Better grading systems for evaluating the degree of lymph node invasion in cancer of the thoracic esophagus

A new classification of lymph node metastases according to the lymph node stations for predicting prognosis in surgical patients with esophageal squamous cell carcinoma

Lymph node metastasis (LNM) is one of the major prognostic factors for esophageal squamous cell carcinoma (ESCC). However there is no consensus regarding the prognostic significance of the location of LNM. Therefore, a novel classification was proposed to identify the lymph node (LN) stations which may be useful in predicting prognosis. A total of 260 ESCC patients were enrolled in this prospective study. The prognostic values of LNM in different lymph node (LN) stations were evaluated by random survival forests (RSF). Their prognostic significance was examined by Cox regression and receiver operating characteristic curve (ROC). The three most frequently involved LN stations were station 16 (24.49%), station 1 (22.22%) and station 2 (21.05%). Stations 1, 2, 8M, 8L and 16 were grouped as dominant LN stations (DLNS) which showed higher values in predicting overall survival (OS) and disease-free survival (DFS) than the remaining LN stations, which we define as non-dominant LN stations (N-DLNS). LNM features of DLNS (number of positive LN stations, number of positive LNs and LN ratio), but not those from N-DLNS, served as independent prognostic factors (P<0.05) whenever used alone or when combined with factors from N-DLNS. Furthermore, the area under ROC indicated that DLNS is a more accurate prediction than N-DLNS (P<0.05). This study demonstrated the value of LNM in DLNS in predicting prognosis in surgical ESCC patients, which outperformed those from N-DLNS. Therefore, the method of dominant and non-dominant classification may serve as an additional parameter to improve individualized therapeutic strategies.

New prognostic score for the survival of patients with esophageal squamous cell carcinoma

PURPOSE

Recent studies have shown that the modified Glasgow Prognostic Score (mGPS), which is an inflammation-based prognostic score, is useful as a prognostic index for some cancer cases. The purpose of this study was to create a prognostic scoring system for patients with esophageal squamous cell carcinoma (ESCC) that was more independent and sensitive than the mGPS.

METHODS

One hundred sixty-eight patients who had undergone esophagectomy for ESCC were included in the study. The new mGPS (NmGPS) was calculated based on the following cutoff values: CRP >0.75 mg/dL indicated NmGPS 1 or 2, depending on the absence or presence of hypoalbuminemia (<3.5 g/dL); and CRP ≤0.75 mg/dL indicated NmGPS 0. We also performed an analysis based on cutoff values of 0.5 and 0.25 mg/dL for CRP.

RESULTS

Only the NmGPS with a cutoff CRP value of 0.5 mg/dL was able to divide into three independent patient groups in the survival curves. In the multivariate analyses, a NmGPS (CRP cutoff; 0.5 mg/dL) of 2 was a more significant independent prognostic factor (HR 4.437, 95 % CI 2.000-9.844, p = 0.0002) than a mGPS of 2 (HR 2.726, 95 % CI 1.021-7.112, p = 0.0449).

CONCLUSIONS

The new prognostic score NmGPS (CRP cutoff; 0.5 mg/dL) was more independent and sensitive than the mGPS for patients with ESCC.

Prognostic and Clinical Evaluation of Axillary Lymph Node Metastasis in Esophageal Cancer

