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Yang J, Liu Q, Bai Y, Zhao H, He T, Zhao Z, Huang M, Jiang M, Zhang R, Zhang M. Prognostic value of lymph node micrometastasis in esophageal cancer: A systematic review and meta-analysis. Front Oncol 2023; 12:1025855. [PMID: 36686727 PMCID: PMC9845692 DOI: 10.3389/fonc.2022.1025855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/06/2022] [Indexed: 01/06/2023] Open
Abstract
Objective Whether lymph node micrometastasis (LNM) increases the risk in esophageal cancer patients remains controversial. We conducted a systematic review and meta-analysis to explore the prognosis value of LNM in esophageal cancer patients. Methods Two reviewers independently searched electronic databases, including PubMed, Embase, and the Cochrane Library, for eligible citations until February 2022. We calculated pooled estimates of the hazards ratio with a random-effects model. The certainty of evidence was determined by the Grade of Recommendations Assessment, Development, and Evaluation (GRADE) method. A sensitivity analysis was performed to assess the stability. Publication bias was assessed using funnel plots and Egger's test. We also performed subgroup analysis to explore the source of heterogeneity. Results A total of 16 studies, with 1,652 patients, were included. The overall survival (OS) was significantly increased with LNM negativity compared with LNM positivity (HR 1.95; 95% CI, 1.53-2.49; P < 0.001; I2 = 0.0%, P = 0.930; certainty of evidence: low). Relapse-free survival (RFS) was significantly increased with LNM negativity compared with LNM positivity (HR 3.39; 95% CI, 1.87-6.16; P < 0.001; I2 = 50.18%, P = 0.060; certainty of evidence: moderate). No significant difference was observed in recurrence between the two groups (certainty of evidence: low). Sensitivity analysis revealed a stable trend. In addition, the funnel plot and Egger's test did not show significant publication bias. Conclusion LNM positivity worsens the prognosis in esophageal cancer, and the evidence for RFS is moderate. Future relevant high-quality studies are warranted to validate our results further and provide a reference for guidelines. Systematic review registration https://www.crd.york.ac.uk/prospero, identifier (CRD42022321768).
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Affiliation(s)
- Jing Yang
- School of Basic Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou, Gansu, China,Department of Pathology, Gansu Provincial Hospital, Lanzhou, Gansu, China,Department of Pathology, The 940th Hospital of Joint Logistics Support Force of Chinese People´s Liberation Army, Lanzhou, China
| | - Qianqian Liu
- School of Basic Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou, Gansu, China,Department of Pathology, Gansu Provincial Hospital, Lanzhou, Gansu, China,Department of Pathology, The 940th Hospital of Joint Logistics Support Force of Chinese People´s Liberation Army, Lanzhou, China
| | - Yuping Bai
- School of Basic Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou, Gansu, China,Department of Pathology, Gansu Provincial Hospital, Lanzhou, Gansu, China,The Department of Pathology, Hainan Provincial Hospital, Haikou, Hainan, China
| | - Haitong Zhao
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Tingting He
- School of Basic Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou, Gansu, China,Department of Pathology, Gansu Provincial Hospital, Lanzhou, Gansu, China,Department of Pathology, The 940th Hospital of Joint Logistics Support Force of Chinese People´s Liberation Army, Lanzhou, China
| | - Ziru Zhao
- School of Basic Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou, Gansu, China,Department of Pathology, Gansu Provincial Hospital, Lanzhou, Gansu, China,Department of Pathology, The 940th Hospital of Joint Logistics Support Force of Chinese People´s Liberation Army, Lanzhou, China
| | - Min Huang
- School of Basic Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou, Gansu, China,Department of Pathology, Gansu Provincial Hospital, Lanzhou, Gansu, China,Department of Pathology, The 940th Hospital of Joint Logistics Support Force of Chinese People´s Liberation Army, Lanzhou, China
| | - Mengyuan Jiang
- School of Basic Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou, Gansu, China,Department of Pathology, Gansu Provincial Hospital, Lanzhou, Gansu, China,Department of Pathology, The 940th Hospital of Joint Logistics Support Force of Chinese People´s Liberation Army, Lanzhou, China
| | - Rui Zhang
- School of Basic Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou, Gansu, China,Department of Pathology, Gansu Provincial Hospital, Lanzhou, Gansu, China,Department of Pathology, The 940th Hospital of Joint Logistics Support Force of Chinese People´s Liberation Army, Lanzhou, China
| | - Min Zhang
- School of Basic Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou, Gansu, China,Department of Pathology, Gansu Provincial Hospital, Lanzhou, Gansu, China,*Correspondence: Min Zhang,
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Nishikawa G, Banik P, Thawani R, Kardosh A, Wood SG, Nabavizadeh N, Chen EY. Comparison of neoadjuvant regimens for resectable gastroesophageal junction cancer: a systematic review of randomized clinical trials across three decades. J Gastrointest Oncol 2022; 13:1454-1466. [PMID: 35837173 PMCID: PMC9274047 DOI: 10.21037/jgo-22-29] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/13/2022] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND The optimal perioperative treatment for adenocarcinoma of gastroesophageal junction (GEJ) tumor remains uncertain. The systematic review aims to assess the best neoadjuvant modality, namely chemotherapy (CT) versus chemoradiotherapy (CRT) based on randomized controlled trials (RCTs) for resectable gastric, esophageal and GEJ tumors. METHODS We performed a comprehensive PubMed database and Cochrane Library search to identify relevant RCTs related to neoadjuvant treatment for resectable GEJ adenocarcinoma. We included all published RCTs (phase 2 or 3) that tested specific neoadjuvant therapies (CT or CRT) if the patient population included GEJ tumors. We applied the Version 2 Cochrane risk-of-bias tool (RoB 2) to all the eligible studies. Outcomes examined included R0 resection and pathological response based on intention-to-treat (ITT) analysis, surgical outcomes, notable adverse events, and overall survival (OS). Each randomized group of every study was noted to be neoadjuvant CRT, CT, or surgery alone in order to compare the outcomes among these treatment approaches. RESULTS We identified 25 RCTs with 7,855 patients published from 1996 to 2019. Seven studies tested preoperative CT versus surgery alone, 7 tested preoperative radiotherapy (RT) or CRT versus surgery alone, 4 tested preoperative RT or CRT versus preoperative CT, and 7 tested other combinations. The R0 resection ranged 47-100% and the 3-year OS ranged 6-66.1% in all the study arms. In an exploratory analysis, CRT strategies showed a superior R0 resection rate [80.2%; 95% confidence interval (CI): 79.8-80.6%] to surgery alone (60.9%; 95% CI: 60.4-61.3%; P<0.01) and to preoperative CT (63.9%; 95% CI: 63.6-64.2%; P<0.01). When comparing 3- and 5-year OS, improvement was noted when comparing CRT to surgery alone (P<0.01), and perioperative CT to surgery alone (P<0.01), but no definite difference was noted between CRT versus CT. DISCUSSION Preoperative CRT showed improvement in R0 resection rate to surgery alone and preoperative CT. However, there is no significant difference in OS between CRT and CT. Both neoadjuvant strategies remain clinically meaningful options for patients with resectable GEJ tumors. Lack of patient-level data and inconsistent reporting of key outcomes across studies were the main limitations of our study.
