Predictors of long-term survival after resection of esophageal carcinoma with nonregional nodal metastases

Surgical and multimodal treatment of metastatic oesophageal cancer: retrospective cohort study

BACKGROUND

In contrast to the well-established multimodal therapy for localized oesophageal cancer, the metastatic stage is commonly treated only with systemic therapy as current international guidelines recommend. However, evidence suggesting that multimodal therapy including surgery could benefit selected patients with metastasized oesophageal cancer is increasing. The aim of this study was to investigate the survival of patients diagnosed with metastatic oesophageal cancer after different treatment regimens.

METHODS

This was a retrospective single-centre study of patients with adenocarcinoma or squamous cell carcinoma of the oesophagus with synchronous or metachronous metastases who underwent Ivor Lewis oesophagectomy between 2010 and 2021. Each patient received an individual treatment for their metastatic burden based on an interdisciplinary tumour board conference. Survival differences between different treatments were assessed using the Kaplan-Meier method, as well as univariable and multivariable Cox regression models.

RESULTS

Out of 1791 patients undergoing Ivor Lewis oesophagectomy, 235 patients diagnosed with metastases were included. Of all of the included patients, 42 (17.9%) only underwent surgical resection of their metastatic disease, 37 (15.7%) underwent multimodal therapy including surgery, 78 (33.2%) received chemotherapy alone, 49 (20.9%) received other therapies, and 29 (12.3%) received best supportive care. Patients who underwent resection or multimodal therapy including surgery of their metastatic burden showed superior overall survival compared with chemotherapy alone (median overall survival of 19.0, 18.0, and 11.0 months respectively) (P < 0.001). This was confirmed in subcohorts of patients with metachronous solid-organ metastases and with a single metastasis. In multivariable analyses, resection with or without multimodal therapy was an independent factor for favourable survival.

CONCLUSION

Surgical resection could be a feasible treatment option for metastasized oesophageal cancer, improving survival in selected patients. Further prospective randomized studies are needed to confirm these findings and define reliable selection criteria.

Neoadjuvant chemoradiotherapy followed by oesophagectomy may be the optimal treatment option for lower thoracic oesophageal cancer with supraclavicular lymph node metastasis: An inverse probability of treatment-weighted analysis of SEER database

INTRODUCTION

Whether supraclavicular lymph node (SCLN) metastasis in patients with oesophageal cancer belongs to regional disease is controversial, leading to heterogeneity in clinical treatment decisions. This study aimed to determine the optimal treatment for lower thoracic oesophageal cancer (LTOC) with SCLN metastasis.

METHODS

Patients with LTOC registered in the Surveillance, Epidemiology, and End Results database during 2010-2015 were identified. Selected patients were grouped according to disease spread as those with locoregional disease, with SCLN metastasis or with distant metastasis, as well as according to treatment modality (neoadjuvant chemoradiotherapy followed by surgery (nCRT+S group), upfront surgery ± adjuvant therapy (upfront S group) and definitive chemoradiotherapy (dCRT group)). The Cox regression analysis and inverse probability of treatment weighting (IPTW) were used to identify the optimal treatment modality for different groups.

RESULTS

Of 11,767 LTOC patients identified from the database, the 5-year overall survival (OS) rates for patients with the locoregional disease (n = 7,541), SCLN metastasis (n = 120) and distant metastasis (n = 4,106) were 28.3%, 10.0% and 3.0%, respectively (P < 0.001). Among patients with SCLN metastasis, median OS in the nCRT+S, upfront S and dCRT groups were 25, 14 and 8 months, respectively (P < 0.001). After IPTW, the nCRT+S group was still associated with better median OS compared with other groups. The multivariate analysis identified treatment modality as an independent prognostic factor for OS.

CONCLUSIONS

Neoadjuvant chemoradiotherapy followed by oesophagectomy may be the optimal treatment modality for LTOC with SCLN metastasis. The findings of this study need to be validated in large prospective studies.

Preoperative Clinical Characteristics Predict Recurrent Laryngeal Nerve Lymph Node Metastasis and Overall Survival in Esophageal Squamous Cell Carcinoma: A Retrospective Study With External Validation

Background

Recurrent laryngeal nerve (RLN) lymph node metastasis (LNM) is not rare in patients with esophageal squamous cell carcinoma (ESCC). We aimed to develop and externally validate a preoperative nomogram using clinical characteristics to predict RLN LNM in patients with ESCC and evaluate its prognostic value.

Methods

A total of 430 patients with ESCC who underwent esophagectomy with lymphadenectomy of RLN LNs at two centers between May 2015 and June 2019 were reviewed and divided into training (center 1, n = 283) and external validation cohorts (center 2, n = 147). Independent risk factors for RLN LNM were determined by multivariate logistic regression, and a nomogram was developed. The performance of the nomogram was assessed in terms of discrimination, calibration, clinical usefulness, and prognostic value. The nomogram was internally validated by the bootstrap method and externally validated by the external validation cohort.

Results

Multivariate analysis indicated that clinical T stage (P <0.001), endoscopic tumor length (P = 0.003), bioptic tumor differentiation (P = 0.004), and preoperative carcinoembryonic antigen level (P = 0.001) were significantly associated with RLN LNM. The nomogram had good discrimination with the area under the curve of 0.770 and 0.832 after internal and external validations. The calibration curves and decision curve analysis confirmed the good calibration and clinical usefulness of this model. High-risk of RLN LNM predicted by the nomogram was associated with worse overall survival in the external validation cohort (P <0.001).

Conclusion

A nomogram developed by preoperative clinical characteristics demonstrated a good performance to predict RLN LNM and prognosis for patients with ESCC.

A Study of Hormonal Receptors in Esophageal Carcinoma: Northeast Indian Tertiary Cancer Center Study

Background  Esophageal cancers, both squamous cell and adenocarcinoma, have poor outcomes with high morbidity and mortality. Our hospital-based registry for the year 2017 to 2018 showed that esophageal cancer constituted 22.7% of annual caseload. Most of our patients present in advanced stages. The aim of this article was to study the role of hormonal receptors in patients with esophageal cancer. Methods  This is a single-institution, prospective, observational study in patients with esophageal carcinoma. Hormonal receptors (estrogen receptor [ER]-α and progesterone receptors) were studied in tumor tissue. Of 160 patients, receptor status was analyzed in 133 patients. Chi-square test was used for the correlation of categorical variables. The value of p < 0.05 was considered as statistically significant. Results  A total of 133 patients was taken into the study of which 96 were males and 37 were females. The mean age of patients was 52 years. Carcinoma esophagus was predominantly seen in males. Estrogen and progesterone receptors were positive in 9.02 and 4.51% of the study population, respectively. Patients with hormonal receptor positivity presented with poor functional status, higher grades of dysphagia, higher stage, and most of the tumors were poorly differentiated with statistically significant p -values. Conclusion  Despite recent advances in various fields of oncology, outcomes of esophageal carcinoma have not improved significantly. Hence, a study of new pathways of pathogenesis in carcinogenesis of esophageal carcinoma is essential. Few recent evidences including our study shows that the hormonal milieu is responsible in the pathogenesis of carcinoma esophagus. The utilization of this data and future study of the role of hormonal therapy might lead to improved outcomes in patients with carcinoma esophagus.

