival rates increased with a higher number of negative LNs. The 5-year disease-specific survival rate was 55% among patients with<or=10 negative LNs, compared with 66% and 75%, respectively, for those with 11 to 17 negative LNs and>or=18 negative LNs. The number of negative LNs was found to be significantly associated with survival in analyses stratified by tumor status. On multivariate regression controlling for age, race/ethnicity, sex, histology, tumor status, and postoperative radiotherapy, a higher number of negative LNs was found to be independently associated with higher disease-specific survival. CONCLUSIONS The presence of LN metastases in patients with esophageal cancer appears to have important prognostic and treatment implications. Data from the current study suggest that patients undergoing surgical resection for esophageal cancer should have at least 18 LNs removed.
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Affiliation(s)
- Alexander J Greenstein
- Department of General Surgery, Mount Sinai School of Medicine, New York, New York 10029, USA
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121
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Prognostic significance of the number of lymph node metastases in esophageal cancer. J Am Coll Surg 2007; 206:239-46. [PMID: 18222375 DOI: 10.1016/j.jamcollsurg.2007.09.003] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2007] [Revised: 08/20/2007] [Accepted: 09/05/2007] [Indexed: 12/26/2022]
Abstract
BACKGROUND Regional lymph node (LN) involvement is one of the most important predictors of survival for patients with esophageal cancer. The current staging classification differentiates only between the presence and absence of LN metastasis. In this study, we examined whether involvement of a higher number of LNs is associated with worse survival among esophageal cancer patients. STUDY DESIGN We identified all patients who underwent operations for node-positive esophageal cancer between 1988 and 2003 from the Surveillance, Epidemiology and End Results cancer registry. Because the number of positive LNs is confounded by the total number of LNs removed, patients were classified into three groups by the ratio of positive-to-total number of LNs removed (LN ratio [LNR]): <or= 0.2, 0.21 to 0.5, and>0.5. Esophageal cancer-specific survival was compared among these groups using Kaplan-Meier curves. Stratified and Cox regression analyses were used to evaluate the relationship between the LNR and survival after adjusting for potential confounders. RESULTS The study cohort included 838 esophageal cancer patients. Disease-specific survival rates decreased with higher LNR. Five-year disease-specific survival was 30% among patients with an LNR<or=0.2, compared with 16% and 13% for those with LNs of 0.21 to 0.5 and>0.5, respectively (p < 0.001). In stratified and multivariable analyses controlling for age, race, gender, histology, tumor-status, and postoperative radiotherapy, a higher LNR was independently associated with worse disease-specific survival. CONCLUSIONS These data suggest that a higher LNR among patients with node-positive esophageal cancer is associated with worse survival. If validated, this prognostic criterion may be included in staging classifications.
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122
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Schwarz RE, Smith DD. Clinical impact of lymphadenectomy extent in resectable esophageal cancer. J Gastrointest Surg 2007; 11:1384-93; discussion 1393-4. [PMID: 17764019 DOI: 10.1007/s11605-007-0264-2] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Accepted: 07/19/2007] [Indexed: 01/31/2023]
Abstract
Esophageal cancer (EC) frequently presents with advanced stages and is associated with high recurrence rates after esophagectomy. The value of an extended lymph node dissection (ELND) remains unclear in this setting. An EC data set was created from the Surveillance, Epidemiology, and End-Results 1973-2003 database. Relationships between the number of lymph nodes (LNs) examined and overall survival (OS) were analyzed. From a cohort of 40,129 EC patients, 5,620 individuals were selected. The median age was 65 (range: 11-102), and 75% were men. The median tumor size was 5.0 cm (0.1-30). On multivariate analysis, total LN count (or negative LN count, respectively) was an independent prognostic variable, aside from age, race, resection status, radiation, T category, N category (all at p < 0.0001), and M category (p = 0.0003). Higher total LN count (>30) and negative LN count (>15) categories were associated with best OS and lowest 90-day mortality (p < 0.0001). The numeric LN effect on OS was independent from nodal status or histology. Greater total and negative LN counts are associated with longer EC survival. Although the mechanism remains uncertain, it does not appear to be limited to stage migration. ELND during potentially curative esophagectomy for EC can be supported by the data.
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Affiliation(s)
- Roderich E Schwarz
- Division of Surgical Oncology, UT Southwestern Cancer Center, Dallas, TX 75390, USA.
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Wilson M, Rosato EL, Chojnacki KA, Chervoneva I, Kairys JC, Cohn HE, Rosato FE, Berger AC. Prognostic significance of lymph node metastases and ratio in esophageal cancer. J Surg Res 2007; 146:11-5. [PMID: 18028955 DOI: 10.1016/j.jss.2007.07.028] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2007] [Revised: 07/02/2007] [Accepted: 07/17/2007] [Indexed: 12/24/2022]
Abstract
BACKGROUND The incidence of carcinoma of the distal esophagus and GE junction is rapidly increasing. A large single-center experience was reviewed to determine the impact of lymph node positivity and ratio on survival. METHODS All patients undergoing esophagogastrectomy at Thomas Jefferson University Hospital between January 1994 and December 2004 were reviewed. Univariate and multivariate analyses were performed using log-rank and Cox proportional hazard models, and survival curves were estimated using the Kaplan-Meier method. RESULTS Of 173 patients with invasive cancer, 123 (71%) underwent preoperative chemoradiation therapy. The largest number of patients (45%) had adenocarcinoma of the GE junction; 29% of patients had esophageal adenocarcinoma while 14% had squamous cell cancer of the esophagus. Perioperative mortality was 5.7%. Median overall survival of the entire group was 22 months and 5-year overall survival was 27%. The most significant prognostic factor for overall survival was the presence of positive LN (P = 0.01). Additionally, patients with zero involved LN had a 5-year survival of 34%, while patients with 1 to 3 positive LN and >3 positive LN had 5-year survival of 27% and 9%, respectively (P = 0.01). Finally, an increasing ratio of positive to examined LN was linearly associated with a worsening 5-year survival, (P = 0.153). CONCLUSIONS Increasing number of positive LN in patients with esophageal cancer and increasing ratio of metastatic to examined LN portend a poor prognosis. These factors should play an important role in determining which patients receive adjuvant therapy.
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Affiliation(s)
- Matthew Wilson
- Department of Surgery, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA 19107, USA
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Ricciardi R, Baxter NN. Association versus causation versus quality improvement: setting benchmarks for lymph node evaluation in colon cancer. J Natl Cancer Inst 2007; 99:414-5. [PMID: 17374823 DOI: 10.1093/jnci/djk106] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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