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Affiliation(s)
- Go Nishikawa
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Pratyusha Banik
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Rajat Thawani
- Division of Hematology/Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Adel Kardosh
- Division of Hematology/Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Stephanie G. Wood
- Division of Gastrointestinal and General Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Nima Nabavizadeh
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Emerson Y. Chen
- Division of Hematology/Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
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Shang QX, Yang YS, Xu LY, Yang H, Li Y, Li Y, Wu ZY, Fu JH, Yao XD, Xu XE, Wu JY, Chen LQ. Prognostic impact of lymph node harvest for patients with node-negative esophageal squamous cell carcinoma: a large-scale multicenter study. J Gastrointest Oncol 2021; 12:1951-1962. [PMID: 34790363 DOI: 10.21037/jgo-20-371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 07/28/2021] [Indexed: 02/05/2023] Open
Abstract
Background We examined the association between the number of resected lymph nodes and survival to determine the optimal lymphadenectomy for thoracic esophageal squamous cell carcinoma (ESCC) patients with negative lymph node. Methods We included 1,836 patients from Chinese three high-volumed hospitals with corresponding clinicopathological characters such as gender, age, tumor location, tumor grade and TNM stage of patients. The median follow-up of included patients was 45.7 months (range, 1.03-117.3 months). X-Tile plot was used to identify the lowest number of lymphadenectomy. The multivariate model's construction was in use of parameters with clinical significance for survival and a nomogram based on clinical variable with P<0.05 in Cox regression analysis. Both two models were validated using a cohort extracted from the Surveillance, Epidemiology, and End Results (SEER) 18 registries database between 1975 and 2016 (n=951). Results More lymphadenectomy numbers were significantly associated with better survival in patients both in training cohort [hazard ratio (HR) =0.980; 95% confidence interval (CI): 0.971-0.988; P<0.001] and validation cohort (HR =0.980; 95% CI: 0.968-0.991; P=0.001). Cut-off point analysis determined the lowest number of 9 for thoracic ESCC patients in N0 stage through training cohort (C-index: 0.623; sensitivity: 80.7%; 1 - specificity: 72.5%) when compared with 10 in validation cohort (C-index: 0.643; sensitivity: 78.2%; 1 - specificity: 63.0%). The cut-off points of 9 were examined in training cohort and validated in the divided cohort from validation cohort (all P<0.05). Meanwhile, nomograms for both cohorts were constructed and the calibration curves for both cohorts agreed well with the actual observations in terms of predicting 3- and 5-year survival, respectively. Conclusions Larger number for lymphadenectomy was associated with better survival in thoracic ESCC patients in N0 stage. Nine was what we got as the lowest number for lymphadenectomy in pN0 ESCC patients through this study, and our result should be confirmed further.
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Affiliation(s)
- Qi-Xin Shang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Yu-Shang Yang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Li-Yan Xu
- Department of Oncology Surgery, Shantou Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hong Yang
- Department of Thoracic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yin Li
- Department of Thoracic Surgery, Cancer Hospital Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Li
- Department of Thoracic Surgery, Cancer Hospital Chinese Academy of Medical Sciences, Beijing, China
| | - Zhi-Yong Wu
- Department of Oncology Surgery, Shantou Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jian-Hua Fu
- Department of Thoracic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiao-Dong Yao
- Department of Oncology Surgery, Shantou Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiu-E Xu
- Department of Oncology Surgery, Shantou Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jian-Yi Wu
- Department of Oncology Surgery, Shantou Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Long-Qi Chen
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
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Pucher PH, Allum WH, Bateman AC, Green M, Maynard N, Novelli M, Petty R, Underwood TJ, Gossage J. Consensus recommendations for the standardized histopathological evaluation and reporting after radical oesophago-gastrectomy (HERO consensus). Dis Esophagus 2021; 34:doab033. [PMID: 33969411 DOI: 10.1093/dote/doab033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/12/2021] [Accepted: 04/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Variation in the approach, radicality, and quality of gastroesophageal surgery impacts patient outcomes. Pathological outcomes such as lymph node yield are routinely used as surrogate markers of surgical quality, but are subject to significant variations in histopathological evaluation and reporting. A multi-society consensus group was convened to develop evidence-based recommendations for the standardized assessment of gastroesophageal cancer specimens. METHODS A consensus group comprised of surgeons, pathologists, and oncologists was convened on behalf of the Association of Upper Gastrointestinal Surgery of Great Britain & Ireland. Literature was reviewed for 17 key questions. Draft recommendations were voted upon via an anonymous Delphi process. Consensus was considered achieved where >70% of participants were in agreement. RESULTS Consensus was achieved on 18 statements for all 17 questions. Twelve strong recommendations regarding preparation and assessment of lymph nodes, margins, and reporting methods were made. Importantly, there was 100% agreement that the all specimens should be reported using the Royal College of Pathologists Guidelines as the minimum acceptable dataset. In addition, two weak recommendations regarding method and duration of specimen fixation were made. Four topics lacked sufficient evidence and no recommendation was made. CONCLUSIONS These consensus recommendations provide explicit guidance for gastroesophageal cancer specimen preparation and assessment, to provide maximum benefit for patient care and standardize reporting to allow benchmarking and improvement of surgical quality.
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Affiliation(s)
- Philip H Pucher
- Department of General Surgery, Guys and St Thomas' Hospital NHS Foundation Trust, London, UK
- Department of General Surgery, Portsmouth University Hospital NHS Trust, Portsmouth, UK
| | - William H Allum
- Department of Academic Surgery, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Adrian C Bateman
- Department of Cellular Pathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michael Green
- Department of General Surgery, Guys and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Nick Maynard
- Department of General Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Marco Novelli
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Russell Petty
- Department of Medical Oncology, Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, Dundee, UK
| | - Timothy J Underwood
- Royal College of Surgeons of England and Association of Upper Gastrointestinal Surgery of GB&I (AUGIS) Surgical Specialty Lead for Oesophageal Cancer, UK
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James Gossage
- Department of General Surgery, Guys and St Thomas' Hospital NHS Foundation Trust, London, UK
- Oesophagogastric Cancer Lead, AUGIS, UK
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Al-Kaabi A, van der Post RS, van der Werf LR, Wijnhoven BPL, Rosman C, Hulshof MCCM, van Laarhoven HWM, Verhoeven RHA, Siersema PD. Impact of pathological tumor response after CROSS neoadjuvant chemoradiotherapy followed by surgery on long-term outcome of esophageal cancer: a population-based study. Acta Oncol 2021; 60:497-504. [PMID: 33491513 DOI: 10.1080/0284186x.2020.1870246] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND With increasing interest in organ-preserving strategies for potentially curable esophageal cancer, real-world data is needed to understand the impact of pathological tumor response after neoadjuvant chemoradiotherapy (CRT) on patient outcome. The objective of this study is to assess the association between pathological tumor response following CROSS neoadjuvant CRT and long-term overall survival (OS) in a nationwide cohort. MATERIAL AND METHODS All patients diagnosed in the Netherlands with potentially curable esophageal cancer between 2009 and 2017, and treated with neoadjuvant CRT followed by esophagectomy were included. Through record linkage with the nationwide Dutch Pathology Registry (PALGA), pathological data were obtained. The primary outcome was pathological tumor response based on ypTNM, classified into pathological complete response (ypT0N0) and incomplete responders (ypT0N+, ypT+N0, and ypT+N+). Multivariable logistic and Cox regression models were used to identify predictors of pathological complete response (pCR) and survival. RESULTS A total of 4946 patients were included. Overall, 24% achieved pCR, with 19% in adenocarcinoma and 42% in squamous cell carcinoma. Patients with pCR had a better estimated 5-year OS compared to incomplete responders (62% vs. 38%, p< .001). Of the patients with incomplete response, ypT+N+ patients (32% of total population) had the lowest estimated 5-year OS rate, followed by ypT0N+ and ypT+ N0 (22%, 47%, and 49%, respectively, p< .001). Adenocarcinoma, well to moderate differentiation, cT3-4, cN+, signet ring cell differentiation and lymph node yield (≥15) were associated with lower likelihood of pCR. CONCLUSION In this population-based study, pathological tumor response based on the ypTNM-stage was associated with different prognostic subgroups. A quarter of patients achieved ypT0N0 with favorable long-term survival, while one-third had an ypT+N+ response with very poor survival. The association between pathological tumor response and long-term survival could help in more accurate assessments of individual prognosis and treatment decisions.