Development of a prediction model for the risk of recurrent laryngeal nerve lymph node metastasis in thoracolaparoscopic esophagectomy with cervical anastomosis

Background

There are no effective preoperative diagnostic measures to predict the probability of left and right recurrent laryngeal nerve (RLN) lymph node (LN) metastasis using preoperative clinical data in patients undergoing thoracolaparoscopic esophagectomy with cervical anastomosis.

Methods

We retrospectively reviewed the clinical data of 1,660 consecutive patients with thoracic esophageal cancer who underwent esophagectomy with cervical anastomosis at the Department of Thoracic Surgery at the First Affiliated Hospital of Zhengzhou University between January 2015 and December 2020.

Results

A total of 299 and 343 patients who underwent left (Cohort 1) and right (Cohort 2) RLN LN dissection were included in the final analyses. The analyses were conducted within each cohort. Among the 299 patients in Cohort 1, left RLN LN involvement was found in 41 patients (13.7%). A multivariable analysis showed that age, tumor location, and short axis were significantly associated with RLN LN metastasis (all P<0.05). Among the 343 patients in Cohort 2, right RLN LN involvement was found in 65 patients (19.0%). A multivariable analysis showed that computed tomography (CT) appearance, tumor location, long axis, and short axis were significantly associated with RLN LN metastasis (all P<0.05). Based on the results of the multivariable analyses, we constructed nomograms that could estimate the probability of RLN LN metastasis. Finally, we stratified the 2 cohorts into risk subgroups using a recursive partitioning analysis (RPA). The risk of left and right RLN LN metastasis was found to be 9.3% and 7.5%, 27.3% and 21.4%, and 52.4% and 47.3% for the low-risk, intermediate-risk, and high-risk groups, respectively.

Conclusions

Our nomograms and RPAs appear to be suitable for the risk stratification of left and right RLN LN metastasis in patients undergoing thoracolaparoscopic esophagectomy with cervical anastomosis. This tool could be used to help clinicians to select more effective locoregional treatments, such as surgical protocols and radiation area selection.

Meta-analysis of prognostic factors of overall survival in patients undergoing oesophagectomy for oesophageal cancer

INTRODUCTION

Currently, the American Joint Commission on Cancer (AJCC) staging system is used for prognostication for oesophageal cancer. However, several prognostically important factors have been reported but not incorporated. This meta-analysis aimed to characterize the impact of preoperative, operative, and oncological factors on the prognosis of patients undergoing curative resection for oesophageal cancer.

METHODS

This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling to determine pooled univariable hazard ratios (HRs). The study was prospectively registered with the PROSPERO database (Registration: CRD42018157966).

RESULTS

One-hundred and seventy-one articles including 73,629 patients were assessed quantitatively. Of the 122 factors associated with survival, 39 were significant on pooled analysis. Of these. the strongly associated prognostic factors were 'pathological' T stage (HR: 2.07, CI95%: 1.77-2.43, P < 0.001), 'pathological' N stage (HR: 2.24, CI95%: 1.95-2.59, P < 0.001), perineural invasion (HR: 1.54, CI95%: 1.36-1.74, P < 0.001), circumferential resection margin (HR: 2.17, CI95%: 1.82-2.59, P < 0.001), poor tumor grade (HR: 1.53, CI95%: 1.34-1.74, P < 0.001), and high neutrophil:lymphocyte ratio (HR: 1.47, CI95%: 1.30-1.66, P < 0.001).

CONCLUSION

Several tumor biological variables not included in the AJCC 8th edition classification can impact on overall survival. Incorporation and validation of these factors into prognostic models and next edition of the AJCC system will enable personalized approach to prognostication and treatment.

The Role of Definitive Radiation and Surgery in Metastatic Esophageal Cancer: An NCDB Investigation

BACKGROUND

Approximately 40% of patients with esophageal cancer present with metastatic disease. Survival with palliative treatment is poor, and the benefit of aggressive focal therapies is unclear. This study aimed to identify a subset of patients with metastatic esophageal cancer with favorable outcomes after curative doses of radiation therapy, esophagectomy, or both.

METHODS

Between 2004 and 2015, the study investigators found 28,101 patients with metastatic esophageal cancer in the National Cancer Database and identified those who underwent chemotherapy and definitive radiation therapy with or without surgery over the study period. The study compared the estimated median overall survival (OS) of all patients with metastatic esophageal cancer with the estimated median OS of patients with metastatic esophageal cancer who underwent radiation therapy with or without surgery. Multivariable analysis was used to examine clinical and pathologic factors associated with OS.

RESULTS

At a median follow-up of 11.1 months, 3219 patients with a median age of 64 years and a radiation dose of 50.4 Gy were identified. Only 202 (6.2%) patients undergoing definitive-dose radiation therapy underwent esophagectomy, with a median age of 60 years. The median OS durations for all patients, for patients treated with radiation, and for patients treated with radiation therapy in combination with esophagectomy were 6.6, 11.5, and 30.2 months, respectively. Among patients undergoing surgery, median OS after surgery was 23.7 months. Patients with lung, liver, or bone metastases were less likely to undergo esophagectomy. On multivariable analysis, esophagectomy and low tumor grade were associated with higher OS, whereas liver and bone metastases at diagnosis were associated with worse OS.

CONCLUSIONS

This analysis suggests that select subsets of patients with primarily nonvisceral, nonosseous metastatic esophageal cancer have favorable survival and may potentially benefit from aggressive local therapies.

Should the clinical significance of supraclavicular and celiac lymph node metastasis in thoracic esophageal cancer be reevaluated?

Background

Lower thoracic esophageal cancer (LTEC) with celiac node metastasis and upper thoracic esophageal cancer (UTEC) with supraclavicular node metastasis were previously categorized as M1a diseases. Our study aimed to investigate whether the clinical significance of supraclavicular and celiac lymph node metastasis should be reevaluated in thoracic esophageal cancer.

Methods

A total of 6178 patients with thoracic esophageal cancer were identified from the Surveillance, Epidemiology, and End Results (SEER) database during 2004–2015. Treatment strategies and outcomes (OS, overall survival; CSS, cancer‐specific survival) of patients with different nodal status were reviewed. The Cox proportional hazards regression model was applied to evaluate the prognostic factors. Statistical analyses were performed in all subgroups.

