Refining esophageal cancer staging

Appraisal of a revised lymph node classification system for esophageal squamous cell cancer

BACKGROUND

Node-positive patients with esophageal carcinoma constitute a heterogeneous population with a variable prognosis, which the current staging system insufficiently addresses. To that end, 863 patients with a curative resection for esophageal squamous cell carcinoma were analyzed to evaluate a useful and simple nodal classification system.

METHODS

Along with standard conventional clinicopathologic factors, data for metastatic lymph node (MLN) number, metastatic to examined LN ratio (MLN ratio), and MLN size were evaluated. The greatest microscopic dimension of the metastatic tumor inside the largest MLN (MLN size) was measured on histopathologic slides. Patients with MLNs were classified into n1 (< 9 mm) and n2 (> or = 9 mm) groups, according to size of MLNs (n-stage).

RESULTS

The paratracheal LNs most frequently contained the largest MLN and among them the right recurrent laryngeal LNs were the most common site (81.8%). Patients were stratified into significant groups by all the nodal criteria. In multivariable analysis, MLN size n-stage and MLN ratio N-stage were the best independent predictors for disease-free and overall survival, respectively. In the disease-free survival, MLN ratio N-stage subcategories were divided into prognostic groups according to the n-stage. A combined nodal staging strategy combining the n-stage and N-stage had the strongest prognostic value and was used for the tumor-node-metastasis classification with distinct separation of patients into prognostic groups.

CONCLUSIONS

Results of this study indicate that the MLN size may serve as an accurate metric to classify node-positive patients and a combination of the MLN ratio and size may have synergism in classifying node-positive patients into prognostically homogenous groups.

The prognostic importance of the number of involved lymph nodes in esophageal cancer: implications for revisions of the American Joint Committee on Cancer staging system

OBJECTIVE

The American Joint Committee on Cancer (AJCC) staging system for esophageal cancer is controversial because it relies on arbitrary definitions of the anatomic location of lymph nodes to establish N and M status. It has been proposed that the number of involved lymph nodes may better predict survival. We reviewed our experience to determine the prognostic impact of the number of involved nodes and the extent of lymphadenectomy on the current staging system.

METHODS

Records of all patients who underwent resection of previously untreated adenocarcinoma and squamous cell carcinoma of the esophagus and gastroesophageal junction were reviewed. Overall survival according to the AJCC staging system and the number of involved lymph nodes was analyzed by the method of Kaplan and Meier and by recursive partitioning methods.

RESULTS

Data were available on 336 patients operated on between January 1996 and September 2003. Recursive partitioning analysis using AJCC staging variables reproduced the AJCC staging system. When the number of involved lymph nodes is added, patients with more than 4 involved lymph nodes have survival similar to that of patients with M1 disease, and patients with no involved lymph nodes have the best prognosis. Recursive partitioning analysis identified 18 lymph nodes as the minimal number required for accurate staging. In patients who have 18 or more lymph nodes removed, survival is only predicted by the presence of nodal involvement and M1 disease.

CONCLUSION

Our analysis suggests that revisions of the current AJCC staging system for esophageal cancer should include N staging based on the number of involved lymph nodes and minimal requirements for the extent of lymphadenectomy.

T2N0M0 esophageal cancer

OBJECTIVE

The study objective was to develop a treatment algorithm for cT2N0M0 esophageal cancer by determining (1) errors in clinical staging and (2) consequences of overtreatment and undertreatment of incorrectly clinically staged patients.

METHODS

Of 742 clinically staged patients, 61 (8.2%) had cT2N0M0 cancer; 45 underwent surgery alone; 8 underwent surgery and postoperative adjuvant therapy; and 8 underwent induction therapy, then surgery. As reference, 31 of 666 patients (4.7%) who underwent surgery first had pT2N0M0 cancer and a 5-year survival of 61% +/- 9.3%. Referent values were calculated from 445 clinically staged patients who underwent surgery first. Unmatched and matched survival comparisons were made using the log-rank test.

