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

Achieving adequate lymph node dissection in treating esophageal squamous cell carcinomas by radical lymphadenectomy: Beyond the scope of numbers of harvested lymph nodes

Previous studies have recommended harvesting a large number of lymph nodes (LNs) to improve the survival of patients with esophageal squamous cell carcinoma (ESCC). These studies or clinical guidelines focus on the total harvested LNs during lymphadenectomy; however, the extent of LN dissection (LND) required in patients with ESCCs remains controversial. The present study proposed a novel individualized adequate LND (ALND) strategy to compliment current guidelines to improve individualized therapeutic efficacy. For N0 cases, ALND was defined as an LN harvest of >55% of the LNs from nodal zones adjacent to the tumor location; and for N⁺ cases, ALND was defined as 8, 8, 8, 8 or 16 LNs dissected from the involved cervical, upper, middle, lower and celiac zones, respectively. Retrospective analysis of the ESCC cohort revealed that the ALND was associated with improved patient survival [hazard ratio (HR)=0.45 and 95% CI=0.30–0.66)]. Stratified analyses revealed that the protective role of ALND was prominent, with the exception of higher pN⁺ staged (pN2-3) cases (HR=0.52, 95% CI=0.23–1.18). Furthermore, ALND was associated with improved survival in local diseases (T1-3/N0-1; HR=0.50, 95% CI=0.30–0.84) and locally advanced diseases (T4/Nany or T1-3/N2-3; HR=0.32, 95% CI=0.15–0.68). These findings suggested that the proposed ALND strategy may effectively improve the survival of patients with ESCC.

Determining the optimal number of lymph nodes harvested during esophagectomy

BACKGROUND

We examined the impact of the number of lymph nodes (LNs) removed during esophagectomy on outcomes in esophageal cancer (EC).

METHODS

From a comprehensive EC database we identified patients who underwent curative resection from 1994 to 2011. The impact of total LNs retrieved on disease-free survival (DFS) and overall survival (OS) was investigated.

RESULTS

In total, 635 patients were identified. Patients were divided on the basis of total number of LNs removed (<8, 9-12, 13-20, and >20). The 5-year OS and DFS rates for the group by LN category were (43%, 42%, 55%, and 36%, P=0.1836) and (44%, 37%, 46%, and 36%, P=0.5166), respectively. Total number of LNs assessed did not correlate with reduced risk of recurrence or improved survival. On multivariate analysis controlling for age, sex, histology, neoadjuvant therapy, only removal of 13-20 LN's correlated to improved oncologic outcomes.

CONCLUSIONS

In a tertiary cancer center, we demonstrated that only removal of 13-20 LNs during esophagectomy correlated to improved survival. While the importance of standardized pathologic examination and adequate nodal staging is of utmost importance for patients with EC undergoing esophagectomy the optimum number of LNs removed clearly warrants further investigation.

Prognostic value of different lymph node staging methods in esophageal squamous cell carcinoma after esophagectomy

BACKGROUND

This study aimed to investigate the prognostic value of number of involved lymph nodes, number of removed lymph nodes, ratio of involved to removed nodes (lymph node ratio), and number of negative lymph nodes in esophageal squamous cell carcinoma (ESCC) patients after esophagectomy.

METHODS

A retrospective review of 603 patients receiving esophagectomy for ESCC was made. Cox regression analysis was performed to identify significant prognostic factors.

RESULTS

The median follow-up time was 36.7 months, and the 5-year overall survival (OS) was 43.5%. Patients with negative lymph node count ≥ 14 had better survival (p < 0.001). Univariate Cox analysis showed that the number of involved lymph nodes, number of removed lymph nodes, lymph node ratio, and number of negative lymph nodes influenced OS (p < 0.05 for all). Multivariate Cox analysis indicated that the number of involved lymph nodes and number of negative lymph nodes were independent prognostic factors for OS, and a higher number of negative lymph nodes was associated with lower mortality. The number of removed lymph nodes and lymph node ratio had no significant effect on OS. The number of negative lymph nodes had prognostic value in different lymph node stages and in two-field or three-field lymphadenectomy.

CONCLUSIONS

For ESCC patients after esophagectomy, the number of involved lymph nodes and the number of negative lymph nodes had a better prognostic value than did the number of removed lymph nodes and lymph node ratio.

Recurrence risk model for esophageal cancer after radical surgery

OBJECTIVE

The aim of the present study was to construct a risk assessment model which was tested by disease-free survival (DFS) of esophageal cancer after radical surgery.

METHODS

A total of 164 consecutive esophageal cancer patients who had undergone radical surgery between January 2005 and December 2006 were retrospectively analyzed. The cutpoint of value at risk (VaR) was inferred by stem-and-leaf plot, as well as by independent-samples t-test for recurrence-free time, further confirmed by crosstab chi-square test, univariate analysis and Cox regression analysis for DFS.

RESULTS

The cutpoint of VaR was 0.3 on the basis of our model. The rate of recurrence was 30.3% (30/99) and 52.3% (34/65) in VaR <0.3 and VaR ≥0.3 (chi-square test, (χ) (2) =7.984, P=0.005), respectively. The 1-, 3-, and 5-year DFS of esophageal cancer after radical surgery was 70.4%, 48.7%, and 45.3%, respectively in VaR ≥0.3, whereas 91.5%, 75.8%, and 67.3%, respectively in VaR <0.3 (Log-rank test, (χ) (2) =9.59, P=0.0020), and further confirmed by Cox regression analysis [hazard ratio =2.10, 95% confidence interval (CI): 1.2649-3.4751; P=0.0041].