Results

Multivariate analysis identified supraclavicular node metastasis but not celiac node metastasis as an independent predictor of both OS and CSS in LTEC. However, metastasis to supraclavicular or celiac nodes was not an independent predictor of OS and CSS in UTEC. Surgery was not associated with increased OS and CSS for UTEC with celiac or supraclavicular node metastasis but was favored as a predictor of better OS and CSS for LTEC with celiac or supraclavicular node metastasis. Radiotherapy benefited OS and CSS in LTEC involving celiac or supraclavicular nodes and in UTEC involving celiac nodes, while only OS benefited from radiotherapy in UTEC involving supraclavicular nodes.

Conclusions

These results provide preliminary evidence that the clinical significance of supraclavicular and celiac lymph node metastasis should be reevaluated in thoracic esophageal cancer with different prognostic information according to the primary sites.

The Predictive Value of Pretreatment Neutrophil-To-Lymphocyte Ratio in Esophageal Squamous Cell Carcinoma

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) has been reported to be both a prognostic biomarker for cancer and associated with inflammation, but its predictive role in tumor immunity is not clear. The present study examined the correlations of the NLR and immune suppression with the prognoses in patients with esophageal squamous cell carcinoma (ESCC).

METHODS

We performed a retrospective review of 1168 patients who were newly diagnosed with stage T1N(+) and T2-T4 ESCC at our hospital. The NLR of each ESCC patient prior to treatment was calculated, and the associations of the NLR with various clinicopathological parameters and prognoses were then examined. In addition, correlations of the proportion of myeloid-derived suppressor cells (MDSCs) and level of interleukin (IL)-6 with the NLR were assessed in 242 ESCC patients.

RESULTS

An elevated NLR was significantly correlated with advanced-stage disease and reduced overall survival (OS) of ESCC patients. Furthermore, the levels of IL-6 in tumors and MDSCs in the peripheral circulation were significantly correlated with the prognoses of ESCC, and the NLR was positively correlated with MDSC levels in the circulation and IL-6 staining intensity in tumor specimens. Moreover, a high NLR was significantly associated with reduced OS in the 926 patients treated with concomitant chemoradiotherapy, but not in the 242 patients who underwent surgical intervention.

CONCLUSION

The NLR may represent a clinically useful biomarker to guide ESCC treatment decisions. Patients with a higher NLR may be an optimal subgroup for IL-6- and MDSC-targeted therapy.

The clinical impact of supraclavicular lymph node metastasis in patients with locally advanced esophageal squamous cell carcinoma receiving curative concurrent chemoradiotherapy

Background

To evaluate the clinical significance of supraclavicular lymph node (SCLN) in patients with locally advanced esophageal squamous cell carcinoma (ESCC) receiving curative concurrent chemoradiotherapy (CCRT).

Materials and methods

We retrospectively analyzed all 369 locally advanced ESCC patients treated with CCRT between 2000 and 2015, including 70 patients with SCLN metastasis and 299 patients without SCLN metastasis.

Results

For these locally advanced ESCC patients treated with curative CCRT, N0-2 were significantly associated with superior progression-free survival (PFS) and overall survival (OS) in univariate and multivariable analyses. However, there were no significant differences in PFS and OS between the SCLN metastasis and non-SCLN metastasis groups; a subgroup analysis also revealed there was no significant differences in PFS and OS between patients with and without SCLN metastasis either in the N0-2 or in the N3 subgroup analysis.

Conclusions

Our study suggests that SCLN metastasis is not a prognostic factor in locally advanced ESCC patients receiving curative CCRT, and that SCLNs should be considered to be regional LNs and treated with curative intent.

Lymph node metastases near the celiac trunk should be considered separately from other nodal metastases in patients with cancer of the esophagus or gastroesophageal junction after neoadjuvant treatment and surgery

Background

The aim of the present study is to identify the incidence and prognostic significance of lymph node metastases near the celiac trunk in patients who underwent neoadjuvant chemo(radio)therapy followed by esophagectomy.

Methods

Between March 1994 and September 2013 a total of 462 consecutive patients with cancer of the esophagus or gastroesophageal junction (GEJ) who underwent potentially curative esophageal resection after neoadjuvant chemotherapy (N=88; 19.0%) or neoadjuvant chemoradiotherapy (CRT) (N=374; 81.0%) were included.

Results

Seventy one (15.4%) patients had truncal node metastases in the resection specimen. Metastases to these nodes occurred more frequently in male patients with adenocarcinoma and in tumors at the gastro-esophageal junction. A lower response to neoadjuvant treatment, higher ypT and ypN stages and a poorer grade of differentiation were significantly related with truncal node metastases. Patients with tumor positive truncal nodes had a worse median overall survival (17 vs. 55 months). In multivariate analysis, truncal node metastases were independently associated with a worse survival. Only 22 (31.0%) of the 71 patients with tumor positive truncal nodes were identified preoperatively with EUS or CT. In contrast, 37 patients had suspicious truncal nodes on EUS or CT, but metastases in the pathology specimen were absent.

Conclusions

In the present study, it is demonstrated that positive truncal nodes in the resection specimen after neoadjuvant therapy, are associated with advanced tumor stages and are an independent factor for inferior survival.

Variables Associated to Pathologic Complete Response, Overall Survival and Disease-Free Survival in the Neoadjuvant Setting for Esophageal Cancer: A Retrospective Cohort Analysis

Objective:

The aim of the study was to evaluate prognostic factors during neoadjuvant therapy that can predict pathologic complete response (pCR), overall survival (OS), or disease-free survival (DFS).

Summary of background data:

Variables that can predict tumor response to neoadjuvant therapy are required for esophageal cancer management.

Methods:

A retrospective cohort was performed with esophageal cancer patients submitted to neoadjuvant therapy. pCR, OS, and DFS were evaluated. Logistic regression was used to evaluate prognostic factors. This study covered 140 patients, 94 squamous cell carcinomas (SCC), and 44 adenocarcinomas. SCC is more often associated with pCR (compared to adenocarcinoma, OR: 8.07, 95% CI: 2.91–22.38); it has higher probability of DFS (HR for death or recurrence was 0.6, 95% CI: 0.37–0.98); and a higher probability of OS (HR for death was 0.59, 95% CI: 0.35–1). Gender, age, grade of cellular differentiation, chemotherapy regimen, and neoplasm circumferential involvement before neoadjuvant therapy are variables that are unrelated to DFS. Relief of dysphagia, and weight gain were also unrelated to the outcomes. In the multivariate analysis, the weight loss during neoadjuvant therapy was related to higher risk for recurrence or death (HR 1.02, 95% CI: 1–1.04). SCC histologic type was associated with higher probability of pCR, and higher OS and DFS rates. Gender, grade of cellular differentiation, and chemotherapy regimen are variables that are unrelated to pCR, OS, and DFS. Relief of dysphagia and increased levels of albumin after neoadjuvant therapy were also unrelated to the studied outcomes. Weight loss during neoadjuvant chemotherapy was associated with poor DFS rate in the multivariate analysis.