RESULTS

Only 7 of 53 cT2N0M0 cancers treated with surgery first were pT2N0M0 (13% positive predictive value). Of incorrectly staged cT2N0M0 cancers (46/53), 29 (63%) were overstaged and 17 (37%) were understaged. Most overstaged cancers were pT1 (11 [38%] T1a and 15 [52%] T1b), and most understaged cancers were pN1 (13 [76%]). Matched overstaged patients treated by surgery alone (25/28) had a 5-year survival similar to that of patients with pTNM (69% +/- 9.8% vs 63% +/- 13%, P =.8). Understaged patients did better at 5 years than patients with pTNM if they had postoperative adjuvant therapy, not surgery alone (43% +/- 22% vs 10% +/- 9.5%, P = .17). Induction therapy decreased 5-year survival compared with all other treatment strategies (13% +/- 12% vs 52% +/- 7.4%, P =.05).

CONCLUSIONS

Patients with cT2N0M0 cancers should undergo surgery first with lymphadenectomy. Clinically understaged patients should receive postoperative adjuvant therapy. In the unlikely event that patients with cT2N0M0 cancers are found to have an uncommon pT2N0M0 cancer, they will have acceptable survival with surgery alone.

Emerging aspects of oesophageal and gastro-oesophageal junction cancer histopathology - an update for the surgical oncologist

Adenocarcinoma of the oesophagus and gastro-oesophageal junction are rapidly increasing in incidence and have a well described sequence of carcinogenesis: the Barrett's metaplasia-dysplasia-adenocarcinoma sequence. During recent years there have been changes in the knowledge surrounding disease progression, cancer management and histopathology specimen reporting. Tumours around the gastro-oesophageal junction (GOJ) pose several specific challenges. Numerous difficulties arise when the existing TNM staging systems for gastric and oesophageal cancers are applied to GOJ tumours. The issues facing the current TNM staging and GOJ tumour classification systems are reviewed in this article. Recent evidence regarding the importance of several histopathologically derived prognostic factors, such as circumferential resection margin status and lymph node metastases, have implications for specimen reporting. With the rising use of multimodal treatments for oesophageal cancer it is important that the response of the tumour to this therapy is carefully documented pathologically. In addition, several controversial and novel areas such as endoscopic mucosal resection, lymph node micrometastases and the sentinel node concept are being studied. We aim to review these aspects, with special relevance to oesophageal and gastro-oesophageal cancer specimen reporting, to update the surgical oncologist with an interest in upper gastrointestinal cancer.

The effects of neoadjuvant chemoradiation on pTNM staging and its prognostic significance in esophageal cancer

For esophageal cancer, it is not clear if pathologic TNM staging after chemoradiation and resection will have the same prognostic significance compared with patients who undergo resection only. From 1995 to 2004, prospectively collected data from 279 patients with intrathoracic squamous cell cancers were analyzed. Patients were given chemoradiation either as part of a randomized trial comparing neoadjuvant chemoradiation with surgical resection alone, or because of advanced disease at presentation. One hundred seventy patients had surgical resection only (surgery), and 109 had neoadjuvant chemoradiation (CRT plus surgery). In the surgery group, pT1, 2, 3, and 4 disease was found in 15, 17, 104, and 34 patients, respectively; their respective pN1 rates were 13.3%, 29.4%, 57.7%, and 64.7%, P < 0.01. In CRT plus surgery, pT0, T1, 2, 3, and 4 were found in 48, 12, 23, 21, and 5 patients, respectively; their respective pN1 rates were 31.3%, 16.7%, 21.7%, 52.4%, and 20%, P = 0.44. Logistic regression analysis of factors predictive of pN1 showed that pT stage correlated with pN1 status (P = 0.005) in the surgery group, but not for the CRT plus surgery group. Cox regression analysis demonstrated that in the surgery group, pT, pN, and R category, and overall pTNM stage, were independent prognostic factors, whereas pN, R category, and gender were identified as relevant for CRT plus surgery. After chemoradiation, pT and overall pTNM stage groupings were not as clearly prognostic as in patients without prior therapy. Nodal status remains an important prognostic factor.

