Sentinel node mapping in adenocarcinoma of the esophagogastric junction

Lymphatic flow mapping using near-infrared fluorescence imaging with indocyanine green helps to predict lymph node metastasis intraoperatively in patients with esophageal or esophagogastric junction cancer not treated with neoadjuvant chemotherapy

BACKGROUND

Lymphatic flow mapping using near-infrared fluorescence (NIR) imaging with indocyanine green (ICG) has been used for the intraoperative prediction of lymph node metastasis in esophageal or esophagogastric junction cancer. However, a consistent method that yields sufficient diagnostic quality is yet to be confirmed. This study explored the diagnostic utility of our newly established lymphatic flow mapping protocol for predicting lymph node metastasis in patients with esophageal or esophagogastric junction cancer.

METHODS

We injected 0.5 mL of ICG (500 μg/mL) into the submucosal layer at four peritumoral points on the day before surgery for 54 patients. We performed lymphatic flow mapping intraoperatively using NIR imaging. After determining the NIR status and presence of metastases, evaluable lymph node stations on in vivo imaging and all resected lymph nodes were divided into four categories: ICG+meta+ (true positive), ICG+meta- (false positive), ICG-meta+ (false negative), and ICG-meta- (true negative).

RESULTS

The distribution of ICG+ and meta+ lymph node stations differed according to the primary tumor site. Sensitivity and specificity for predicting meta+ lymph nodes among ICG+ ones were 50% (95% CI 41-59%) and 75% (73-76%), respectively. Predicting meta+ lymph node stations among ICG+ stations improved these values to 66% (54-77%) and 77% (74-79%), respectively. Undergoing neoadjuvant chemotherapy was an independent risk factor for having meta+ lymph nodes with false-negative diagnoses (odds ratio 4.82; 95% CI 1.28-18.19). The sensitivity of our technique for predicting meta+ lymph nodes and meta+ lymph node stations in patients who did not undergo neoadjuvant chemotherapy was 79% (63-90%) and 83% (61-94%), respectively.

CONCLUSION

Our protocol potentially helps to predict lymph node metastasis intraoperatively in patients with esophageal or esophagogastric junction cancer undergoing esophagectomy who did not undergo neoadjuvant chemotherapy.

Minimum number of necessary lymph nodes for the accurate staging of adenocarcinoma of esophagogastric junction

OBJECTIVE

This study aims to explore the minimum number of lymph nodes (LNs) necessary for assessing the postoperative staging of adenocarcinoma of esophagogastric junction (AEG).

METHODS

We extracted the data of patients from the Surveillance Epidemiology and End Results (SEER) database, who were pathologically diagnosed with AEG between 2000 and 2017. We explored the associations between the number of LNs and overall survival (OS) by univariate and multivariate analyses and determined the proper cutoff value of the number of LNs necessary for accurate postoperative staging.

RESULTS

Of the patients with AEG in the SEER database, 2668 met our inclusion criteria. The total number of regional LNs dissected was found to be significantly associated with survival in analyses stratified by T stage. Univariate and multivariate regression showed that age, grade, positive LNs, number of LNs examined, and T stage were independently associated with OS. For patients with T1-2 tumors, the 5-year survival rate was 58.7%, and patients with more than 11 LNs examined obtained a greater survival benefit. Among patients with T3-4 tumors, the 5-year survival rates were 28.9% and 39.7% for those with 1-16 LNs examined and for those with more than 17 LNs examined, respectively.

CONCLUSION

To accurately determine the pathological stage of patients with AEG, no less than 11 LNs must be resected for patients with stage T1-2 disease, and no less than 16 LNs must be resected for patients with stage T3-4 disease.

The Value of Paratracheal Lymphadenectomy in Esophagectomy for Adenocarcinoma of the Esophagus or Gastroesophageal Junction: A Systematic Review of the Literature

Background

The role of upper mediastinal lymphadenectomy for distal esophageal or gastroesophageal junction (GEJ) adenocarcinomas remains a matter of debate. This systematic review aims to provide a comprehensive overview of evidence on the incidence of nodal metastases in the upper mediastinum following transthoracic esophagectomy for distal esophageal or GEJ adenocarcinoma.