Axillary lymph node metastasis (ALNM) from esophageal cancer is rare. Its prognosis and effective treatments remain unknown. Between 1997 and 2005, esophagectomy was performed in 361 patients with esophageal cancer in our hospital. ALNM was identified in four patients (1.1%). All patients had left ALNM with ipsilateral left supraclavicular lymph node metastasis. In two patients ALNM developed after radical esophagectomy with regional lymphadenectomy and in the other two patients after chemoradiotherapy of primary lesions. Axillary lymphadenectomy with chemoradiotherapy was given to all patients. Median survival time and disease-free survival (DFS) after initial treatment for primary esophageal cancer were 30.5 months and 11.5 months, respectively. One patient, who had a small number of regional lymph node metastases (two lymph nodes) at esophagectomy and prolonged DFS (22 months) until axillary node recurrence, is still alive, 67 months after axillary lymphadenectomy. The other three patients, who had larger numbers of regional lymph node metastases (average, 8.3) and shorter DFS (average, 9.7 months), died of recurrence an average of 13.3 months after axillary lymphadenectomy. In conclusion, although ALNM is considered a type of distant organ metastasis, if it is a solitary recurrence, good survival may be obtained after appropriate loco-regional therapy. The number of metastatic regional lymph nodes at initial esophagectomy and the duration of DFS until axillary node recurrence can help to guide the decision whether aggressive treatments are warranted.

The prognostic significance of lymph node size in patients with squamous esophageal cancer

BACKGROUND

The prognosis of patients with esophageal cancer remains dismal, and their care poses a great challenge of customizing therapeutic strategies for individual patients. Lymph node staging is still less than ideal in esophageal cancer patients. Therefore, we investigated a new approach to lymph node analysis.

METHODS

One hundred eighty-seven patients curatively resected for squamous cell cancer of the esophagus were studied. The long diameter of the largest metastatic lymph node (MLN) was measured on a histopathologic slide and was considered as the MLN size.

RESULTS

Patient survival decreased with each millimeter increment in MLN size. By using MLN size as the lymph node classification criterion, patients with MLN <10 mm had both a significantly better overall and cancer-specific survival than those with MLN >or=10 mm. Patients with fewer than four MLNs were separated into prognostic groups according to the MLN size. Among the several prognostic factors, MLN size remained the strongest independent predictor of survival by multivariate analysis. This nodal analysis allowed stratification of patients into four stages with distinctly different survivals.

CONCLUSIONS

This approach supplements traditional nodal staging strategies and therefore has potential for guiding the development of treatment strategies in this carcinoma.

Significance of immunohistochemical nodal micrometastasis as a prognostic indicator in potentially curable oesophageal carcinoma

Background

The number of positive lymph nodes is an important prognostic predictor in patients with oesophageal cancer. However, the significance of nodal micrometastasis in patients with overt nodal metastasis is unknown. The aim of this study was to clarify the clinical implications of nodal micrometastasis in patients undergoing curative oesophagectomy for oesophageal cancer.

Methods

Cervical, mediastinal and abdominal lymph nodes systematically removed from 104 patients with oesophageal cancer were examined immunohistochemically to detect cells that stained positively for cytokeratins with the monoclonal antibody cocktail AE1/AE3. The postoperative course and survival rates were compared among patients with and without micrometastases, after numerical classification of overt metastatic nodes (none, between one and four, five or more).

Results

Univariate analysis showed T stage, nodal micrometastasis and number of overt nodal metastases to be significant prognostic factors after oesophagectomy. Multivariate analysis revealed nodal micrometastasis and number of overt nodal metastases to be independent prognostic factors. The presence of micrometastases had a significant adverse effect on postoperative survival in patients with no overt metastasis and in patients with one to four overt metastatic nodes, but no such impact in patients with five or more overt metastatic nodes.

Conclusion

Assessment of nodal status by both histological examination for overt metastases and immunohistochemical examination for micrometastases is useful in stratifying patients undergoing curative oesophagectomy.

The pattern of metastatic lymph node dissemination from adenocarcinoma of the esophagogastric junction

BACKGROUND

The incidence of adenocarcinoma of the esophagogastric junction is rapidly increasing, and the extent of lymphadenectomy for such tumors remains controversial. The aim of this study was to identify the pattern of dissemination by examination of all lymph nodes retrieved from resected tumors of the esophagogastric junction.

METHODS

The endoscopic and pathologic reports of patients who underwent RO resection for adenocarcinoma of the esophagogastric junction between January 1996 and November 1999 were examined. Patients with type 1 tumors (distal esophagus) underwent subtotal esophagectomy with 2-field lymphadenectomy. Patients with type 2 (gastric cardia) tumors underwent transhiatal D2 total gastro-esophagectomy. Lymph node groups were dissected from the main specimens and examined separately.