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Affiliation(s)
- Ali Al-Kaabi
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | - Bas P. L. Wijnhoven
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maarten C. C. M. Hulshof
- Department of Radiotherapy, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Hanneke W. M. van Laarhoven
- Department of Medical Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Rob H. A. Verhoeven
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Research & Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
| | - Peter D. Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
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Survival Trends of Patients With Surgically Resected Gastric Cardia Cancer From 1988 to 2015: A Population-based Study in the United States. Am J Clin Oncol 2020; 42:581-587. [PMID: 31157623 DOI: 10.1097/coc.0000000000000558] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The incidence of gastric cardia cancer (GCC) patients has been increasing, while the survival trends of GCC patients over time remains unclear. Thus, the aim of our study was to determine the survival trends of GCC patients over time using a population-based data in the United States. METHODS A total of 9044 surgically resected GCC patients during 1988 to 2015 from the Surveillance, Epidemiology, and End Results (SEER) database were identified. The survival probabilities were calculated by Kaplan-Meier method and the different survival probabilities between groups were examined by log-rank test. RESULTS The median overall survival time was 27 (interquartile range, 12 to 99) months, and the median disease-specific survival time was 32 (interquartile range, 13 to 320) months for GCC patients. There was a statistically significant increase in median overall survival time (17 to 46 mo; P<0.001) and disease-specific survival time (19 to 67 mo; P<0.001) from 1988 to 1997 to 2008 to 2015. More GCC patients were diagnosed at an early stage in recent years. Meanwhile, adequate lymph nodes examined (eLNs) were obtained in more GCC patients during surgery. Also, the proportion of GCC patients who received chemoradiotherapy increased significantly. Moreover, early diagnosis, adequate eLNs, and chemoradiotherapy were associated with mortality. CONCLUSIONS The survival rates of surgically resected GCC patients had a significant improvement from 1988 to 1997 to 2008 to 2015 in the United States, which might relate to the early discovery of GCC, greater utilization of adequate eLNs, and chemoradiotherapy.
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Karstens KF, Ghadban T, Effenberger K, Sauter G, Pantel K, Izbicki JR, Vashist Y, König A, Reeh M. Lymph Node and Bone Marrow Micrometastases Define the Prognosis of Patients with pN0 Esophageal Cancer. Cancers (Basel) 2020; 12:cancers12030588. [PMID: 32143307 PMCID: PMC7139797 DOI: 10.3390/cancers12030588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/27/2020] [Accepted: 03/02/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Pathological routine lymph node staging is postulated to be the main oncological prognosticator in esophageal cancer (EC). However, micrometastases in lymph nodes (LNMM) and bone marrow (BNMM) are discussed as the key events in tumor recurrence. We assessed the prognostic significance of the LNMM/BNMM status in initially pN0 staged patients with curative esophagectomy. METHODS From 110 patients bone marrow aspirates and lymph node tissues were analyzed. For LNMM detection immunohistochemistry was performed using the anticytokeratin antibody AE1/AE3. To detect micrometastases in the bone marrow a staining with the pan-keratin antibody A45-B/B3 was done. Results were correlated with clinicopathologic parameters as well as recurrence and death during follow-up time. RESULTS Thirty-eight (34.5%) patients showed LNMM, whereas in 54 (49.1%) patients BNMM could be detected. LNMM and BNMM positive patients showed a correlation to an increased pT category (p = 0.017). Univariate and multivariate analyses revealed that the LNMM/BNMM status and especially LNMM skipping the anatomical lymph node chain were significant independent predictors of overall survival and recurrence-free survival. CONCLUSIONS This study indicates that routine pathological staging of EC is insufficient. Micrometastases in lymph nodes and the bone marrow seem to be the main reason for tumor recurrence and they are a strong prognosticator following curative treatment of pN0 EC.
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Affiliation(s)
- Karl-F. Karstens
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; (K.-F.K.); (T.G.); (K.E.); (J.R.I.); (Y.V.); (A.K.)
| | - Tarik Ghadban
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; (K.-F.K.); (T.G.); (K.E.); (J.R.I.); (Y.V.); (A.K.)
| | - Katharina Effenberger
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; (K.-F.K.); (T.G.); (K.E.); (J.R.I.); (Y.V.); (A.K.)
| | - Guido Sauter
- Department of Pathology, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany;
| | - Klaus Pantel
- Department of Tumor Biology, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany;
| | - Jakob R. Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; (K.-F.K.); (T.G.); (K.E.); (J.R.I.); (Y.V.); (A.K.)
| | - Yogesh Vashist
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; (K.-F.K.); (T.G.); (K.E.); (J.R.I.); (Y.V.); (A.K.)
| | - Alexandra König
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; (K.-F.K.); (T.G.); (K.E.); (J.R.I.); (Y.V.); (A.K.)
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; (K.-F.K.); (T.G.); (K.E.); (J.R.I.); (Y.V.); (A.K.)
- Correspondence:
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Fiehn AMK, Jepsen DNM, Achiam MP, Ugleholdt H, Federspiel B. Isolated tumor cells in regional lymph nodes in patients with adenocarcinoma of the esophagogastric junction might represent part of true metastases. Hum Pathol 2019; 93:90-96. [DOI: 10.1016/j.humpath.2019.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 08/15/2019] [Accepted: 08/15/2019] [Indexed: 12/26/2022]
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9
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Minimal Residual Disease in Head and Neck Cancer and Esophageal Cancer. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1100:55-82. [DOI: 10.1007/978-3-319-97746-1_4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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10
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Mantel HTJ, Wiggers JK, Verheij J, Doff JJ, Sieders E, van Gulik TM, Gouw ASH, Porte RJ. Lymph Node Micrometastases are Associated with Worse Survival in Patients with Otherwise Node-Negative Hilar Cholangiocarcinoma. Ann Surg Oncol 2015; 22 Suppl 3:S1107-15. [PMID: 26178761 PMCID: PMC4686550 DOI: 10.1245/s10434-015-4723-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Indexed: 12/18/2022]
Abstract
Background Lymph node metastases on routine histology are a strong negative predictor for survival after resection of hilar cholangiocarcinoma. Additional immunohistochemistry can detect lymph node micrometastases in patients who are otherwise node negative, but the prognostic value is unsure. The objective of this study was to assess the effect on survival of immunohistochemically detected lymph node micrometastases in patients with node-negative (pN0) hilar cholangiocarcinoma on routine histology. Methods Between 1990 and 2010, a total of 146 patients underwent curative-intent resection of hilar cholangiocarcinoma with regional lymphadenectomy at two university medical centers in the Netherlands.
Ninety-one patients (62 %) without lymph node metastases at routine histology were included. Micrometastases were identified by multiple sectioning of all lymph nodes and additional immunostaining with an antibody against cytokeratin 19 (K19). The association with overall survival was assessed in univariable and multivariable analysis. Median follow-up was 48 months. Results Micrometastases were identified in 16 (5 %) of 324 lymph nodes, corresponding to 11 (12 %) of 91 patients. There were no differences in clinical variables between K19 lymph node-positive and -negative patients. Five-year survival rates in patients with lymph node micrometastases were significantly lower compared to patients without micrometastases (27 vs. 54 %, P = 0.01). Multivariable analysis confirmed micrometastases as an independent prognostic factor for survival (adjusted Hazard ratio 2.4, P = 0.02). Conclusions Lymph node micrometastases are associated with worse survival after resection of hilar cholangiocarcinoma. Immunohistochemical detection of lymph node micrometastases leads to better staging of patients who were initially diagnosed with node-negative (pN0) hilar cholangiocarcinoma on routine histology.