CONCLUSIONS

The model could be applied for integrated assessment of recurrence risk after radical surgery for esophageal cancer.

Adjuvant radiation therapy and lymphadenectomy in esophageal cancer: a SEER database analysis

OBJECTIVES

This study seeks to determine the effects of postoperative radiation therapy and lymphadenectomy on survival in esophageal cancer.

METHODS

An analysis of patients with surgically resected esophageal cancer from the SEER database between 2004 and 2008 was performed to determine association of adjuvant radiation and lymph node dissection on survival. Survival curves were calculated according to the Kaplan-Meier method and log-rank analysis. Multivariate analysis (MVA) was performed by the Cox proportional hazard model.

RESULTS

We identified 2109 patients who met inclusion criteria. Radiation was associated with increased survival in stage III patients (p = 0.005), no benefit in stage II (p = 0.075) and IV (p = 0.913) patients, and decreased survival in stage I patients (p < 0.0001). Univariate analysis revealed that radiation therapy was associated with a survival benefit node positive (N1) patients while it was associated with a detriment in survival for node negative (N0) patients. Removing >12 and >15 lymph nodes was associated with increased survival in N0 patients, while removing >8, >10, >12, >15, and >20 lymph nodes was associated with a survival benefit in N1 patients. MVA revealed that age, gender, tumor and nodal stage, tumor location, and number of lymph nodes removed were prognostic for survival in N0 patients. In N1 patients, MVA showed the age, tumor stage, number of lymph nodes removed, and radiation were prognostic for survival.

CONCLUSION

The number of lymph nodes removed in esophageal cancer is associated with increased survival. The benefit of adjuvant radiation therapy on survival in esophageal cancer is limited to N1 patients.

Body mass index and perioperative complications after oesophagectomy for adenocarcinoma: a systematic database review

OBJECTIVE

Given the increasing rate of obesity, the effects of excessive body weight on surgical outcomes constitute a relevant quality of care concern. Our aim was to determine the relationship between preoperative body mass index (BMI) on perioperative complications after oesophagectomy for adenocarcinoma of the oesophagus.

DESIGN

Retrospective database review.

SETTING

Single institution high volume oncological tertiary care referral centre.

PARTICIPANTS

From our comprehensive oesophageal cancer database consisting of 709 patients, we stratified patients according to BMI: 155 normal-weight (BMI 20-24), 198 overweight (BMI 25-29) and 187 obese (BMI ≥30) patients.

INTERVENTIONS

All patients underwent oesophagectomy for cancer.

PRIMARY AND SECONDARY OUTCOME MEASURES

Incidences of preoperative risk factors and perioperative complications in each group were analysed.

RESULTS

The patient cohort consisted of 474 men and 66 women with a mean age of 64.3 years (28-86). They were similar in terms of demographics and comorbidities, with the exception of a younger age (65.2 vs 65.4 vs 62.5 years, p=0.0094), and a higher incidence of diabetes (9.1% vs 13.2% vs 22.7%, p=0.001), hiatal hernia (16.8% vs 17.8% vs 28.8%, p=0.009) and Barrett oesophagus (24.7% vs 25.4% vs 36.2%, p=0.025) for obese patients. The type of surgery performed, overall blood loss, extent of lymphadenectomy, R0 resections and complications were not influenced by BMI on univariate and multivariate analysis.

CONCLUSIONS

In our experience, patients with an elevated BMI and oesophageal adenocarcinoma do not experience an increase in morbidity and mortality after oesophagectomy as stated in previous reports, when performed at a high volume centre. Additionally, BMI did not affect the quality of oncological resection as determined by number of harvested lymph-nodes and rates of R0 resections.

TRIAL REGISTRATION

MCC 15030, IRB 105286.

Significant variation of resected meso-esophageal tissue volume in two-stage subtotal esophagectomy specimens: a retrospective morphometric study

BACKGROUND

Differences in the extent and quality of surgical resection for esophageal cancer may influence the pathological staging and patient outcome. There are no data in the literature qualitatively and/or quantitatively characterizing esophagectomy specimens.

METHODS

Macroscopic images of 161 esophagectomy specimens were analyzed retrospectively. The extent of resection was qualitatively classified as "muscularis propria," "intra-meso-esophageal," or "meso-esophageal." The volume of meso-esophageal tissue was quantified morphometrically. The number of muscle defects per specimen was counted. Results were related to clinicopathological variables, including survival.

RESULTS

Sixty-two (39%) specimens were classified as "muscularis propria," 65 (40%) as "intra-meso-esophageal," and 34 (21%) as "meso-esophageal." The morphometrically measured meso-esophageal tissue volume was different between the three types (P < 0.001). The specimen type was related to the total number of lymph nodes (P = 0.02), number of metastatic lymph nodes (P = 0.024), and depth of tumor invasion (P = 0.013), but not related to extramural tumor volume, circumferential resection margin status, or the surgeon performing the resection. The number of muscle defects per specimen was similar in all resection types. The resection specimen classification was related to survival in patients treated by surgery alone (P = 0.027).

CONCLUSIONS

This is the first study to quantify and classify the volume of tissue resected during esophagectomy. Our study shows significant variation of the resected tissue volume impacting pathological tumor staging. This variation was not associated with individual surgeon performance. A prospective, multicenter study is needed to validate our results and to investigate the potential biological mechanisms influencing the resectable volume of meso-esophageal tissue in cancer patients.