Pattern of lymph node metastases of squamous cell esophageal cancer based on the anatomical lymphatic drainage system: efficacy of lymph node dissection according to tumor location

Knowing the anatomical lymphatic drainage of the esophagus is crucial to understanding the dissemination pattern of esophageal tumor. During the embryonal growth, the middle and lower part of the esophagus stretches as the lymphatic networks develop in the submucosal layer. The abundant submucosal lymphatics drain in a longitudinal fashion directly to their proximal and distal ends. The lymphatic route from the proximal esophagus through recurrent nerve nodes to supraclavicular nodes are a component of the mesentery of the proximal esophagus. The lower esophagus mostly drains its lymph into paracardial nodes related to celiac nodes through the mesentery of the distal esophagus. Lymphatic routes to mid and lower paraesophageal nodes usually originate from the intermuscular area of the muscularis propria. The lymphatic communication between the submucosa and intermuscular area is limited. The anatomical concept was confirmed clinically by a large series of single institution and the nationwide registry in Japan. The clinical data for the incidence of involved nodes verified the anatomical observations that long longitudinal extension of lymphatic drainage in the submucosa connected to the upper mediastinum lymphatics and paracardial lymphatics. The extent of dissection should be not tailored according to the anatomical distance from the tumor but according to the incidences of metastasis of each area, those were differed by tumor location. The areas for node dissection should be modified according to the tumor location. Although in patients with tumor limited to within the submucosal layer, even with tumors located in the mid- and lower esophagus, lymphatic metastasis was frequent in the upper mediastinum and perigastric area via the abundant submucosal lymphatics in a longitudinal fashion. When tumor invades or penetrates the muscle layer, the incidence of paraesophageal lymph node metastasis in the middle and lower mediastinum increases.

Solute Carrier Family 39 Member 6 Gene Promotes Aggressiveness of Esophageal Carcinoma Cells by Increasing Intracellular Levels of Zinc, Activating Phosphatidylinositol 3-Kinase Signaling, and Up-regulating Genes That Regulate Metastasis

BACKGROUND & AIMS

A common variant in the solute carrier family 39 member 6 gene (SLC39A6) has been associated with survival times of patients with esophageal squamous cell carcinoma (ESCC). We investigated the function of SLC39A6 and ways in which this variant affects tumor progression by studying ESCC samples and cell lines.

METHODS

SLC39A6 was expressed or knocked down by expression of short hairpin RNAs in ESCC cells (KYSE30 and KYSE450) and HeLa cells using lentiviral vectors; we analyzed effects on proliferation, colony formation, migration, and invasion in vitro. Cells were grown as xenograft tumors in nude mice and tumor volume and metastases were quantified; tumors were collected and analyzed histologically. Cells were also analyzed for levels of intracellular zinc and messenger RNA (mRNA) expression patterns. We obtained ESCC and adjacent normal esophageal tissues from 94 patients who underwent esophagectomy in China from 2010 through 2014. Survival times of patients were measured from the date of diagnosis to the date of last follow-up or death. We sequenced mRNAs and compared levels between tumor and non-tumor tissues using the Wilcox rank-sum test. Total proteins in cell lines or tissue samples were measured by immunoblotting. We searched publicly available databases for variants of SLC39A6 in human tumor and non-tumor tissues.

RESULTS

Knockdown of SLC39A6 reduced proliferation of ESCC cells in culture and metastasis of xenograft tumors in mice. Cells that overexpressed SLC39A6 had significant increases in intracellular levels of zinc and were more invasive in assays, activating phosphatidylinositol 3-kinase signaling to AKT serine/threonine kinase 1 and mitogen-activated protein kinase 1. Cells that overexpressed SLC39A6 had increased expression of mRNAs and proteins associated with metastasis, such as matrix metalloproteinase (MMP) 1, MMP3, MYC, and snail family transcriptional repressor 2 (SNAI2 or SLUG). Levels of MMP1, MMP3, MYC, and SLUG mRNAs correlated with levels of SLC39A6 mRNA in ESCC samples from patients. ESCC tissues had increased levels of SLC39A6 mRNA compared with non-tumor tissues; the increase correlated with tumor metastasis to lymph node and reduced patient survival time.

CONCLUSIONS

In an analysis of ESCC samples and cell lines, we associated increased expression of SLC39A6 with tumor invasiveness, intracellular level of zinc, and patient survival time. ESCC cell lines that overexpress SLC39A6 up-regulate expression MMP1, MMP3, MYC, and SLUG and form metastatic xenograft tumors in mice. Up-regulation of SLC39A6 might be used to determine prognoses of patients with ESCC or as a therapeutic target.

The prognostic role of coeliac node metastasis after resection for distal oesophageal cancer

It is uncertain whether coeliac node metastasis precludes long-term survival in distal oesophageal cancer. This nationwide population-based cohort study included patients who underwent surgical resection for stage III or IV distal oesophageal cancer in 1987-2010 with follow-up until 2014. A minority (17.0%) had neoadjuvant therapy. The prognosis in patients with coeliac node metastasis was compared with patients with no such metastasis and patients with more distant metastasis. Multivariable Cox proportional-hazards regression models provided hazard ratios (HRs) with 95% confidence intervals (CIs) of disease-specific and overall mortality. Among 446 patients, 346 (77.6%) had no coeliac node metastasis, 56 (12.6%) had coeliac node metastasis, and 44 (9.9%) had more distant metastasis. Compared to coeliac node negative patients, coeliac node positive patients were at a 52% increased risk of disease-specific mortality (HR = 1.52, 95% CI 1.10-2.10), while patients with more distant metastasis had a 27% statistically non-significant increase (HR = 1.27, 95% CI 0.88-1.83). Patients with distant metastasis had no increase in disease-specific mortality compared to those with coeliac node metastasis (HR 0.71, 95% CI 0.40-1.27). Thus, patients with distal oesophageal cancer with coeliac node metastasis seem to have a similarly poor survival as patients with more distant metastasis, and thus may not benefit from surgery.