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Affiliation(s)
- Hendrik T J Mantel
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Jim K Wiggers
- Department of Hepato-Pancreatico-Biliary Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Joanne Verheij
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan J Doff
- Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Egbert Sieders
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Thomas M van Gulik
- Department of Hepato-Pancreatico-Biliary Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Annette S H Gouw
- Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Tissue invasion and metastasis: Molecular, biological and clinical perspectives. Semin Cancer Biol 2015; 35 Suppl:S244-S275. [PMID: 25865774 DOI: 10.1016/j.semcancer.2015.03.008] [Citation(s) in RCA: 336] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 03/17/2015] [Accepted: 03/18/2015] [Indexed: 12/12/2022]
Abstract
Cancer is a key health issue across the world, causing substantial patient morbidity and mortality. Patient prognosis is tightly linked with metastatic dissemination of the disease to distant sites, with metastatic diseases accounting for a vast percentage of cancer patient mortality. While advances in this area have been made, the process of cancer metastasis and the factors governing cancer spread and establishment at secondary locations is still poorly understood. The current article summarizes recent progress in this area of research, both in the understanding of the underlying biological processes and in the therapeutic strategies for the management of metastasis. This review lists the disruption of E-cadherin and tight junctions, key signaling pathways, including urokinase type plasminogen activator (uPA), phosphatidylinositol 3-kinase/v-akt murine thymoma viral oncogene (PI3K/AKT), focal adhesion kinase (FAK), β-catenin/zinc finger E-box binding homeobox 1 (ZEB-1) and transforming growth factor beta (TGF-β), together with inactivation of activator protein-1 (AP-1) and suppression of matrix metalloproteinase-9 (MMP-9) activity as key targets and the use of phytochemicals, or natural products, such as those from Agaricus blazei, Albatrellus confluens, Cordyceps militaris, Ganoderma lucidum, Poria cocos and Silybum marianum, together with diet derived fatty acids gamma linolenic acid (GLA) and eicosapentanoic acid (EPA) and inhibitory compounds as useful approaches to target tissue invasion and metastasis as well as other hallmark areas of cancer. Together, these strategies could represent new, inexpensive, low toxicity strategies to aid in the management of cancer metastasis as well as having holistic effects against other cancer hallmarks.
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Wang D, Smit JK, Zwaan E, Muijs CT, Groen H, Hollema H, Plukker JT. Neoadjuvant therapy reduces the incidence of nodal micrometastases in esophageal adenocarcinoma. Am J Surg 2013; 206:732-8. [DOI: 10.1016/j.amjsurg.2013.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 02/12/2013] [Accepted: 03/21/2013] [Indexed: 12/20/2022]
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Yaremko BP, Palma DA, Erickson AL, Pierce G, Malthaner RA, Inculet RI, Dar AR, Rodrigues GB, Yu E. Adjuvant concurrent chemoradiation using intensity-modulated radiotherapy and simultaneous integrated boost for resected high-risk adenocarcinoma of the distal esophagus and gastro-esophageal junction. Radiat Oncol 2013; 8:33. [PMID: 23398690 PMCID: PMC3599957 DOI: 10.1186/1748-717x-8-33] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 12/28/2012] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Multimodality therapy leads to improved outcomes for adenocarcinoma of the distal esophagus and gastroesophageal junction (GEJ) over surgery alone. At our institution, adjuvant chemoradiation (chemoRT) using IMRT and SIB is standard of care for resected high-risk disease. In this study, we review our experience with a recent cohort of patients treated in this manner. METHODS AND MATERIALS We identified 18 patients with resected T3 and/or N1 adenocarcinoma of the distal esophagus and GEJ who received adjuvant chemoRT. A large elective volume (PTV1) and a smaller high-risk volume (PTV2) were irradiated simultaneously using IMRT and an SIB technique. All patients received concurrent chemotherapy. Relevant clinical outcomes are reported. RESULTS The median dose to 95% of PTV1 was 3747cGy and to 95% of PTV2 was 4876cGy. All RT was given in a median of 28 daily fractions. Four patients did not complete chemotherapy. At a median follow up of 952 days from the start of RT, 7 of 18 patients were dead; of these, 3 had developed local recurrence only; 3 had developed both local and distant recurrence; 1 died of a late toxicity, without recurrence. OS was 88% at 1year, 76% at 2 years and 58% at 3 years. Freedom from local recurrence was 88% at 1 year, 82% at 2 years and 82% at 3 years. Freedom from distant recurrence was 72% at 1 year, 67% at 2 years and 56% at 3 years. Toxicity was acceptable. CONCLUSIONS Adjuvant concurrent chemoRT with IMRT and SIB is feasible for resected high-risk adenocarcinoma of the distal esophagus and GEJ. Our results describe how modern treatment techniques can be employed as part of a treatment paradigm that is neither commonly used nor commonly described in the literature.
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Affiliation(s)
- Brian P Yaremko
- Department of Radiation Oncology, Western University, London Regional Cancer Program Room A3-810 Ed and Irene Fregin Building 790 Commissioners Road E, N6A-4L6, London, ON, Canada
- Department of Radiation Oncology, Western University, London Regional Cancer Centre, 790 Commissioners Road East, N6A 4L6, London, ON, Canada
| | - David A Palma
- Department of Radiation Oncology, Western University, London Regional Cancer Centre, 790 Commissioners Road East, N6A 4L6, London, ON, Canada
| | - Abigail L Erickson
- Department of Radiation Oncology, Western University, London Regional Cancer Centre, 790 Commissioners Road East, N6A 4L6, London, ON, Canada
| | - Gregory Pierce
- Department of Radiation Oncology, Western University, London Regional Cancer Centre, 790 Commissioners Road East, N6A 4L6, London, ON, Canada
| | - Richard A Malthaner
- Department of Surgical Oncology, Western University, London Regional Cancer Centre, 790 Commissioners Road East, N6A 4L6, London, ON, Canada
| | - Richard I Inculet
- Department of Surgical Oncology, Western University, London Regional Cancer Centre, 790 Commissioners Road East, N6A 4L6, London, ON, Canada
| | - A Rashid Dar
- Department of Radiation Oncology, Western University, London Regional Cancer Centre, 790 Commissioners Road East, N6A 4L6, London, ON, Canada
| | - George B Rodrigues
- Department of Radiation Oncology and Department of Clinical Epidemiology and Biostatistics, Western University, London Regional Cancer Centre, 790 Commissioners Road East, N6A 4L6, London, ON, Canada
| | - Edward Yu
- Department of Radiation Oncology, Western University, London Regional Cancer Centre, 790 Commissioners Road East, N6A 4L6, London, ON, Canada
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Kayani B, Zacharakis E, Ahmed K, Hanna GB. Lymph node metastases and prognosis in oesophageal carcinoma--a systematic review. Eur J Surg Oncol 2011; 37:747-53. [PMID: 21839394 DOI: 10.1016/j.ejso.2011.06.018] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2010] [Revised: 02/09/2011] [Accepted: 06/28/2011] [Indexed: 12/27/2022] Open
Abstract
Oesophageal cancer is the 7th most common cause of cancer-related death in the developed world and the incidence of oesophageal adenocarcinoma is now the fastest growing of any gastrointestinal cancer. Lymph node involvement is the single most important prognostic factor in oesophageal cancer. Imaging to determine the extent of lymph node involvement and plan treatment often requires a combination of modalities to avoid under-staging. The 7th edition of the staging system released by the International Union Against Cancer (IUCC) has stratified lymph node involvement according to the number of lymph nodes involved and redefined its groupings for location of metastatic lymph node involvement. This review discusses the prognostic and treatment implications of these modifications and explores micrometastatic lymph node involvement, capsular infiltration and lymph node ratio as possible additions to the staging system.