Methods

A literature search was performed using Medline, Embase and Cochrane databases up to November 2020 to include studies on patients who underwent transthoracic esophagectomy with upper mediastinal lymphadenectomy for distal esophageal and/or GEJ adenocarcinoma. The primary endpoint was the incidence of metastatic nodes in the upper mediastinum based on pathological examination. Secondary endpoints were the definition of upper mediastinal lymphadenectomy, recurrent laryngeal nerve (RLN) palsy rate and survival.

Results

A total of 17 studies were included and the sample sizes ranged from 10-634 patients. Overall, the median incidence of upper mediastinal lymph node metastases was 10.0% (IQR 4.7-16.7). The incidences of upper mediastinal lymph node metastases were 8.3% in the 7 studies that included patients undergoing primary resection (IQR 2.0-16.6), 4,4% in the 1 study that provided neoadjuvant therapy to the full cohort, and 10.6% in the 9 studies that included patients undergoing esophagectomy either with or without neoadjuvant therapy (IQR 8.9-15.8%). Data on survival and RLN palsy rates were scarce and inconclusive.

Conclusions

The incidence of upper mediastinal lymph node metastases in distal esophageal adenocarcinoma is up to 10%. Morbidity should be weighed against potential impact on survival.

Performance of Indocyanine-Green Imaging for Sentinel Lymph Node Mapping and Lymph Node Metastasis in Esophageal Cancer: Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Lymphatic mapping with indocyanine-green (ICG) and near-infrared light fluorescent imaging is widely used for sentinel lymph node staging in different types of cancer but is not fully accepted for all procedures because studies have reported heterogeneous results. This study aimed to assess the detection rate (DR) of ICG imaging for sentinel lymph node mapping (SLNM) and lymph node metastases (LNMs) in esophageal cancer.

METHODS

A systematic search was performed to identify relevant studies examining the use of ICG imaging for SLNM in patients with esophageal cancer. Extracted results were pooled in a single-proportion meta-analysis, with a random-effects model, presented as forest plots.

RESULTS

Six studies were included in the analysis. The ICG DR for SLNM was 89% [95% confidence interval (CI) 71%-96%]. The pooled sensitivity and specificity values for the detection of LNMs were 84% (95% CI 64%-94%) and 15% (95% CI 3%-45%), respectively. A trend towards a lower DR was found with increasing mean latency time between ICG injection and SLNM.

CONCLUSIONS

ICG imaging is a technique that potentially could improve lymph node yield excision and, as a consequence, improve the detection of lymph node metastases.

Current status and challenges in sentinel node navigation surgery for early gastric cancer

As an optimal surgical procedure to accurately evaluate lymph node (LN) metastasis during surgery with minimal surgical resection, we have been developing sentinel node (SN) biopsy for early gastric cancer since the 1990s. Twelve institutions from the Japanese Society of Sentinel Node Navigation Surgery (SNNS), including Keio University Hospital, conducted a multicenter prospective trial to validate the SN concept using the dual-tracer method with blue dye and a radioisotope. According to the results, 397 patients were included in the final analysis, and the overall accuracy in detecting LN metastasis using SN biopsy was 99% (383 of 387). Based on the validation study, we are targeting cT1N0 with a primary tumor of ≤4 cm in diameter as an indication for SN biopsy for gastric cancer. We are currently running a multicenter nonrandomized phase III trial to assess the safety and efficacy of SN navigation surgery. The Korean group has reported the result of a multicenter randomized phase III trial. Since meticulous gastric cancer in the remnant stomach was rescued by subsequent gastrectomy, the disease-specific survival was comparable between the two techniques, implying that SN navigation surgery can be an alternative to standard gastrectomy. With the development of SN biopsy procedure and treatment modalities, the application of SN biopsy will be expanded to achieve an individualized minimally invasive surgery.

Evolution of Esophagectomy for Cancer Over 30 Years: Changes in Presentation, Management and Outcomes

Background

Esophageal cancer has seen a considerable change in management and outcomes over the last 30 years. Historically, the overall prognosis has been regarded as poor; however, the use of multimodal treatment and the integration of enhanced recovery pathways have improved short- and long-term outcomes.

Objective

The aim of this study was to evaluate the changing trends in presentation, management, and outcomes for patients undergoing surgical treatment for esophageal cancer over 30 years from a single-center, high-volume unit in the UK.