Supraclavicular and/or celiac lymph node metastases from thoracic esophageal squamous cell carcinoma did not compromise survival following neoadjuvant chemoradiotherapy and surgery

This study is to evaluate the prognostic significance of supraclavicular and/or celiac lymph node (LN) metastases in locally advanced thoracic esophageal squamous cell carcinoma (ESCC) patients treated with neoadjuvant chemoradiotherapy (NACRT) and surgery. Among the total 199 patients, 75 (37.7%) had supraclavicular and/or celiac LN metastasis. Surgery was performed following NACRT in 168 patients (84.4%). After the median 18.7 (1.0-147.2) months’ follow-up, 2-year rates of progression-free survival (PFS) and overall survival (OS) in all patients were 48.1% and 65.7%, respectively. In multivariate analyses, negative surgical margin (p < 0.001), ypT0 stage (p = 0.004), and ypN0 stage (p = 0.020) were significantly favorable factors for PFS, and negative surgical margin (p < 0.001) was the only significantly favorable factor for OS. Metastasis to the supraclavicular and/or celiac LNs was significant factor neither for PFS (p = 0.311) nor OS (p = 0.515). Supraclavicular and/or celiac LN metastasis did not compromise the clinical outcomes following NACRT and surgery.

Neoadjuvant vs. adjuvant treatment of Siewert type II gastroesophageal junction cancer: an analysis of data from the surveillance, epidemiology, and end results (SEER) registry

BACKGROUND

Cancer of the gastroesophageal junction (GEJ) has been rising in incidence in recent years. The role of radiation therapy (RT) in the treatment of GEJ cancer remains unclear, as the largest prospective trials advocating for either adjuvant or neoadjuvant chemoradiotherapy (CRT) combine GEJ cancer with either gastric or esophageal cancer. The aim of the present study is to examine the association of neoadjuvant versus adjuvant treatment with overall and disease-specific survival (DSS) for patients with surgically resected cancer of the true GEJ (Siewert type II).

METHODS

The surveillance, epidemiology, and end results (SEER) registry database (2001-2011) was queried for cases of surgically resected Siewert type II GEJ cancer. A total of 1,497 patients with resectable GEJ cancer were identified, with 746 receiving adjuvant RT and 751 receiving neoadjuvant RT. Retrospective analysis was performed with the endpoints of overall and DSS.

RESULTS

Using cox regression and controlling for independent covariates (age, sex, race, stage, grade, histology, and year of diagnosis), we showed that adjuvant RT was associated with a significantly lower death risk [hazard ratio (HR), 0.84; 95% confidence interval 0.73-0.97; P value=0.0168] and significantly lower disease-specific death risk (HR, 0.84; 95% confidence interval, 0.72-0.97; P value=0.0211) as compared to neoadjuvant RT.

CONCLUSIONS

This analysis of SEER data showed that adjuvant RT was associated with a survival benefit as compared to neoadjuvant RT for the treatment of Siewert type II GEJ cancer. We suggest future prospective studies to compare outcomes of adjuvant versus neoadjuvant treatment for true GEJ cancer.

Prognostic value of preoperative platelet-lymphocyte and neutrophil-lymphocyte ratio in patients undergoing surgery for esophageal squamous cell cancer

Increasing evidence has suggested that the host inflammatory status is associated with prognosis of several solid tumors. Preoperative platelet-lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR), both acquired from routine blood tests, can reflect the status of systematic inflammation. However, whether they are correlated with clinical outcomes of esophageal carcinoma is still unknown. The purpose of this study was to determine the prognostic value of preoperative PLR and NLR in patients with resected esophageal squamous cell carcinoma (ESCC). Preoperative PLR and NLR were evaluated in 317 eligible ESCC patients from September 2008 to December 2010. Receiver operating characteristic curves were applied to establish optimal cutoff points. The prognostic values of PLR and NLR were determined by both univariate and multivariate analyses. The optimal cutoff value of preoperative PLR and NLR were 103.0 and 2.1, respectively. One hundred and ninety-seven (62.1%) patients showed high level of preoperative PLR, while 148 (46.7%) patients showed high level of preoperative NLR. Both elevated PLR (P < 0.001) and NLR (P = 0.009) were correlated with poor disease-specific survival in univariate analysis. However, only preoperative PLR (P = 0.003) had a significant correlation with prognosis in multivariate analysis. In subgroup analyses, the predictive value of PLR was significant for stage I (P = 0.008) and stage II (P = 0.044) patients, but not for stage III patients (P = 0.100). Preoperative PLR is easily obtained from a routine blood test and may provide additional prognostic information for ESCC patients, especially in the early stage.

PTEN gene is infrequently hypermethylated in human esophageal squamous cell carcinoma

Whether promoter hypermethylation of phosphatase and tensin homologue deleted from chromosome 10 (PTEN) is associated with loss of PTEN expression was not yet elucidated in esophageal squamous cell carcinoma (ESCC). The methylation status of PTEN gene was evaluated in 74 ESCC specimens and four esophageal cancer cell lines. Its association with clinicopathological factors or the prognosis was investigated by statistical analysis. We further measured messenger RNA (mRNA) and protein level of PTEN by quantitative RT-PCR and immunohistochemistry and studied the role of PTEN hypermethylation in loss of PTEN expression in clinical samples. Next, demethylation of PTEN gene with 5-azaC in EC9706 was performed to confirm the clinical findings. PTEN methylation was only found in 14 (18.9 %) of 74 ESCC tumor samples and one (EC9706) of four esophageal cancer cell lines. PTEN methylation was not statistically associated with clinicopathological factors and the prognosis (p > 0.05). In addition, 41 patients (55.4 %) and 38 patients (51.4 %) showed reduced mRNA level of PTEN and negative expression of PTEN protein in ESCC tumors, respectively. Detailed analysis indicated that PTEN methylation was a possible mechanism of loss of PTEN expression in ESCC, and further 5-azaC demethylation revealed inversed methylation status and increased mRNA or protein level of PTEN in EC9706. However, the role of PTEN methylation in loss of PTEN expression was still limited due to low frequency of methylation in ESCC. PTEN hypermethylation is a rare event and did not play an important role in the prognosis and loss of PTEN expression in ESCC.

Prognostic significance of lymph node ratio in esophageal cancer

N staging predicting esophageal cancer patient prognosis has been studied. Lymph node ratio, which is considered to show metastatic lymph node status more accurately, is found to have prognostic significance in several tumors. We investigated whether lymph node ratio (LNR) was associated with the prognosis of esophageal cancer in this study. Esophageal cancer patients who underwent esophagectomy at Qilu Hospital of Shandong University from January 2007 to December 2008 were studied. A total of 209 cases were evaluated in this study. The median disease-free survival (DFS) of this cohort was 35.2 months, and 5-year DFS rate was 32.1%. The median overall survival (OS) was 46.4 months, and 5-year OS rate was 40.0%. Kaplan-Meier survival analysis revealed that patients with LNR higher than 0.2 had significantly poorer DFS (p < 0.001) and OS (p < 0.001) than those with LNR less than 0.2. In a multivariate analysis, LNR was found to be an independent prognostic factor for DFS (p = 0.008, HR 1.863, 95% CI 1.180-2.942) and OS (p = 0.025, HR 1.708, 95% CI 1.068-2.731). N stage (p = 0.028, HR 1.626, 95% CI 1.055-2.506) was also found to be an independent prognostic factors for OS. Subgroups analysis revealed significant difference in OS and DFS rates between different LNR categories within the same N stages (p < 0.05) but not between different N stages within the same LNR category (p > 0.05). LNR was recognized as an independent factor in both OS and DFS in esophageal cancer. Besides, LNR showed a better prognostic value than N stage for esophageal cancer.