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Affiliation(s)
- B Kayani
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, Praed Street, London W2 1NY, UK
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Sgourakis G, Gockel I, Lyros O, Hansen T, Mildenberger P, Lang H. Detection of lymph node metastases in esophageal cancer. Expert Rev Anticancer Ther 2011; 11:601-612. [DOI: 10.1586/era.10.150] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Grotenhuis BA, van Heijl M, Wijnhoven BPL, van Berge Henegouwen MI, Biermann K, ten Kate FJW, Busch ORC, Dinjens WNM, Tilanus HW, van Lanschot JJB. Lymphatic micrometastases in patients with early esophageal adenocarcinoma. J Surg Oncol 2011; 102:863-7. [PMID: 20872812 DOI: 10.1002/jso.21719] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Both endoscopic and surgical treatments are recommended for m3- or sm1-adenocarcinomas of the esophagus, depending on patients' lymph nodal status. Lymphatic dissemination is related to tumor infiltration depth, but varying incidences have been reported in m3- and sm1-adenocarcinomas. The study aim was to investigate whether the presence of occult tumor cells in lymph nodes could explain this variation. METHODS Sixty-three node-negative (N0) patients with early esophageal adenocarcinoma (m2/m3/sm1-tumors) were included. Multilevel-sectioning of lymph nodes was performed; sections were stained by means of immunohistochemistry with cytokeratin marker CAM5.2. Two pathologists searched for micrometastases (0.2-2.0 mm) and isolated tumor cells (ITCs, <0.2 mm). RESULTS Positive CAM5.2 staining in lymph nodes was not seen in any of the 18 m2-patients. In 2/25 m3-tumors (8.0%) an ITC was found, but no micrometastases. Tumor cells were identified in 4/20 sm1-tumors (20.0%): three micrometastases and one ITC. Median follow-up was 121 months. Two m3-patients (3.2%) died due to disease recurrence, including one patient in whom an ITC was detected. CONCLUSIONS Lymphatic migration of tumor cells was found in node-negative m3- and sm1-adenocarcinomas of the esophagus (8.0% and 20.0%, respectively). However, the clinical relevance of these occult tumor cells should become apparent from large series of endoscopically treated patients.
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Marjanovic G, Schricker M, Walch A, zur Hausen A, Hopt UT, Imdahl A, Makowiec F. Detection of lymph node involvement by cytokeratin immunohistochemistry is an independent prognostic factor after curative resection of esophageal cancer. J Gastrointest Surg 2011; 15:29-37. [PMID: 20976569 DOI: 10.1007/s11605-010-1359-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 10/12/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Involved lymph nodes (LN) are a negative prognostic factor in esophageal cancers. To assess the role of nodal micrometastases, we performed immunohistochemical analyses of LN after resection of node-negative esophageal cancers and correlated the results with survival. METHODS Seventy patients with esophageal cancer after curative resection and conventionally negative nodes were included. The LN were examined with six consecutive sections (three hematoxylin and eosin (HE) stained and three stained immunohistochemically with the cytokeratin (CK) antibodies AE1/AE3). Survival was evaluated uni- and multivariately. Median follow-up was 4.1 years. RESULTS Immunohistochemical analysis showed CK-positive LN in 16 (23%) patients. Of those 16 cases with CK-positive LN, nine had aviable macrometastases, ten had CK-positive scars/fibrosis and five had viable micrometastases. All patients with aviable macrometastases or CK-positive scars/fibrosis had undergone neoadjuvant chemoradiation. Five-year survival was 48% in all patients. In univariate analysis, survival was worse in patients with CK-positive LN (5-year survival of 30% vs. 54% in CK-negative LN; p < 0.02) and in patients with squamous cell carcinoma (5-year survival of 38% vs. 75% in adenocarcinoma; p = 0.05). Multivariate analysis revealed CK-positive LN (p = 0.02) and (borderline) squamous cell carcinoma (p = 0.06) as negative prognostic factors. CONCLUSIONS The immunohistochemical analysis of LN may detect (viable or non-viable) tumor cells in lymph nodes after resection of conventionally node-negative esophageal cancers. Conventional pathological analysis by HE, therefore, understages esophageal cancer in these cases. The detection of CK-positive cells in resected LN is an independent prognostic factor in otherwise LN-negative esophageal cancer.
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Affiliation(s)
- Goran Marjanovic
- Department of Surgery, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
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Incidence of micrometastases in histologically negative para-aortic lymph nodes in advanced cervical cancer patients. Gynecol Oncol 2010; 119:76-80. [DOI: 10.1016/j.ygyno.2010.06.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 06/11/2010] [Accepted: 06/18/2010] [Indexed: 11/17/2022]
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Thompson SK, Bartholomeusz D, Devitt PG, Lamb PJ, Ruszkiewicz AR, Jamieson GG. Feasibility study of sentinel lymph node biopsy in esophageal cancer with conservative lymphadenectomy. Surg Endosc 2010; 25:817-25. [PMID: 20725748 DOI: 10.1007/s00464-010-1265-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Accepted: 07/14/2010] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Lymphoscintigraphy and sentinel node mapping is established in breast cancer and melanoma but not in esophageal cancer, even though many centers have shown that occult tumor deposits in lymph nodes influence prognosis. We report our initial experience with lymphoscintigraphy and sentinel lymph node biopsy in patients undergoing resection for esophageal cancer. METHODS Sixteen of 17 consecutive patients underwent resection for invasive esophageal cancer along with sentinel lymph node retrieval (resection rate, 94%). Peritumoral injection of (99m)Tc antimony colloid was performed by upper endoscopy prior to the operation. A two-surgeon synchronous approach via right thoracotomy and laparotomy was performed with conservative lymphadenectomy. Sentinel lymph nodes were identified using a gamma probe both in vivo and ex vivo. Sentinel lymph nodes were sent off separately for serial sections and immunohistochemistry. RESULTS Median patient age was 60.4 years (range, 45-75 years). Fifteen were male, and thirteen had adenocarcinoma. At least one sentinel lymph node (median, 2) was identified in 14 of 16 patients (success rate, 88%). Sentinel nodes were present in more than one nodal station in five patients (31%). In all 14 patients, the sentinel lymph node accurately predicted findings in non-sentinel nodes (accuracy, 100%). Three patients with positive sentinel lymph nodes had metastases identified in non-sentinel nodes (sensitivity, 100%). CONCLUSIONS Sentinel lymph node biopsy is feasible in esophageal resection with conservative lymphadenectomy, and initial results suggest it is accurate in predicting overall nodal status. Further study is needed to assess impact on patient management and prognosis.
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Affiliation(s)
- Sarah K Thompson
- Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia.
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21
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Abstract
Carcinoma of the oesophagus including carcinoma of gastro-oesophageal junction are rapidly increasing in incidence. During recent years there have been changes in the knowledge surrounding biology of the disease progression. Identification of dysplasia in mucosal biopsies is the most reliable pathologic indicator of an increased risk of development of squamous cell carcinoma and passes through the sequence of chronic esophagitis, low-grade and high-grade dysplasia and invasive carcinoma. Although Barrett's esophagus is a precursor to esophageal adenocarcinoma and have a well described sequence of carcinogenesis: the Barrett's metaplasia-dysplasia-adenocarcinoma sequence, not all patients with this disorder require intensive surveillance. The natural history of dysplasia is poorly understood, particularly in low-risk regions, and prospective follow-up studies are needed. Adjunctive methods to improve reproducibility, such as immunostaining for alpha-methylacyl-coenzyme A racemase (AMACR), show promise, but require confirmation in larger studies. In addition, several controversial methods such as detection of p16, p53, and DNA content abnormalities may help identify patients at particularly high risk for progression to cancer, but these techniques are not yet widely available for routine clinical application. More studies are needed to define other early nonmorphologic biomarkers for risk of squamous cell carcinoma. Recent evidence regarding the importance of several histopathologically derived prognostic factors, such as circumferential resection margin status and lymph node metastases are evaluated, including lymph node micrometastases and the sentinel node concept. With the rising use of multimodal treatments for oesophageal cancer it is important that the response of the tumour to this therapy can be carefully documented by histopathology.