Patients and Methods

Data from consecutive patients undergoing esophagectomy for cancer (adenocarcinoma or squamous cell carcinoma) between 1989 and 2018 from a single-center, high-volume unit were reviewed. Presentation method, management strategies, and outcomes were evaluated. Patients were grouped into successive 5-year cohorts for comparison and evaluation of changing trends.

Results

Between 1989 and 2018, 1486 patients underwent esophagectomy for cancer. Median age was 65 years (interquartile range [IQR] 59–71) and 1105 (75%) patients were male. Adenocarcinoma constituted 1105 (75%) patients, and overall median survival was 29 months (IQR 15–68). Patient presentation changed, with epigastric discomfort now the most common presentation (70%). An improvement in mortality from 5 to 2% (p < 0.001) was seen over the time period, and overall survival improved from 22 to 56 months (p < 0.001); however, morbidity increased from 54 to 68% (p = 0.004).

Conclusions

Long-term outcomes have significantly improved over the 30-year study period. In addition, mortality and length of stay have improved despite an increase in complications. The reasons for this are multifactorial and include the use of perioperative chemo(radio)therapy, the introduction of an enhanced recovery pathway, and improved patient selection.

High-risk group of upper and middle mediastinal lymph node metastasis in patients with esophagogastric junction carcinoma

AIM

The aim of the present study was to clarify esophagogastric junction (EGJ) carcinoma patients who are at high risk of upper and middle mediastinal lymph node (MLN) metastasis.

METHODS

This was a retrospective study and included 110 consecutive patients with EGJ carcinoma who underwent R0/R1 resection at Keio University Hospital between January 2000 and December 2013.

RESULTS

Of the 110 patients, 18 (16.3%) had MLN metastasis, and the number increased to 23 (20.9%) when recurrence cases were added (adenocarcinoma, N = 11; squamous cell carcinoma, N = 12). Patients whose tumor epicenter was located above the EGJ had a significantly higher incidence of MLN metastasis/recurrence (18/51 [35.3%]) than those whose tumor epicenter was located below the EGJ (5/59 [8.5%]). The MLN metastasis/recurrence rate was particularly high when the distance from the EGJ to the proximal edge of the primary tumor was >3 cm for the upper and middle mediastinum (18.8%). Patients in a selected group (≥T2 and tumor epicenter located above the EGJ or below the EGJ with ≥3 cm esophageal invasion) showed 17.9% and 15.4% upper and middle MLN metastasis/recurrence rates, respectively. Therapeutic value of MLN dissection was relatively high (#105 + 106: 8.9, #110: 12.2).

CONCLUSIONS

Therapeutic value of MLN dissection to treat EGJ carcinomas was relatively high in patients with MLN metastasis. Our algorithm could select patients at high risk for MLN metastasis.

Low risk of lymph node metastasis in 495 early gastric cardiac carcinomas: a multicenter clinicopathologic study of 2101 radical gastrectomies for early gastric carcinoma

Clinical decision-making on endoscopic vs. surgical resection of early gastric cardiac carcinoma remains challenging because of uncertainty on risk of lymph node metastasis. The aim of this multicenter study was to investigate risk factors of lymph node metastasis in early gastric cardiac carcinoma. Guided with the World Health Organization diagnostic criteria, we studied 2101 radical resections of early gastric carcinoma for risk factors associated with lymph node metastasis, including tumor location, gross pattern, size, histology type, differentiation, invasion depth, lymphovascular, and perineural invasion. We found that the risk of lymph node metastasis was significantly lower in early gastric cardiac carcinomas (6.7%, 33/495), compared with early gastric non-cardiac carcinomas (17.1%, 275/1606) (p < 0.0001). In early gastric cardiac carcinoma, no lymph node metastasis was identified in intramucosal carcinoma (0/193) and uncommon types of carcinomas (0/24), irrespective of the gross pattern, size, histologic type, differentiation, and invasion depth. Ulceration, size > 3 cm, and submucosal invasion were not significant independent risk factors for lymph node metastasis. In 33 early gastric cardiac carcinomas with lymph node metastasis, either lymphovascular invasion or poor differentiation was present in 16 (48.5%) cases and together in six cases. By multivariate analysis, independent risk factors of lymph node metastasis in early gastric cardiac carcinoma included lymphovascular invasion (Odds Ratio (OR): 7.6, 95% Confidence Interval (CI): 2.8-20.2) (p < 0.0001) and poor differentiation (OR: 6.0, 95% CI: 1.4-25.9) (p < 0.05). In conclusion, lymph node metastasis was not identified in early gastric cardiac intramucosal carcinoma and uncommon types of carcinoma. The risk of lymph node metastasis was also significantly lower in tumors with submucosal invasion, especially for cases without lymphovascular invasion or poor differentiation. These results lend support to the role of endoscopic therapy in the treatment of patients with early gastric cardiac carcinoma.