RESULTS

One hundred and four type 1 and 48 type 2 tumors were studied. Median nodal recovery was 23 lymph nodes (type 1, 22 lymph nodes; type 2, 23 lymph nodes). Seventy-eight percent of the type 1 tumors with nodal metastases had dissemination in both the abdomen and mediastinum. The common abdominal sites were the paracardiac and the left gastric stations. Within the mediastinum, paraesophageal, paraaortic and tracheobronchial metastases were more often encountered. Type 2 tumors had positive lymph nodes most frequently in the left and right paracardiac, lesser curve (N1 group), and left gastric (N2 group) territories. Nodal status correlated with increasing depth of tumor invasion (P =.002).

CONCLUSIONS

The pattern of nodal dissemination for cardia tumors concurs with that described by other studies. The current definition of nodal fields in the abdomen and mediastinum for esophageal tumors relates to experience with squamous carcinomas. Our results demonstrate a different pattern of dissemination for junctional esophageal adenocarcinomas. The nodal stations to be resected in radical lymphadenectomies for such tumors should be redefined.

A comparison of staging systems for localized extremity soft tissue sarcoma

BACKGROUND

Staging systems for soft tissue sarcoma (STS) are important to identify patients with similar systemic risk who might benefit from specific treatments. This study compared four commonly used staging systems for predicting systemic outcomes of patients with localized extremity STS, as proposed by the fourth and fifth editions of the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) staging system, the Memorial Sloan-Kettering Cancer Center (MSK) system, and the Surgical Staging System (SSS) of the Musculoskeletal Tumor Society.

METHODS

Three hundred consecutive adult patients with newly diagnosed nonmetastatic STS of the lower extremity were treated at Memorial Sloan-Kettering Cancer Center between 1982 and 1989. Metastasis free survival was the end point of the study. The prognostic value of the four staging systems and their components were examined in univariate and multivariate analyses. The Akaike information criterion (AIC) was used to identify the system that best predicted the risk of systemic recurrence.

RESULTS

Compartment status, depth, grade, and size were all independent predictors of outcome within their respective staging systems. However, when compared with one another, only depth, grade, and size retained their prognostic significance. Of the four models, the AIC predicted that the MSK was the best predictor of systemic relapse, followed by the fifth edition of the AJCC/UICC staging system.

CONCLUSIONS

Staging systems such as the MSK system or the fifth edition of the AJCC/UICC system, which include tumor depth, grade, and size as prognostic factors, are the most predictive of systemic relapse in patients presenting with localized extremity STS. Both of these systems identify the same group of patients at the highest risk who would be the most suitable for adjuvant chemotherapy trials.

Prognostic factors of oesophageal squamous cell carcinoma from the perspective of molecular biology

Recent developments in molecular biology have revealed that several oncogenes, suppressor genes and adhesion molecules are involved in the development of oesophageal cancer; however, the role of these genes is still unknown. To evaluate which molecular biological factors are related to patients' prognosis and recurrence, we checked p53, p16, p21/Waf1, cyclin D1, Ki-67, epidermal growth factor receptor (EGFR), vascular endothelial growth factor (VEGF), Mdm2, Bcl2, E-cadherin and MRP1/CD9 by means of immunohistochemical analysis in 116 cases of oesophageal cancer (R0). We also checked the regrowth capability of the primary cultures of the resected tumours and the effect of post-operative treatment. Although univariate analysis revealed that pN (pTNM), pT (pTNM), sex, cyclin D1, Ki-67, VEGF, E-cadherin and cell regrowth capability were prognostic factors, multivariate analysis revealed that pN (risk ratio (RR) 3.17), sex (RR 8.13), cell regrowth capability (RR 3.03) and E-cadherin (RR 0.30) were prognostic factors. Interestingly, step-wise analysis revealed that the following five factors were prognostic factors: pN (RR 5.74), sex (RR 3.14), cyclin D1 (RR 2.29), E-cadherin (RR 0.26) and cell regrowth capability (RR 1.94). Logistic regression analysis revealed that the risk factors of haematogenous recurrence were pN (odds ratio (OR) 8.97), cyclin D1 (OR 4.52) and EGFR (OR 0.18). On the other hand, the risk factor of lymph node recurrence was pN (OR 5.16). With regard to the effect of postoperative treatment, post-operative radiotherapy was a favourable risk factor (RR 0.43) and reduced the haematogenous recurrence (OR 0.18). Our data indicate that combination analysis using pN, sex, cyclin D1, E-cadherin, EGFR and cell regrowth capability may be useful for the prediction of patient survival and recurrence.