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Gretschel S, Schlag PM. Current status of sentinel lymph node biopsy in adenocarcinoma of the distal esophagus, gastric cardia, and proximal stomach. Recent Results Cancer Res 2010; 182:107-114. [PMID: 20676875 DOI: 10.1007/978-3-540-70579-6_9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The resection of the adenocarcinoma of the esophagogastric junction should be considered to the extent of the lymphatic drainage. This, on the other hand, depends on the possible lymphatic metastasizing. As an adenocarcinoma of the esophagogastric junction is located along the borderline between two visceral cavities (mediastinal/abdominal), it can, in principle, metastasize in both cavities. There is not, however, an imaging (CT, MRI, PET) that can adequately assure the detection of a beginning lymph node metastasis in particular. The sentinel lymph node biopsy could provide the beginning of a solution in this case. The initial results, with all of the necessary accompanying technical work, have been encouraging. The paper presented here provides an introduction to the challenge of the SLNB and the background of a specialized surgical therapy of the AEG. If a lymph nodal metastasis can be definitely confirmed or ruled out, many patients could be spared an unnecessary lymphadenectomy. This is especially important at the AEG because minimizing the evasiveness of the surgery with adequate radical oncological resection (e.g., without thoracotomy) would mean a substantial reduction of postoperative mortality.
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Affiliation(s)
- Stephan Gretschel
- Charité-Universitätsmedizin Berlin, Campus Mitte, Klinik für Allgemein-Visceral-, Gefäss- und Thoraxchirurgie, Charitéplatz 1, 10117, Berlin, Germany.
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Klein CA, Stoecklein NH. Lessons from an aggressive cancer: evolutionary dynamics in esophageal carcinoma. Cancer Res 2009; 69:5285-8. [PMID: 19549904 DOI: 10.1158/0008-5472.can-08-4586] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rapid progression to metastatic disease and an intrinsic resistance to any type of systemic therapy are hallmarks of aggressive solid cancers. The molecular basis for this phenotype is not clear. A detailed study of the somatic progression from local to early systemic esophageal cancer revealed rapid diversification of cancer cells isolated from various sites, but also evidence for early clonal expansion. These findings have implications for diagnostic pathology and therapeutic decision making.
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Affiliation(s)
- Christoph A Klein
- Department of Pathology, Division of Oncogenomics, University of Regensburg, Regensburg, Germany.
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Scudiere JR, Montgomery EA. New treatments, new challenges: pathology's perspective on esophageal carcinoma. Gastroenterol Clin North Am 2009; 38:121-33, ix. [PMID: 19327571 DOI: 10.1016/j.gtc.2009.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
While frank esophageal carcinoma rarely presents a diagnostic challenge, early lesions are often tricky to assess. This difficulty stems in part from drawbacks in the classification systems designed to stratify early lesions as a guide for deciding treatment. These systems are complex and wrought with specific pathologic challenges brought on by new treatment modalities. Such interventions as endoscopic mucosal resection, photodynamic therapy, and chemotherapy/radiation combinations present the pathologist with new histologic challenges that have a direct impact on patient care. In this article, we discuss staging issues pertinent to early cancers, histologic sequelae of various treatments, and how these factors affect the pathologist's role in evaluating esophageal carcinoma.
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Affiliation(s)
- Jennifer R Scudiere
- Department of Pathology, The Johns Hopkins Medical Institutions, 401 N. Broadway, Baltimore, MD 21231-2410, USA
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Grotenhuis BA, Wijnhoven BPL, van Marion R, van Dekken H, Hop WC, Tilanus HW, van Lanschot JJB, van Eijck CHJ. The sentinel node concept in adenocarcinomas of the distal esophagus and gastroesophageal junction. J Thorac Cardiovasc Surg 2009; 138:608-12. [PMID: 19698844 DOI: 10.1016/j.jtcvs.2008.11.061] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Revised: 10/17/2008] [Accepted: 11/27/2008] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The sentinel node concept is of great value in the treatment of various malignancies. In this study we investigated whether the application of the sentinel node procedure is feasible in esophageal adenocarcinoma and whether it can tailor surgical treatment of the individual patient. METHODS In 40 patients with an adenocarcinoma of the distal esophagus or gastroesophageal junction, blue dye was injected around the tumor intraoperatively. Sentinel nodes (blue-stained) and nonsentinel nodes were identified and dissected during transhiatal esophagectomy. In sentinel nodes negative for tumor cells on routine hematoxylin-eosin examination, multilevel sectioning and immunohistochemical staining were performed to search for micrometastases. RESULTS The sentinel node procedure was technically successful in 39 of 40 patients (98%). The median number of sentinel nodes identified was 4. Sentinel nodes were present in more than 1 nodal station in 8 patients (21%). In 6 patients in whom the sentinel node was negative for metastasis, nonsentinel nodes were positive for tumor cells (false-negative rate 6/39 = 15%). Micrometastases and isolated tumor cells were detected in 7 of 19 patients (37%) with sentinel nodes, but this finding did not affect the false-negative rate. CONCLUSION Detection of sentinel nodes is technically feasible during esophagectomy for cancer. However, given the relatively high false-negative rate of 15% and the high frequency of sentinel nodes in more than 1 nodal station, the clinical relevance of the sentinel node concept (through application of the blue dye technique) in the current treatment of patients with an adenocarcinoma of the distal esophagus or gastroesophageal junction seems limited.
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Carboni F, Lorusso R, Santoro R, Lepiane P, Mancini P, Sperduti I, Santoro E. Adenocarcinoma of the esophagogastric junction: the role of abdominal-transhiatal resection. Ann Surg Oncol 2008; 16:304-10. [PMID: 19050964 DOI: 10.1245/s10434-008-0247-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Revised: 10/01/2008] [Accepted: 10/28/2008] [Indexed: 12/23/2022]
Abstract
The surgical strategy for adenocarcinoma of the esophagogastric junction is still controversial. The aim of this study was to evaluate surgical results of the abdominal-transhiatal approach for 100 consecutively operated type II and III cardia adenocarcinoma, to clarify clinicopathological differences between these tumors, and to define prognostic factors. A prospectively maintained database identified 100 consecutively operated patients with Siewert type II and III cardia adenocarcinoma. Survival was analyzed by the Kaplan-Meier method. Differences between subgroups and prognostic factors were evaluated by the log rank test and Cox regression. Concerning clinicopathological characteristics, only the incidence of T1-2 stage was significantly higher in Siewert II type (P = .006). A complete (R0) resection was obtained in 74 patients (74%). Overall postoperative mortality and morbidity rates were 6% and 28%, respectively. Overall actuarial 5-year survival rate in resected patients was 27.4% (median 27 months), with 20.6% for type II and 34 for type III cancers (P = .07). Considering R0 resections, overall actuarial 5-year survival rate was 33.9% (median 33 months), with 26.7% for type II and 40.5 for type III cancer (P = .06). Pathologic T and N stage and R status were independent prognostic factors by multivariate analysis, and Siewert type showed a trend toward significance. The abdominal-transhiatal approach is a safe surgical approach, allowing complete tumor resection and adequate lymphadenectomy in these patients. True carcinoma of the cardia may be a distinct clinical entity with a more aggressive natural history than subcardial gastric carcinoma.
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Affiliation(s)
- Fabio Carboni
- Department of Digestive Surgery, Regina Elena Cancer Institute, Rome, Italy.