Activating transcription factor 4 promotes esophageal squamous cell carcinoma invasion and metastasis in mice and is associated with poor prognosis in human patients

Background

Activating transcription factor 4 (ATF4) is a stress response gene that is involved in homeostasis and cellular protection. However, its expression and function in esophageal squamous cell carcinoma (ESCC) remains unknown. In this study, we aimed to determine the clinicopathologic significance of ATF4 in ESCC and its potential role in ESCC invasion and metastasis.

Methodology/Principal Findings

We demonstrated that ATF4 overexpression is correlated with multiple malignant characteristics and indicates poor prognosis in ESCC patients. ATF4 expression was an independent factor that affected the overall survival of patients with ESCC after surgical resection. ATF4 promoted cell invasion and metastasis by promoting matrix metalloproteinase (MMP)-2 and MMP-7 expression, while its silencing significantly attenuated these activities both in vitro and in vivo.

Conclusions/Significance

We report that ATF4 is a potential biomarker for ESCC prognosis and that its dysregulation may play a key role in the regulation of invasion and metastasis in ESCC cells. The targeting of ATF4 may provide a new strategy for blocking ESCC metastasis.

Overall survival analysis of neoadjuvant chemoradiotherapy and esophagectomy for esophageal cancer

BACKGROUND

Patients treated with neoadjuvant chemoradiotherapy (NAC) followed by esophagectomy are more likely to have negative margins at resection, be downstaged, and have improved overall survival (OS). The specific aim of this study was to analyze OS outcomes using NAC followed by esophagectomy at a single, tertiary care academic medical center.

METHODS

We retrospectively analyzed 106 patients that underwent NAC with platinum-based chemotherapy plus 5-fluorouracil (5-FU) or capecitabine followed by esophagectomy from September 1996 to May 2011. OS was analyzed by the Kaplan Meier method.

RESULTS

Initial staging determined that of 106 patients, 62% had stage III (n=66), 31% stage II (n=33), and 7% had stage I disease (n=7). Following NAC, 92.5% (n=98) were resected with negative (R0) margins and pathologic staging revealed 59% (n=62) were downstaged, 9% (n=10) were upstaged, and 32% (n=34) remained at the same stage. A pathologic complete response (pCR) was achieved in 29% (n=31) of the cohort. Median OS was 35.2 months for all patients, 42 months for downstaged patients, 13 months when upstaged, and 17 months for those who remained at the same stage (P=0.08). OS by histological type was 30 months for adenocarcinoma and 71 months for squamous cell carcinoma (P=0.06).

CONCLUSIONS

NAC was effective in downstaging 59% of patients and effectively increased the chance for an R0 resection. These patients, in turn, had improved OS compared to the median OS. Patients with squamous cell carcinoma showed a trend towards more favorable OS.

Supraclavicular node metastasis from thoracic esophageal carcinoma: A surgical series from a Japanese multi-institutional nationwide registry of esophageal cancer

OBJECTIVES

In the present TNM classification, involvement of supraclavicular nodes is defined as distant metastases. However, the therapeutic value of supraclavicular node dissection remains controversial. The purpose of this study was to evaluate the survival benefit of dissection of metastases to the supraclavicular lymph nodes in patients with thoracic esophageal carcinoma by using a large nationwide registry of esophageal cancer maintained by the Japanese Esophageal Society.

METHODS

The study group comprised 1309 patients with thoracic esophageal carcinoma treated in 2001, 2002, and 2003, who underwent esophagectomy with 3-field dissection for curative intent, and in whom the locations of pathologic metastatic lymph nodes and outcome evaluations were available.

RESULTS

Of 1309 patients, 559 (42.7%) had no nodal metastases, 560 (42.8%) had at least 1 positive node but were supraclavicular node-negative, and 190 (14.5%) had supraclavicular node metastases. The 5-year survival was 73.7% for patients with N0, 40.4% for node-positive patients without supraclavicular node disease, and 24.1% for patients with supraclavicular node metastasis. In a multivariate analysis, male sex (P<.001), deeper T category (P<.001), and more positive nodes (P<.001) retained statistical significance as adverse prognostic factors for overall survival. Supraclavicular node metastasis was not significant (P=.062).

CONCLUSIONS

The survival benefit of dissection of metastases to the supraclavicular lymph nodes was indicated in patients with thoracic esophageal carcinoma. Supraclavicular nodes appear to be regional nodes similar to other regional nodes.

Survival in esophageal high-grade dysplasia/adenocarcinoma post endoscopic resection

BACKGROUND

Endoscopic resection followed by ablative therapy is frequently used to treat esophageal high-grade dysplasia or early esophageal adenocarcinoma.

AIMS

To study outcomes in patients with high-grade dysplasia compared to those with esophageal adenocarcinoma after endoscopic resection.

METHODS

Retrospective, observational, descriptive, single-centre study from a prospective database. We extracted data from 116 endoscopic resections. Survival was plotted using Kaplan-Meier curves multivariable Cox-proportional hazard assess for possible predictors of survival post-endoscopic resection was performed.

RESULTS

116 patients (64 esophageal adenocarcinoma, 52 high-grade dysplasia) underwent endoscopic resection from May 2003 to June 2010. Mean age was 71 ± 11 years for high-grade dysplasia and 72 ± 10 years for esophageal adenocarcinoma. Median follow-up was 17 months. Eighty-five patients had negative margins on endoscopic resection. Five-year survivals for high-grade dysplasia and esophageal adenocarcinoma were 86% (range 68-100%) and 78% (59-96%), respectively. Survival was not significantly different between groups (p=0.20). Overall mortality rate was 10.6% (9/85). At multivariable Cox regression increased Barrett's oesophagus length was associated with worse survival (HR 1.18 [1.06-1.33], p=0.0039). Survival was not affected by the pathology before resection: HR 2.4 [95%CI, 0.70-8.4], p=0.16.

CONCLUSIONS

Survival in patients with high-grade dysplasia of the oesophagus is similar to those with esophageal adenocarcinoma. Longer Barrett's oesophagus segments are associated with decreased survival.