Prognostic factors in adenocarcinoma of the esophagus or gastroesophageal junction

The incidence of adenocarcinoma of the esophagus is rising rapidly in Western Europe and North America. It is an aggressive disease with early lymphatic and hematogenous dissemination. TNM cancer staging systems predict survival on the basis of the anatomic extent of the tumor. However, the adequacy of the current TNM staging system for adenocarcinoma of the esophagus or gastroesophageal junction (GEJ) is questioned repeatedly. Numerous prognostic factors have been described, but are not included in the TNM system. This review describes clinical parameters, aspects of operative technique, response to preoperative chemoradiotherapy therapy, complications and established pathologic determinants found in the resection specimen that have a prognostic impact. Furthermore, their potential application in the clinical setting in patients with adenocarcinoma of the esophagus or GEJ is discussed. Future directions to improve staging systems are given.

Influence of the number of malignant regional lymph nodes detected by endoscopic ultrasonography on survival stratification in esophageal adenocarcinoma

BACKGROUND & AIMS

The nodal staging of esophageal cancer accounts for the absence or presence of metastatic lymph nodes (N0 or N1, respectively). Surgical data suggest that patients have worse survival when esophagectomy specimens contain higher numbers of regional malignant lymph nodes. It has been proposed that the staging system for esophageal cancer be modified to include the number of malignant lymph nodes. The aim of this study was to determine the influence of the number of malignant-appearing regional lymph nodes detected on endoscopic ultrasonography (EUS) on survival in patients with esophageal adenocarcinoma.

METHODS

Historical case series involved patients with esophageal adenocarcinoma who underwent EUS staging at a single center between 1994 and 2004. Endoscopy reports were reviewed to determine the number of malignant-appearing periesophageal lymph nodes seen on EUS examination. Subjects were categorized as having 0, 1-2, or >2 periesophageal lymph nodes. A regional cancer registry prospectively obtained survival data.

RESULTS

Among 85 patients with esophageal adenocarcinoma, the Kaplan-Meier curves showed distinct survival advantages in those with fewer malignant-appearing regional lymph nodes (P=.0008). The median survivals were 66 months, 14.5 months, and 6.5 months for 0, 1-2, and >2 malignant-appearing lymph nodes, respectively. Survival was also influenced by celiac lymph nodes and tumor length, both of which were associated with increased number of malignant nodes.

CONCLUSIONS

The number of malignant-appearing periesophageal lymph nodes detected by EUS is associated with improved survival stratification in patients with esophageal adenocarcinoma and should be considered in the presurgical staging of esophageal cancer.

Extracapsular lymph node involvement in node-positive patients with adenocarcinoma of the distal esophagus or gastroesophageal junction

In adenocarcinoma of the esophagus or gastroesophageal junction, little attention has been paid to the biologic significance of extracapsular lymph node involvement (LNI). In the present study, a consecutive series of 251 patients with lymph node dissemination were reviewed. All patients underwent esophagectomy for adenocarcinoma and were prospectively followed. A total of 1562 positive lymph nodes were reexamined. Extracapsular LNI was identified in 456 lymph nodes (29%) in 166 patients (66%). Extracapsular LNI was confined to one lymph node in 63 patients (38%). The occurrence of extracapsular LNI increased significantly with the depth of invasion, presence of positive resectable truncal nodes, number of resected nodes, number of positive nodes, and lymph node ratio. The median potential follow-up period was 58 months (range, 12-143 months). In this period, 178 patients died of recurrent disease. The pattern of recurrence was comparable between patients with and without extracapsular LNI (P = 0.938). The median survival in patients with extracapsular LNI was 15 months (95% confidence interval, 12-18 months) compared with 41 months (95% confidence interval, 19-64 months) in those without extracapsular LNI (P < 0.001). Median survival of patients with 2 or more lymph nodes was 12 months (95% confidence interval, 8-15 months). Multivariate analysis demonstrated that T-stage, extracapsular LNI, and lymph node ratio were independent prognostic factors. The presence of extracapsular LNI identifies a subgroup with a significantly worse long-term survival. Together with the T-stage and the lymph node ratio, extracapsular LNI reflects a particularly aggressive biologic behavior and has significant prognostic potential.

Tumor length as a prognostic factor in esophageal malignancy: univariate and multivariate survival analyses

BACKGROUND AND OBJECTIVES

Gastrointestinal specialists generally feel that long esophageal tumors carry a worse prognosis and are likely to be more advanced than shorter lesions. Our aim was to investigate the relationship between histologically determined tumor length and aspects of tumor pathology and survival for patients with resected esophageal malignancy.