Update on the indications and results of sentinel node mapping in upper GI cancer

The clinical utilization of sentinel node (SN) mapping for early esophageal cancer or gastric cancer has been unclear for a long time. However, previous investigations regarding SN mapping of these cancers have shown relatively good results with regard to the detection rate and diagnostic accuracy for determining the lymph node status. SN mapping helps obtain information about individual metastatic status and allows the modification of the operation in early-stage upper gastrointestinal (GI) disease. Radio-guided methods for identifying SNs in early esophageal cancer have been established via endoscopic injection of technetium-99m tin colloid. Previous studies have reported that the SN concept seems valid, and radio-guided SN mapping can be feasible in cT1N0 esophageal cancer. SN navigation surgery are believed to have potential as strategies for minimally invasive modified surgery for early esophageal cancer. A Japanese study group conducted a prospective multicenter trial of SN mapping for early gastric cancer using a dual tracer method with radioactive colloid and blue dyes; they demonstrated a high detection rate and accuracy for determining the metastatic status based on SN mapping. Subsequently, minimized gastrectomy, including partial gastrectomy and segmental gastrectomy with individualized selective and modified lymphadenectomy for early gastric cancer with a negative SN has been performed to evaluate the long-term survival and postoperative quality of life (QOL) in a multicenter prospective trial. This study verified the SN concept in early-stage upper GI disease with cN0 and found that function-preserving esophagectomy or gastrectomy may help maintain patients' post-surgical QOL.

Clinical significance of esophageal invasion length for the prediction of mediastinal lymph node metastasis in Siewert type II adenocarcinoma: A retrospective single-institution study

AIM

This study investigated whether esophageal invasion length (EIL) of a tumor from the esophagogastric junction could be a possible indicator of mediastinal lymph node metastasis and survival in patients with Siewert type II adenocarcinoma.

METHODS

One hundred and sixty-eight patients with Siewert type II tumor who underwent surgery were enrolled. Metastatic stations and recurrent lymph node sites were classified into cervical, upper/middle/lower mediastinal, and abdominal zones. EIL was correlated with overall metastasis or recurrence in individual zones and with survival.

RESULTS

Siewert type II patients with an EIL of more than 25 mm (>25 mm EIL group) had a higher incidence of overall metastasis or recurrence in the upper and middle mediastinal zones than those with an EIL of less than or equal to 25 mm (≤25 mm EIL group) (P = .001 and P < .001). Disease-free and overall survival in the >25 mm EIL group were significantly lower than those of the ≤25 mm EIL group (P < .001). None of the Siewert type II patients with metastasis or recurrence in the upper and middle mediastinal zones survived for more than 5 years. Only an EIL of more than 25 mm was a significant preoperative predictor of overall metastasis or recurrence in the upper and middle mediastinal zones (odds ratio, 8.85; 95% CI, 2.31-33.3; P = .001).

CONCLUSION

A multimodal-therapeutic strategy should be investigated in Siewert type II patients once the tumor has invaded more than 25 mm to the esophageal wall.

Short-Term Dynamic Observation of the Color Change and Enhancement Effect of Polyethylenimine-Entrapped Gold Nanoparticles Used for Indirect Lymphography

AIMS

To dynamically observe the color change and enhancement effect of gadolinium-loaded polyethylenimine-entrapped gold nanoparticles (Gd-Au PENPs) as a dual-mode CT/MRI contrast agent for sentinel lymph node (SLN) identification.

METHODS

In 6 rabbits, Gd-Au PENPs were injected into the right side tongue submucosa, after which the color change of cervical draining lymph nodes was observed. Then the draining lymph nodes were examined by CT/MRI scan. Another 6 rabbits were randomly divided into a CT lymphography (CT-LG) and a MRI lymphography (MRI-LG) group and examined by CT/MRI scan 1 and 30 min after injection. Then SLNs were identified under the guidance of CT/MRI-LG.