Lipopolysaccharide-induced toll-like receptor 4 signaling enhances the migratory ability of human esophageal cancer cells in a selectin-dependent manner

BACKGROUND

Esophageal cancer is an aggressive malignancy, and emerging data suggest that postoperative infections may promote cancer progression. Systemic exposure to lipopolysaccharide (LPS), a Gram-negative bacterial antigen involved in such infections, has been shown to increase cancer cell adhesion to the hepatic sinusoids in vivo. We investigated the direct impact of LPS on the migratory ability of esophageal cancer cells via the LPS receptor toll-like receptor 4 (TLR4).

METHODS

Human esophageal squamous carcinoma cell lines and immortalized normal esophageal mucosa cells were tested for TLR4 surface expression by reverse transcription polymerase chain reaction (RT-PCR) and flow cytometry. TLR4 signaling in response to LPS stimulation was tested in these cells by measuring p38 MAP kinase phosphorylation on Western blot. The impact of TLR4 signaling was measured by static adhesion assays in vitro and on early in vivo migration by intravital microscopy of the liver.

RESULTS

Upon LPS stimulation, phosphorylation of p38 was detected in the human esophageal cancer cells HKESC-2. Also, LPS-stimulated HKESC-2 cells showed a twofold increased adhesion to fibronectin and to hepatic sinusoidal endothelium. These effects were abolished by TLR4 inhibition using the small-molecule inhibitor eritoran. Adhesion to fibronectin and hepatic sinusoidal endothelium was also diminished by blockade of p38 phosphorylation and inhibitors of selectin-selectin ligand binding.

CONCLUSION

LPS can increase the migratory ability of human esophageal cancer cells by increasing their adhesive properties through TLR4 signaling and selectin ligands. TLR4, p38, and selectin blockade may therefore prove to be a new therapeutic strategy for this aggressive malignancy.

Genome-wide association study identifies common variants in SLC39A6 associated with length of survival in esophageal squamous-cell carcinoma

We conducted a genome-wide scan of SNPs to identify variants associated with length of survival in 1,331 individuals with esophageal squamous-cell carcinoma (ESCC), with associations validated in 2 independent sets including 1,962 individuals with this cancer. We identified rs1050631 in SLC39A6 as associated with the survival times of affected individuals, with the hazard ratio for death from ESCC in the combined sample being 1.30 (95% confidence interval (CI) = 1.19-1.43; P = 3.77 × 10(-8)). rs7242481, located in the 5' UTR of SLC39A6, disturbs a transcriptional repressor binding site and results in upregulation of SLC39A6 expression. Immunohistochemical staining of ESCC tissues showed that higher expression of SLC39A6 protein was correlated with shorter length of survival in individuals with advanced ESCC (P = 0.013). Knockdown of SLC39A6 expression suppressed proliferation and invasion in ESCC cells. These results suggest that SLC39A6 has an important role in the prognosis of ESCC and may be a potential therapeutic target.

Prognostic value of HOXB7 mRNA expression in human oesophageal squamous cell cancer

OBJECTIVE

This study was to determine the role of HOXB7 in predicting outcomes of patients with oesophageal squamous cell cancer (OSCC).

METHODS

Samples were collected from 179 OSCC patients. HOXB7 mRNA expression was measured by quantitative real-time polymerase chain reaction.

RESULTS

HOXB7 mRNA expression was up-regulated in 85.1% of OSCC tumorous tissues, and correlated with age, pathological T and N category, as well as cancer-specific survival (CSS). However, subgroup analysis revealed its discernibility on CSS was only pronounced in early stage.

CONCLUSIONS

HOXB7 mRNA expression might serve as a novel prognostic biomarker for resected OSCC patients in early stage.

Multidrug resistance in primary tumors and metastases in patients with esophageal squamous cell carcinoma

Studies have demonstrated that radical esophagectomy can significantly prolong disease-free survival and improve the survival rate of patients with T3 or T4 esophageal cancer and lymph node metastasis. Multidrug resistant cancer cells have active efflux mechanisms that prevent the accumulation of chemotherapeutic drugs in the cells. The purpose of this study was to compare the expression of five MDR related proteins between primary tumors in patients with thoracic esophageal squamous cell carcinoma (ESCC) and metastatic cancer in lymph nodes to explore the clinical significance of heterogeneity in MDR metastatic cancer cells. Fifty-four patients with ESCC and lymph node metastasis were included. All patients underwent subtotal esophagectomy and D2/D3 lymph node resection. The expression of lung resistance-related protein (LRP), P-glycoprotein, topoisomerase-II, thymidylate synthase, and glutathione S-transferase P1-1 (GST-π) were determined in the primary tumors and lymph nodes via immunohistochemistry. The expression of LRP was significantly different between the primary tumors and lymph nodes (P = 0.026). No significant differences were found for the other four proteins, and protein expression was not associated with either degree of differentiation or disease stage. It was also found that GST-π was expressed in all patients in both the primary tumors and lymph nodes, suggesting that the design and application of chemotherapeutic protocols capable of reducing GST-π expression may be beneficial for patients with ESCC. Additional research regarding the clinical utility of MDR protein expression in ESCC is warranted to design effective chemotherapeutic protocols.

Lymph node invasion might have more prognostic impact than R status in advanced esophageal adenocarcinoma

BACKGROUND

Advanced esophageal adenocarcinomas are associated with 5-year survival rates ranging from 14% to 35%. Nodal status and tumor clearance are the main prognostic factors. However, their respective prognostic values have not been compared to date.

METHODS

Seventy consecutive patients with stage T3 adenocarcinomas of the esophagus or gastric cardia were retrospectively assessed. Neoadjuvant therapy was indicated in all cases. Prognostic values of R0 resection and nodal status were evaluated using univariate and multivariate analyses.

RESULTS

Neoadjuvant therapy was achieved in 62 patients, 41 with radiochemotherapy and 21 with perioperative chemotherapy. Transthoracic esophagectomy and transhiatal esophagectomy were performed in 54 and 15 patients, respectively. Clavien-Dindo grade III or IV complications occurred in 16 patients (23%). Two patients died in the hospital (3%). In univariate and multivariate analyses, nodal status was the main independent factor predicting overall survival; tumor clearance (R0 or R1) had less prognostic impact and was not statistically significant. Furthermore, R1 resection was a prognostic indicator for metastatic recurrence.

CONCLUSIONS

These results indicate that nodal status has more prognostic impact than R status in stage T3 adenocarcinomas of the esophagus or gastric cardia. Thus, local control in R1 patients by postoperative radiotherapy is not justified.