METHODS

Three hundred and nine patients who underwent esophageal resection with curative intent in our unit between 1994 and 2003 were retrospectively analyzed. Pathological details such as TNM stage, differentiation, completeness of surgical resection, and overall stage were collected. Survival data were obtained for each patient and univariate and multivariate analyses were performed. Overall survival was used as the primary endpoint.

RESULTS

There were 225 adenocarcinomas, 72 squamous cell carcinomas, and 12 other tumor types with a median tumor length of 3.5 cm (range 0.5-14 cm). Tumor length greater than 3.5 cm was associated with increasing T stage (P = 0.0001), N stage (P = 0.032), overall stage (P = 0.003), and involvement of the longitudinal resection margins (P = 0.02). Univariate analysis found tumor length greater than 3.5 cm was associated with worse overall survival compared with shorter tumors (P = 0.0002). Tumor length remained a significant prognostic factor on multivariate analysis (P = 0.04). Other prognostic factors on multivariate analysis were age, tumor differentiation, nodal involvement, and resection margin status.

CONCLUSION

Tumor length greater than 3.5 cm (as determined histologically) is associated with worse disease stage and poor overall patient survival. If preoperative endoscopic tumor length bears a similar relationship, this could assist in patient selection for appropriate treatments.

Prospective trial of radiotherapy for patients 80 years of age or older with squamous cell carcinoma of the thoracic esophagus

PURPOSE

To assess the safety and efficacy of external beam radiotherapy for elderly patients with esophageal cancer.

METHODS AND MATERIALS

A trial testing external beam radiotherapy (66 Gy within 6.5 weeks) as a single-modality treatment was performed for biopsy-proven squamous cell carcinoma of the thoracic esophagus clinically staged as Stage I and IIA (T1-T3N0M0, International Union Against Cancer, 1987) in patients aged > or =80 years.

RESULTS

From January 1999 through December 2002, 51 evaluable patients (35 men and 16 women) with a median age of 83 years (range, 80-91 years) were enrolled from 22 institutions. Of the 51 patients, 18 (35%) had Stage T1 and 33 (65%) had Stage T2-T3 disease. Radiotherapy could be completed in 47 patients (92%) within 43-58 days (median, 49). The actuarial incidence of Grade 3 or worse cardiopulmonary complications at 3 years was 26%, with 3 early deaths, and correlated significantly with the size of the anteroposterior radiotherapy portals. The median survival time and overall survival rate at 3 years was 30 months and 39% (95% confidence interval, 25-52%), respectively.

CONCLUSION

The results of high-dose radiotherapy in octogenarians are comparable to those in younger patients, but meticulous treatment planning and quality control is required.

Developing an appropriate staging system for esophageal carcinoma

BACKGROUND

Development of an optimal staging system for esophageal cancer is essential to estimate prognostic factors accurately and treat them appropriately. In this study, we evaluated the surgical outcomes of esophageal cancer according to five existing staging systems and assessed their prognostic significance.

STUDY DESIGN

For 113 patients with esophageal cancer who had undergone curative resection, lymph-node metastasis was classified using the 8th and 9th editions of the Japanese classification, the 6th edition of the Union Internationale Contre le Cancer (UICC) TNM classification, and systems based on the number (0, 1 to 3, or > or = 4) or ratio (0, < 0.15, or > or = 0.15) of metastatic lymph nodes. Survival and prognostic factors of the respective stages were evaluated.

RESULTS

Univariate analysis of disease-specific survival revealed that depth of invasion and lymph-node classification notably affected prognosis. Multivariate analysis confirmed that each classification independently influenced prognosis. According to the criteria of the two Japanese classifications, there was no clear correlation between lymph-node stage and survival. The Union Internationale Contre le Cancer/TNM classification, and those based on the number or ratio of metastatic lymph nodes showed a clear correlation between lymph-node metastasis and survival. These systems had better stratification than the Japanese classifications.