RESULTS

The ipsilateral afferent lymphatic vessels, cervical draining lymph nodes and efferent lymphatic vessels were stained black orderly and constantly after Gd-Au PENPs injection. Thirty minutes after injection, all cervical lymph nodes were excised to be examined by CT/MRI scan, and only the black-stained draining lymph nodes were enhanced. The 6 rabbits with CT/MRI-LG showed clear enhancement of SLNs. With indirect lymphography, the black-stained SLNs were easily visualized at autopsy. In all rabbits, the identification rate of lingual SLNs was 100%.

CONCLUSIONS

Rabbit lingual SLNs could be identified with indirect lymphography using Gd-Au PENPs as a dual-mode contrast agent.

Clinical comparison of antrum-preserving double tract reconstruction vs roux-en-Y reconstruction after gastrectomy for Siewert types II and III adenocarcinoma of the esophagogastric junction

AIM: To explore a reasonable method of digestive tract reconstruction, namely, antrum-preserving double-tract reconstruction (ADTR), for patients with adenocarcinoma of the esophagogastric junction (AEG) and to assess its efficacy and safety in terms of long-term survival, complications, morbidity and mortality.

METHODS: A total of 55 cases were retrospectively collected, including 18 cases undergoing ADTR and 37 cases of Roux-en-Y reconstruction (RY) for AEG (Siewert types II and III) at North Sichuan Medical College. The cases were divided into two groups. The clinicopathological characteristics, perioperative outcomes, postoperative complications, morbidity and overall survival (OS) were compared for the two different reconstruction methods.

RESULTS: Basic characteristics including sex, age, body mass index (BMI), Siewert type, pT status, pN stage, and lymph node metastasis were similar in the two groups. No significant differences were found between the two groups in terms of perioperative outcomes (including the length of postoperative hospital stay, operating time, and intraoperative blood loss) and postoperative complications (consisting of anastomosis-related complications, wound infection, respiratory infection, pleural effusion, lymphorrhagia, and cholelithiasis). For the ADTR group, perioperative recovery indexes such as time to first flatus (P = 0.002) and time to resuming a liquid diet (P = 0.001) were faster than those for the RY group. Moreover, the incidence of reflux esophagitis was significantly decreased compared with the RY group (P = 0.048). The postoperative morbidity and mortality rates for overall postoperative complications and the rates of tumor recurrence and metastasis were not significantly different between the two groups. Survival curves plotted using the Kaplan-Meier method and compared by log-rank test demonstrated similar outcomes for the ADTR and RY groups. Multivariate analysis of significantly different factors that presented as covariates on Cox regression analysis to assess the survival and recurrence among AEG patients showed that age, gender, BMI, pleural effusion, time to resuming a liquid diet, lymphorrhagia and tumor-node-metastasis stage were important prognostic factors for OS of AEG patients, whereas the selection of surgical method between ADTR and RY was shown to be a similar prognostic factor for OS of AEG patients.

CONCLUSION: ADTR by jejunal interposition presents similar rates of tumor recurrence, metastasis and long-term survival compared with classical reconstruction with RY esophagojejunostomy; however, it offers considerably improved near-term quality of life, especially in terms of early recovery and decreased reflux esophagitis. Thus, ADTR is recommended as a worthwhile digestive tract reconstruction method for Siewert types II and III AEG.

Lymph node metastasis and lymphadenectomy of resectable adenocarcinoma of the esophagogastric junction

Based on Siewert classification, adenocarcinomas of the esophagogastric junction (AEGs) have different behaviors of perigastric-mediastinal nodal metastasis. Siewert type I AEGs have higher incidence of mediastinal nodal metastasis than those of type II or III, especially at middle-upper mediastinum. With regard to the necessity of mediastinal lymphadenectomy, theoretically, transthoracic esophagogastrectomy with complete mediastinal lymphadenectomy is suggested for Siewert type I AEGs, while transhiatal total gastrectomy with lower mediastinal and D2 perigastric lymphadenectomy is a standard surgery for type II-III AEGs. Nevertheless, the mediastinal nodal metastasis is an independent factor of poor prognosis for any type of AEG.