[Squamous cell carcinoma of the esophagus]

The prognosis of locally advanced squamous cell carcinomas (SCC) of the esophagus after surgery only is poor. Therefore a definitive chemoradiotherapy (RCTx) was also discussed as the therapy of choice. Besides tumor biology, patient-related factors, such as alcohol and nicotine abuse increase the perioperative mortality and morbidity. Multimodal treatment can improve the outcome in comparison to surgery alone. A recently published meta-analysis confirmed that preoperative RCTx followed by surgery improves the prognosis compared to surgery alone in SCC of the esophagus. After chemotherapy this effect is less pronounced. Patients with a complete histopathological response (pCR) after preoperative RCTx have a 5-year survival rate of more than 55% and a low probability of local recurrence. However, a pCR cannot be predicted neither by negative biopsy nor by negative FDG-PET uptake after RCTx. Up to now FDG-PET has shown a low impact for response prediction or therapy modification in SCC of the esophagus in clinical studies. Responding patients should be transferred to surgery after preoperative treatment, because of a reduced perioperative morbidity and mortality and improved prognosis.

Predictors of cervical and recurrent laryngeal lymph node metastases from esophageal cancer

BACKGROUND

Although patients with esophageal cancer (EC) often develop lymph node metastases in the cervical and recurrent laryngeal (CRL) distribution, lymphadenectomy in this field is rarely performed. The purpose of this study was to determine factors associated with CRL node positivity and to determine the appropriate indications to perform a "three field" lymphadenectomy.

METHODS

In a retrospective review, EC patients who underwent three-field lymphadenectomy were analyzed. Predictors of positive CRL nodes were examined univariately, then selected for inclusion in a multivariate logistic regression model.

RESULTS

From 1994 to 2009, 185 patients had a three-field lymphadenectomy, of whom 46 patients (24.9%) had positive CRL nodes. Final pathology stages (seventh edition) were I in 24 patients, II in 43, III in 109, and IV in 1 patient. Eight patients had a major pathologic response after induction therapy. On univariate analysis, variables significantly associated with positive CRL nodes included squamous cell histology, proximal location, advanced clinical presentation, the presence of clinical nodal disease, higher pT classification, and higher pN classification. There was no reduction in the rate of positive CRL nodes after induction chemotherapy. On multivariate analysis, higher pN classification (adjusted odds ratio 16.25, 95% confidence interval: 5.40 to 48.87; p < 0.0001) and squamous histology (adjusted odds ratio 6.04, 95% confidence interval: 2.21 to 16.56; p < 0.0001) predicted positive CRL nodes.

CONCLUSIONS

Complete lymphadenectomy is necessary in esophageal cancer to appropriately stage patients. Low rates of positive CRL nodes are present with early clinical stage, with pT0-2 tumors, and with pN0 classification, particularly in patients with adenocarcinoma and gastroesophageal junction tumors. Dissection of the CRL field should be considered with advanced disease for adenocarcinoma and in all patients with squamous cell cancer.

Prognostic factors and family history for survival of esophageal squamous cell carcinoma patients after surgery

BACKGROUND

Surgical resection is the most effective treatment for patients with isolated esophageal cancer, but the 5-year survival rate is still very poor in spite of recent advances in early diagnosis and extended lymphadenectomy. To identify the high-risk group and the factors affecting postoperative course, we analyzed the prognostic factors including the family history of esophageal cancer in survival after esophagectomy.

METHODS

A total of 1,553 patients with esophageal squamous cell carcinoma after surgery were the subject of the present study. Thirty-one percent of all these patients have family history of esophageal cancer. The prognostic factors analyzed in this study included age, sex, tumor size, tumor location, lymphadenopathy, histologic type, grade of differentiation, stage of cancer, adjuvant treatments, and family history of esophageal cancer.

RESULTS

The overall 3-year and 5-year postoperative survival rates were 43.7% and 26.2%, respectively, for all patients with esophagectomy. The five prognostic factors determined as significant by univariate p value were tumor size, lymphadenopathy, grade of differentiation, stage of cancer, and family history of esophageal cancer. Multivariate analysis showed that the independent prognostic factors were tumor size, grade of differentiation, stage of cancer, and family history of esophageal cancer. Our study also found that patients in groups with mid and upper segment esophageal squamous cell carcinoma, smaller tumor size, earlier stage of cancer, and poor differentiation of tumor cells had a significantly higher rate of positive family history than in the other groups, respectively.

CONCLUSIONS

Tumor size, grade of differentiation, lymphadenopathy, stage of cancer, and family history of esophageal cancer were identified as prognostic factors after esophagectomy. Family history of esophageal cancer is an important prognostic factor that surgeons should take into consideration when selecting a treatment method.

Probing the link between oestrogen receptors and oesophageal cancer

BACKGROUND

Human oesophageal carcinoma is considered to be one of the most aggressive malignancies and has a very poor prognosis. The incidence of oesophageal cancer shows a gender bias and is higher in males compared with females, the ratio between males and females varying from 3:1 to 7:1. This sex ratio is not entirely attributable to differences in the prevalence of known risk factors between the sexes. The potential role of oestrogen receptors (ER) in oesophageal cancer has been debated for several years but the significance of the receptors in this cancer remains unknown. Most of the work has been based on immunohistochemistry and has not been validated with other available techniques. The inconsistencies in the published literature on the link between ER expression and oesophageal cancer warrant a thorough evaluation of the potential role of ERs in this malignancy. Even the expression of the two ER isoforms, ERalpha and ERbeta, and its implications for outcome of treatments in histological subtypes of oesophageal tumours is ill defined. The aim of this article is to provide updated information from the available literature on the current status of ER expression in oesophageal cancer and to discuss its potential therapeutic role.

METHODS AND RESULTS

We performed a comprehensive literature search and analysed the results regarding ER expression in oesophageal tumours with special emphasis on expression of different oestrogen receptors and the role of sex hormones in oesophageal cancer. This article also focuses on the significance of the two main ER subtypes and mechanisms underlying the presumed male predominance of this disease.

CONCLUSION

We postulate that differential oestrogen receptor status may be considered a biomarker of poor clinical outcome based on tissue dedifferentiation or advanced stage of the disease. Further, if we can establish the importance of oestrogen and its receptors in the context of oesophageal cancer, then this may lead to a new future direction in the management of this malignancy.

Controllable metastasis: the trap for the esophageal cancer cells?

The prognosis of esophageal cancer (EC) remains poor, lymph node metastasis is one of the most important factors for determining the prognosis of patients with EC. Extensive lymph node dissection has long been considered as the favorable procedure to achieve an accurate pathologic staging and a better prognosis. However, the effect of extensive lymphadenectomy during esophagectomy on survival of EC patients has been doubted. Herein we present the hypotheses that the selective lymphadenectomy might be a potential strategy for EC by creating the traps of cancer cells. Once metastatic cancer cells immersed in, patients will acquire remarkable survival profit by surgical removal these traps.