CONCLUSIONS

Staging systems for esophageal cancer based on the number or ratio of metastatic lymph nodes showed better prognostic significance than those based on the anatomic distribution of metastatic lymph nodes, because of their good stratification and clinical utility. Such classifications are suitable for use throughout the world.

Long-term results of definitive radiotherapy for stage I esophageal cancer

PURPOSE

To analyze retrospectively the long-term results of external beam radiotherapy (RT) with or without intraluminal brachytherapy (ILBT) for patients with Stage I esophageal cancer.

METHODS AND MATERIALS

A total of 34 patients with esophageal squamous cell carcinoma, clinically diagnosed as having Stage I disease, were treated with definitive RT, with or without ILBT. The median age was 69 years. Seven patients were treated with external beam RT alone (median, 64 Gy), and 27 were treated with external beam RT (median, 52 Gy) plus ILBT (8-12 Gy in two to three fractions).

RESULTS

The 5-year overall survival, local relapse-free survival, and cause-specific survival rate was 58.9%, 68.4%, and 80.0%, respectively, with a median follow-up of 61 months. Of 9 patients with local recurrence after initial therapy, 7 were successfully treated, and the 5-year cumulative rate of esophagectomy was 19.6%. The 2-year local relapse-free rate for patients with and without ILBT was 79.1% and 53.6%, respectively.

CONCLUSION

Although local recurrence was frequent within 2 years, the disease-specific survival rate was high owing to effective salvage therapy. Definitive RT is a reasonable treatment option for highly comorbid and elderly patients with Stage I esophageal cancer. The role of ILBT needs to be clarified.

Current staging of esophageal carcinoma

The rational treatment of esophageal cancer requires the complete evaluation and preoperative staging of this disease. As the incidence of esophageal cancer increases, more clinicians will face the difficult task of allocating the appropriate treatment course for these patients. Accurate esophageal cancer staging is critical if stage-dependent algorithms are used to direct appropriate therapies. Although all of the staging techniques discussed may potentially provide useful information, it is not possible to use all techniques in all patients, especially given the limited availability of resources. The optimal staging strategy has not yet been determined; the authors provide the general algorithm used in our institution. Ultimately,minimally invasive surgical approaches will allow surgeons to evaluate locoregional disease with little or no procedure-associated morbidity, much as mediastinoscopy is used in lung cancer staging. Although currently the use of molecular biologic techniques may only be investigational, it holds great promise in the future.

Tissue inhibitor of metalloproteinase-3 (TIMP-3) gene is methylated in the development of esophageal adenocarcinoma: loss of expression correlates with poor prognosis

Amongst involvement in diverse physiological and pathological processes, TIMP-3 may have an important role in tumour development, growth and metastasis by interaction with metalloproteases in the extracellular matrix. We studied the role and prognostic effect of TIMP-3 in esophageal adenocarcinoma (EADC). TIMP-3 gene methylation and TIMP-3 mRNA expression were analysed in 5 esophageal cell lines and 24 resected EADCs. TIMP-3 protein expression was examined in the 5 cell lines and 79 resected EADCs with known clinicopathological features. TIMP-3 methylation signal was only detected in the OE33 EADC cell line. In tissues, 0% of case-matched normal, 72% of BE and 90% of EADC were positive for methylation. TIMP-3 mRNA was detected in all the cell lines and normal, metaplastic and tumour tissues. TIMP-3 protein was localised to the cytoplasm in cell lines and tissues. Demethylating treatment of OE33 increased protein expression. At the invading edge of tumours, protein staining was equal to, or reduced, compared to normal tissues. Reduction of protein expression was associated with disease stage (p = 0.046) and poor patient survival (OR 2.1, 95% CI 1.2-3.5, p = 0.007). Mean survival time was halved in patients with reduced tumour TIMP-3 expression, from 49 to 24 months. These studies have demonstrated association between methylation of the TIMP-3 gene and BE and EADC. Reduced expression of TIMP-3 protein in EADC is associated with increased tumour invasiveness and reduced patient survival.

Proposed revision of the esophageal cancer staging system to accommodate pathologic response (pP) following preoperative chemoradiation (CRT)

OBJECTIVE

To determine the impact of pathologic response following preoperative chemoradiation (CRT) on the AJCC esophageal cancer staging system.