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Meier I, Merkel S, Papadopoulos T, Sauer R, Hohenberger W, Brunner TB. Adenocarcinoma of the esophagogastric junction: the pattern of metastatic lymph node dissemination as a rationale for elective lymphatic target volume definition. Int J Radiat Oncol Biol Phys 2008; 70:1408-17. [PMID: 18374226 DOI: 10.1016/j.ijrobp.2007.08.053] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2007] [Revised: 08/21/2007] [Accepted: 08/21/2007] [Indexed: 01/28/2023]
Abstract
PURPOSE Regional nodal metastasis after neoadjuvant chemoradiation of adenocarcinoma of the esophagogastric junction (AEG) predicts survival. We aimed to clarify the lymph node (LN) distribution of AEG according to location of the tumor mass and invasion of neighboring areas for the selection of radiotherapy planning target volume (PTV) margins. METHODS AND MATERIALS Patterns of regional spread were analyzed in pathology reports of 326 patients patients with AEG who had undergone primary resection, with > or = 15 lymph nodes examined. Tumors were classified into AEG types based on endoscopy and pathology reports. Fisher's exact test was used to compare nodal disease and tumor characteristics. Pulmonary dose-volume histograms were tested in 8 patients. RESULTS Nodes were positive in 81% of T2 to T4 tumors. Type of AEG, tumor size, lymphovascular invasion, and grading significantly influenced nodal distribution. We found that marked esophageal invasion of AEG II/III significantly correlated with paraesophageal nodal disease, and T3 to T4 AEG II/III had a significant rate of splenic hilum/artery nodes. Middle and lower paraesophageal nodes should be treated in T2 to T4 AEG I and AEG II with > or = 15 mm involvement above the Z-line, and T3 to T4 AEG II. The splenic hilum and artery nodes can be spared in T2 AEG tumors, especially Type I tumors. The influence of paraesophageal nodal treatment on the risk of postoperative pulmonary complications can be estimated from dose-volume histograms. CONCLUSIONS Accurate pretherapeutic staging predicts the risk of subclinical nodal disease and should be used to select the appropriate radiotherapeutic PTV. Careful selection of the PTV can be used to maximize the therapeutic window in multimodal therapy for AEG.
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Affiliation(s)
- Iris Meier
- Department of Radiation Oncology, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
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McGuill MJ, Byrne P, Ravi N, Reynolds J. The prognostic impact of occult lymph node metastasis in cancer of the esophagus or esophago-gastric junction: systematic review and meta-analysis. Dis Esophagus 2008; 21:236-40. [PMID: 18430105 DOI: 10.1111/j.1442-2050.2007.00765.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Attempts to define the clinical significance of occult lymph node metastasis have yielded mixed results. We set out to quantify the influence on disease-free survival of occult lymph node metastasis in cases of esophageal or gastro-esophageal cancer previously staged as lymph node-negative by conventional H&E staining. We performed a systematic review and meta-analysis of observational studies published between 1966 and 2006 (identified through Medline and Embase). Twelve suitable cohort studies were identified. These studies suggest there is a significant (P < 0.001) association between occult lymph node metastasis and prognosis in cancer of the esophagus or esophago-gastric junction (pooled hazard ratio 3.16 with 95% confidence intervals of 2.25-4.42). We did not demonstrate study quality, number of nodes examined or number of lymph node sections examined to be significant sources of intertrial heterogeneity. Data from observational studies suggest that occult lymph node metastasis is an important prognostic factor in cancer of the esophagus or gastro-esophagus. Meta-analysis using individual patient data can now be justified.
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Affiliation(s)
- M J McGuill
- Clinical Surgery, St. James's Hospital & Trinity College Dublin, Ireland
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Schwarz RE, Smith DD. Clinical impact of lymphadenectomy extent in resectable esophageal cancer. J Gastrointest Surg 2007; 11:1384-93; discussion 1393-4. [PMID: 17764019 DOI: 10.1007/s11605-007-0264-2] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Accepted: 07/19/2007] [Indexed: 01/31/2023]
Abstract
Esophageal cancer (EC) frequently presents with advanced stages and is associated with high recurrence rates after esophagectomy. The value of an extended lymph node dissection (ELND) remains unclear in this setting. An EC data set was created from the Surveillance, Epidemiology, and End-Results 1973-2003 database. Relationships between the number of lymph nodes (LNs) examined and overall survival (OS) were analyzed. From a cohort of 40,129 EC patients, 5,620 individuals were selected. The median age was 65 (range: 11-102), and 75% were men. The median tumor size was 5.0 cm (0.1-30). On multivariate analysis, total LN count (or negative LN count, respectively) was an independent prognostic variable, aside from age, race, resection status, radiation, T category, N category (all at p < 0.0001), and M category (p = 0.0003). Higher total LN count (>30) and negative LN count (>15) categories were associated with best OS and lowest 90-day mortality (p < 0.0001). The numeric LN effect on OS was independent from nodal status or histology. Greater total and negative LN counts are associated with longer EC survival. Although the mechanism remains uncertain, it does not appear to be limited to stage migration. ELND during potentially curative esophagectomy for EC can be supported by the data.
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Affiliation(s)
- Roderich E Schwarz
- Division of Surgical Oncology, UT Southwestern Cancer Center, Dallas, TX 75390, USA.
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Gervasoni JE, Sbayi S, Cady B. Role of lymphadenectomy in surgical treatment of solid tumors: an update on the clinical data. Ann Surg Oncol 2007; 14:2443-62. [PMID: 17597349 DOI: 10.1245/s10434-007-9360-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2006] [Accepted: 01/09/2007] [Indexed: 12/31/2022]
Abstract
BACKGROUND The role of lymphadenectomy as an adjunct of standard excision for treatment of cancer is highly debated and controversial. Standard practice for treatment of solid tumors is resection with regional lymphadenectomy. This surgical concept assumes that cancers grow and spread in an orderly manner, from primary cancer to regional lymph nodes and finally to vital organs. We reviewed randomized trials, published a description of lymphatic anatomy and physiology, and presented data that disputed the role of lymphadenectomy as standard practice. The present review updates the literature and reiterates the concept that lymphadenectomy does not increase survival in the surgical treatment of solid tumors. METHODS We reviewed the English-language literature (Medline) for prospective randomized trials and nonrandomized reports, as well as retrospective studies addressing the role of lymphadenectomy in cancers of the esophagus, lung, stomach, pancreas, breast, and skin (melanoma) reported between 2000 and 2006. RESULTS This extensive review demonstrates that there are few prospective randomized trials assessing patient survival with solid tumors that contrast resection with or without lymphadenectomy. However, there was at least one, and for some cancers more than one, prospective randomized trial for each organ site studied, and the data demonstrate no statistically significant difference in overall survival of patients treated with or without lymphadenectomy. Most nonrandomized and retrospective studies, with a few exceptions, support the conclusions of randomized trials; lymphadenectomy does not improve overall survival in solid tumors. Overall survival is primarily a function of the biological nature of the primary tumor, as evidenced by lymphovascular invasion, lymph node involvement, and other prognostic features. CONCLUSIONS This extensive literature review of recent reports indicates that lymphadenectomy does not improve overall survival. Lymph node resection should be conceived in terms of staging, prognosis, and regional control only.
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Affiliation(s)
- James E Gervasoni
- Department of Surgery, Saint Peter's University Hospital, 254 Easton Ave, New Brunswick, New Jersey 08901, USA.
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MacGuill MJ, Barrett C, Ravi N, MacDonald G, Reynolds JV. Isolated tumour cells in pathological node-negative lymph nodes adversely affect prognosis in cancer of the oesophagus or oesophagogastric junction. J Clin Pathol 2007; 60:1108-11. [PMID: 17220206 PMCID: PMC2014831 DOI: 10.1136/jcp.2006.044149] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIMS To determine the prevalence of isolated tumour cells (ITC) in lymph nodes of patients with pathological node-negative (pN0) tumours and to assess their impact on disease-free and overall survival. METHODS Paraffin embedded lymph nodes from oesophagogastrectomy specimens were examined immunohistochemically using monoclonal anti-cytokeratin antibody (MNF118). Clinical and pathological features were summarised and overall and relapse-free survival were estimated. RESULTS Isolated tumour cells were detected in 12 of 146 patients (8%), and 24 of 1694 (1%) lymph nodes. With a median follow-up time of 28 months (range 0-160 months), both relapse-free and overall survival were significantly (p<0.05) associated with the presence of ITC in pN0 lymph nodes. There was no significant difference in the prevalence of ITC between patients who underwent multimodal therapy and those treated with surgery alone. CONCLUSIONS ITC in pN0 lymph nodes may be less frequent than previously considered, but their presence is associated with poorer outcomes compared with true node negative disease.