Genetic alterations in patients with esophageal cancer with short- and long-term survival rates after curative esophagectomy

OBJECTIVE

The objective of this study was to ascertain the exact relation between specific oncogenes and long- and short-term survival rates in patients with esophageal cancer.

SUMMARY BACKGROUND DATA

Recent developments in molecular biology have shown that several oncogenes and suppressor genes are involved in the development of esophageal cancer. However, the role of these genes still is unknown.

METHODS

The clinical outcome of 84 cases of R0-resected esophageal carcinomas (from 1986-1993) and the molecular and biologic characteristics of these tumors were studied. The patients studied were divided into three groups, which were designated as follows: shortest term survivors (up to 6 months), short-term survivors (7-12 months), and long-term survivors (>5 years). These groups included 23, 17, and 44 subjects, respectively. For the genomic analysis, CyclinD1, int-2, murine double minute 2 (MDM2), retinoblastoma, p53, adenomatous polyposis coli (APC), deleted in colorectal carcinoma (DCC), and human papillomavirus were studied in these patients. The regrowth capability of primary cultures and the clinicopathologic characteristics of these patients also were analyzed.

RESULTS

The CyclinD1 and int-2 genes, which are located in the 11q13 chromosome, and the MDM2 gene were related to short survival. However, the p53 mutation and human papillomavirus infection were not related to short-term survival. The average ratio of genomic abnormalities to genes examined was higher in the shortest and short-term survival groups than in the long-term survival group. Regrowth capability in primary cultures also was related to short-term survival. Among the long-term survival patients, 7 (16%) of 44 cases suffered further cancer after esophagectomy.

CONCLUSIONS

These results suggest that the 11q13 amplicon and MDM2 may play an important role in the progression of esophageal cancer, and an accumulation of genomic abnormalities may result in poor prognosis. Careful follow-up testing for double cancer is needed in long-term survivors of esophageal cancer.

Evaluating the rational extent of dissection in radical esophagectomy for invasive carcinoma of the thoracic esophagus

To define the rational extent of dissection in radical esophagectomy for esophageal cancer, survival was studied according to nodal status in 154 patients undergoing extended radical esophagectomy. The incidence of cervical metastasis in patients with upper or middle esophageal tumors did not differ between those with favorable (grade N < or = 4) or unfavorable (grade N > or = 5) lymph node status, at 28.6% vs 20%, respectively. On the other hand, in patients with lower esophageal tumors, the incidence of cervical metastasis was significantly lower in those with favorable grade (grade N < or = 4) node status than in those with unfavorable grade (grade N > or = 5) node status, at 6.5% vs 46.7%, respectively. Survival did not differ in patients with upper or middle esophageal tumors according to whether they had regional (n = 42) or distant (n = 15) lymph node metastases, the 5-year survival rates being 11.6% vs 25%, respectively. However, in patients with lower esophageal tumors, none of 10 patients with distant node metastases survived for more than 4 years, whereas the survival rate was 43.7% at 5 years for 36 patients with regional node metastases. These results show that cervical lymphadenectomy should only be performed as part of radical esophagectomy in those patients with upper or middle esophageal cancer.