SUMMARY BACKGROUND DATA

Increasing numbers of locoregionally advanced esophageal cancer patients are treated with preoperative CRT prior to surgical resection.

METHODS

Five hundred ninety-three pts from 1985 to 2003 with esophageal cancer who underwent surgery with (n = 239) or without CRT (n = 354) were reviewed. Resected esophageal tumors were assessed for pathologic response by determining extent of residual tumor following CRT (P0, 0% residual; P1, 1%-50% residual; P2, >50% residual).

RESULTS

After CRT down-staging, pTNM specific survival was similar, irrespective of treatment group (P = 0.98). The pTNM stage distribution was more favorable in the CRT group (P < 0.001) despite a more advanced initial cTNM stage distribution (P < 0.001). Following CRT, the pathologic response (pP) at the primary tumor as defined by extent of residual tumor predicted overall survival (3 years: P0, 0% residual = 74%; P1, 1%-50% residual = 54%; P2, >50% residual = 24%, P < 0.001) and stage specific survival with greater accuracy than pTNM stage alone.

CONCLUSIONS

Our analyses demonstrate that following CRT, pTNM continues to predict survival. The extent of pathologic response following CRT is an independent risk factor for survival (pP) and should be incorporated in the pTNM esophageal cancer staging system to better predict patient outcome in esophageal cancer.

Prognosis after surgical resection of M1a/M1b esophageal squamous cell carcinoma

This study was undertaken to examine prognosis after resection for M1 disease in squamous cell esophageal carcinoma. Fifty-six patients with M1 esophageal cancer underwent esophageal resection with two or three-field nodal dissection from 1994 to 2001. Operative mortality occurred in 3 patients. Primary tumor sites were as follows; 10 upper, 23 middle, and 20 lower thoracic esophagus. They were found to have M1 disease by pathologic examination of dissected nodes, 24 M1a and 29 M1b. Forty-two patients (79%) were considered to have undergone curative resection. Chemotherapy and/or radiation therapy was given to 38 patients perioperatively. Recurrence was identified in 35 patients (66%) during a mean follow-up of 23 months. Overall median and 5-yr survivals were 19 months and 12.7%. Five-year survivals for M1a and M1b disease were 23.9% and 6.1%, respectively (p=0.0488). Curative resection tended to show better survival (p=0.3846). Chemotherapy and/or radiation therapy provided no advantage (p=0.5370). Multivariate analysis showed that M1b was significant risk factor over M1a disease. Our conclusion is that surgical resection can provide acceptable survival in thoracic squamous esophageal cancer with M1a disease. Survival differences between M1a and M1b disease support the current subclassification staging system.

Pathological determinants of survival in node-negative oesophageal cancer

Background

Many studies have analysed prognostic factors following oesophagectomy, but few have examined survival determinants in node-negative (N0) oesophageal cancer. The prognostic significance of a number of histological variables following surgical resection of N0 oesophageal cancer was studied.

Methods

The case notes of 219 patients undergoing potentially curative oesophagectomy for N0 squamous cell carcinoma or adenocarcinoma of the oesophagus were reviewed. Details of the patient's sex, age at operation, histological type, longitudinal tumour length, tumour (T) stage, circumferential resection margin involvement, tumour grade, presence of vascular invasion, perineural invasion, Barrett's metaplasia, and survival were noted. Univariate and multivariate analyses were performed to identify prognostic factors.

Results

Univariate analysis revealed three factors that correlated with poor prognosis: T stage (P = 0·024), adenocarcinoma (P = 0·033) and degree of differentiation (P = 0·001). Multivariate analysis revealed that all three were significant independent adverse prognostic indicators.

Conclusion

Surgical resection of node-negative oesophageal cancer is associated with diverse long-term outcomes. This diversity of outcome is not reflected in the tumour node metastasis (TNM)-based staging system. The utility of the TNM system in predicting prognosis after surgical resection is open to question.

The Prognostic Importance of Immunohistochemically Detected Node Metastases in Resected Esophageal Adenocarcinoma

BACKGROUND

The number or ratio of lymph node metastases detected by hematoxylin & eosin (H&E) staining is the most important predictor of survival in esophageal cancer. The survival effect of lymph node metastases detected on immunohistochemistry (IHC) is controversial. My colleagues and I hypothesized that the extent of nodal disease determined by both H&E and IHC examination would more accurately predict survival than either technique alone.