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Affiliation(s)
- Martin J MacGuill
- Department of Surgery, St James's Hospital and Trinity College, Dublin, Ireland
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Gretschel S, Bembenek A, Schulze T, Kemmner W, Schlag PM. [Minimal residual tumor in gastrointestinal carcinoma. Relevance to prognosis and oncologic surgical consequences]. Chirurg 2006; 77:1104-17. [PMID: 17119886 DOI: 10.1007/s00104-006-1263-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Isolated tumor cells as a consequence of minimal residual disease are often not detectable by routine diagnostic procedures. However, before or after surgery, isolated tumor cells in lymph nodes, the peritoneal cavity, blood, or bone marrow can frequently be identified by immunohistochemical or molecular methods. Failure to reveal the presence of such cells results in under-staging of tumor patients and may constitute the source of unexpected tumor recurrence after radical surgery. These facts emphasize the importance of isolated tumor cells at least as a surrogate marker. The frequency of appearance of isolated tumor cells in different organ systems also depends on the type of primary tumor. Developments in modern detection methods have led to increasing sensitivity but at the expense of specificity. Isolated tumor cells demonstrate remarkable heterogeneity with respect to proliferative potential and tumorigenicity. This characteristic is also reflected by a striking variability in the expression of various genes conditioning the aforementioned biological behavior. Unfortunately there is also remarkable heterogeneity in methods used for sampling and processing patient material as well as for the enrichment and detection of isolated tumor cells. Despite the ongoing controversies concerning detection methods and biological significance of isolated tumor cells, several clinical trials providing data supporting the prognostic relevance of minimal residual disease should also be considered for gastrointestinal carcinoma. In future this finding should be integrated in the planning of trials in surgical oncology, and "minimal residual disease" should receive stronger attention as a stratification criterion in such clinical studies.
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Affiliation(s)
- S Gretschel
- Klinik für Chirurgie und Chirurgische Onkologie, Robert-Rössle-Klinik am Helios Klinikum Berlin, Universitätsmedizin Berlin, Charite Campus Buch, Lindenberger Weg 80, 13125 Berlin
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Griffiths EA, Pritchard SA, Mapstone NP, Welch IM. Emerging aspects of oesophageal and gastro-oesophageal junction cancer histopathology - an update for the surgical oncologist. World J Surg Oncol 2006; 4:82. [PMID: 17118194 PMCID: PMC1664566 DOI: 10.1186/1477-7819-4-82] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2006] [Accepted: 11/21/2006] [Indexed: 12/29/2022] Open
Abstract
Adenocarcinoma of the oesophagus and gastro-oesophageal junction are rapidly increasing in incidence and have a well described sequence of carcinogenesis: the Barrett's metaplasia-dysplasia-adenocarcinoma sequence. During recent years there have been changes in the knowledge surrounding disease progression, cancer management and histopathology specimen reporting. Tumours around the gastro-oesophageal junction (GOJ) pose several specific challenges. Numerous difficulties arise when the existing TNM staging systems for gastric and oesophageal cancers are applied to GOJ tumours. The issues facing the current TNM staging and GOJ tumour classification systems are reviewed in this article. Recent evidence regarding the importance of several histopathologically derived prognostic factors, such as circumferential resection margin status and lymph node metastases, have implications for specimen reporting. With the rising use of multimodal treatments for oesophageal cancer it is important that the response of the tumour to this therapy is carefully documented pathologically. In addition, several controversial and novel areas such as endoscopic mucosal resection, lymph node micrometastases and the sentinel node concept are being studied. We aim to review these aspects, with special relevance to oesophageal and gastro-oesophageal cancer specimen reporting, to update the surgical oncologist with an interest in upper gastrointestinal cancer.
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Affiliation(s)
- Ewen A Griffiths
- Department of General Surgery, The University Hospitals of Morecambe Bay NHS Trust, Royal Lancaster Infirmary, Ashton Road, Lancaster, LA1 4RP, UK
| | - Susan A Pritchard
- Department of Histopathology, South Manchester University Hospitals NHS Trust, Wythenshawe Hospital, South Moor Road, Wythenshawe, Manchester, M23 9LT, UK
| | - Nicholas P Mapstone
- Department of Pathology, The University Hospitals of Morecambe Bay NHS Trust, Royal Lancaster Infirmary, Ashton Road, Lancaster, LA1 4RP, UK
| | - Ian M Welch
- Department of Gastrointestinal Surgery, South Manchester University Hospitals NHS Trust, Wythenshawe Hospital, South Moor Road, Wythenshawe, Manchester, M23 9LT, UK
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Lagarde SM, ten Kate FJW, Reitsma JB, Busch ORC, van Lanschot JJB. Prognostic factors in adenocarcinoma of the esophagus or gastroesophageal junction. J Clin Oncol 2006; 24:4347-55. [PMID: 16963732 DOI: 10.1200/jco.2005.04.9445] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The incidence of adenocarcinoma of the esophagus is rising rapidly in Western Europe and North America. It is an aggressive disease with early lymphatic and hematogenous dissemination. TNM cancer staging systems predict survival on the basis of the anatomic extent of the tumor. However, the adequacy of the current TNM staging system for adenocarcinoma of the esophagus or gastroesophageal junction (GEJ) is questioned repeatedly. Numerous prognostic factors have been described, but are not included in the TNM system. This review describes clinical parameters, aspects of operative technique, response to preoperative chemoradiotherapy therapy, complications and established pathologic determinants found in the resection specimen that have a prognostic impact. Furthermore, their potential application in the clinical setting in patients with adenocarcinoma of the esophagus or GEJ is discussed. Future directions to improve staging systems are given.
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Affiliation(s)
- Sjoerd M Lagarde
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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Schurr PG, Yekebas EF, Kaifi JT, Lasch S, Strate T, Kutup A, Cataldegirmen G, Bubenheim M, Pantel K, Izbicki JR. Lymphatic spread and microinvolvement in adenocarcinoma of the esophago-gastric junction. J Surg Oncol 2006; 94:307-15. [PMID: 16917878 DOI: 10.1002/jso.20582] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Adenocarcinoma of the esophago-gastric junction (EGJ) potentially spreads to abdominal and mediastinal lymph nodes. METHODS Eighty-five patients with type I and II EGJ cancer underwent curative esophagectomy or esophago-gastrectomy and radical abdominal and mediastinal lymphadenectomy. Microinvolvement was detected with the mAb Ber-Ep4 in all histopathologically free lymph nodes. RESULTS In type I tumors (n = 40), lower mediastinal lymph nodes were positive in 24% and among type II tumors (n = 45) in 10% of patients. Ber-Ep4+ cells in apparently free lymph nodes were found in 49% of patients. On inclusion of Ber-Ep4+ nodes, positive mediastinal lymph node staging was rising to 40 and 33% in type I and II patients, respectively. After a median observation time of 27.1 months, 37 of 85 patients (43.5%) had died of tumor disease. Kaplan-Meier analysis revealed a significant impact of nodal microinvolvement on disease-specific survival for type I and type II tumors (P = 0.016 and P < 0.001, respectively). Cox regression analysis revealed a 2.77 higher independent risk (P = 0.002) for nodal microinvolvement. CONCLUSIONS Lymphatic microinvolvement shows a high incidence in curatively resected EGJ cancer. Spread to mediastinal lymph nodes seems to necessitate lymphadenectomy of the thoracic cavity in either type.
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Affiliation(s)
- Paulus G Schurr
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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