METHODS

The study population consisted of 37 patients who underwent en bloc esophagectomy as primary therapy for esophageal adenocarcinoma 5 or more years ago. All had mediastinal and upper abdominal lymphadenectomy. No patient received neoadjuvant or adjuvant therapy. Tissue blocks were sectioned for H&E staining to confirm the initial histology, and a second slide was stained with monoclonal antibodies AE1 and CAM 5.2, which are directed at a number of cytokeratin antigens. The slides were reviewed by an investigator blinded to clinical outcome. The effect of IHC staining on prognosis was assessed by comparing 5-year survival based on H&E and IHC findings.

RESULTS

A total of 1,970 nodes were examined in the 37 patients. Routine H&E staining detected metastases in 29 patients (78%); the remaining 8 with N0 disease all survived at least 5 years after operation (median not reached). In the 29 patients with N1 disease, survival was 41% at 5 years. In 20 of the 29 N1 patients, metastases were detected by H&E in less than 10% of the nodes removed; 55% of the patients survived 5 years, and 39% survived 8 years. Nine of the 29 patients had metastases detected in more than 10% of the nodes removed, and all died at a median of 17 months. IHC staining was performed on the nodes from the 8 N0 patients and the 20 patients with less than 10% nodal involvement (a total of 28 patients). Additional nodal metastases, not identified on H&E examination, were found in 51 nodes from 17 patients (60.7%). Of the 8 patients who were node negative on H&E examination, 3 had metastases detected by IHC, and all survived 5 years or more free of disease. Of the 20 patients with less than 10% nodal metastases on H&E, 14 (70%) had additional metastases detected by IHC (median, 2 nodes per patient). When combined with the results of H&E staining, the node ratio remained less than 10% in 13 patients and exceeded 10% in 7. Survival in patients whose ratio remained less than 10% was significantly better than in those whose ratio exceeded 10% (actual 5-year survival, 77% vs 14%; chi2 = 4.662; p = 0.03).

CONCLUSIONS

IHC staining techniques can identify nodal metastases missed by routine H&E examination in a large number of patients. The combination of H&E and IHC examination is useful in patients with less than 10% nodal involvement by H&E examination in that IHC detection of micrometastases allows classification into low-risk (> 75% survival) and high-risk (< 15% survival) groups. IHC-detected micrometastases are not of prognostic importance in N0 patients or those with greater than 10% nodal metastases on H&E.

Recurrent Barrett's esophagus and adenocarcinoma after esophagectomy

Background

Esophagectomy is considered the gold standard for the treatment of high-grade dysplasia in Barrett's esophagus (BE) and for noninvasive adenocarcinoma (ACA) of the distal esophagus. If all of the metaplastic epithelium is removed, the patient is considered "cured". Despite this, BE has been reported in patients who have previously undergone esophagectomy. It is often debated whether this is "new" BE or the result of an esophagectomy that did not include a sufficiently proximal margin. Our aim was to determine if BE recurred in esophagectomy patients where the entire segment of BE had been removed.

Methods

Records were searched for patients who had undergone esophagectomy for cure at our institution. Records were reviewed for surgical, endoscopic, and histopathologic findings. The patients in whom we have endoscopic follow-up are the subjects of this report.

Results

Since 1995, 45 patients have undergone esophagectomy for cure for Barrett's dysplasia or localized ACA. Thirty-six of these 45 patients underwent endoscopy after surgery including 8/45 patients (18%) with recurrent Barrett's metaplasia or neoplasia after curative resection.

Conclusion

Recurrent Barrett's esophagus or adenocarcinoma after esophagectomy was common in our patients who underwent at least one endoscopy after surgery. This appears to represent the development of metachronous disease after complete resection of esophageal disease. Half of these patients have required subsequent treatment thus far, either repeat surgery or photodynamic therapy. These results support the use of endoscopic surveillance in patients who have undergone "curative" esophagectomy for Barrett's dysplasia or localized cancer.