Nodal skip metastasis is associated with a relatively poor prognosis in thoracic esophageal squamous cell carcinoma

The Prognostic Value of Nodal Skip Metastasis in Patients with Esophageal Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Esophageal cancer (EC) is the sixth leading cause of cancer deaths worldwide. Nodal skip metastasis (NSM), a common form of lymphatic spread in EC, can be defined as the metastatic involvement of distant lymph nodes (LNs) without prior involvement of adjacent LNs. The results of the previous studies investigating the association between NSM and survival outcomes in patients with EC were inconsistent and even contradictory. The aim of this systematic review and meta-analysis is to investigate the prognostic value of NSM and to summarize the NSM definitions of EC in previous studies.

METHODS

Four databases were used in this meta-analysis. The association between NSM and overall survival (OS) was evaluated by using pooled HRs and their 95% confidence interval (CI). The sensitivity analysis and funnel plot were used to assess the publication bias.

RESULTS

Nine studies were included in this meta-analysis. The pooled results of meta-analysis indicated that there was no significant association between NSM and OS (HR = 0.99, 95% CI: 0.75-1.31; P = 0.951). Meanwhile, according to the results of sub-group analysis on the basis of histological feature, method of lymphadenectomy, node staging system, and NSM definitions, no significant association was found between NSM and OS.

CONCLUSIONS

On the basis of available evidences, NSM could not be used as a prognostic factor for patients with EC. For future studies investigating the prognostic value of NSM, only three-field lymphadenectomy with adequate harvested LNs can be performed. NSM definitions based on lymph node station and anatomical compartment could both be feasible classification for EC.

Extended lower paratracheal lymph node resection during esophagectomy for cancer - safety and necessity

BACKGROUND

The ideal extent of lymphadenectomy (LAD) in esophageal oncological surgery is debated. There is no evidence for improved survival after standardized paratracheal lymph node resection performing oncological esophagectomy. Lymph nodes from the lower paratracheal station are not standardly resected during 2-field Ivor-Lewis esophagectomy for esophageal cancer. The objective of this study was to evaluate the impact of lower paratracheal lymph node (LPL) resection on perioperative outcome during esophagectomy for cancer and analyze its relevance.

METHODS

Retrospectively, we identified 200 consecutive patients operated in our center for esophageal cancer from January 2017 - December 2019. Patients with and without lower paratracheal LAD were compared regarding demographic data, tumor characteristics, operative details, postoperative complications, tumor recurrence and overall survival.

RESULTS

103 out of 200 patients received lower paratracheal lymph node resection. On average, five lymph nodes were resected in the paratracheal region and cancer infiltration was found in two patients. Those two patients suffered from neuroendocrine carcinoma and melanoma respectively. Cases with lower paratracheal lymph node yield had significantly less overall complicated procedures (p = 0.026). Regarding overall survival and recurrence rate no significant difference could be detected between both groups (p = 0.168 and 0.371 respectively).

CONCLUSION

The resection of lower paratracheal lymph nodes during esophagectomy remains debatable for distal squamous cell carcinoma or adenocarcinoma of the esophagus. Tumor infiltration was only found in rare cancer entities. Since resection can be performed safely, we recommend LPL resection on demand.

Prognostic value of node skip metastasis on esophageal cancer: A systematic review and meta-analysis

The association between NSM and prognosis of esophageal cancer remains controversial, though several studies have been conducted drawing their own conclusion. Therefore, we firstly carried out this meta-analysis aiming to explore the association. We performed a comprehensive literature search online, including PubMed, Embase and Web of Science. We selected deaths at 5 years and hazard ratio (HR) with 95% (CI) to perform the meta-analysis with Review Manager 5.3, predicting value of clinic-pathological features in NSM also been analyzed. A total of 7 studies were finally enrolled in this study. NSM, defined by either JSED criterion or anatomical compartment criterion, neither showed significant prognostic value on OS of esophageal cancer (P = 0.64), (P = 0.24). Subgroup analysis of JSED criterion, NSM was not a prognostic factor in solitary node metastasis patients (P = 0.39), whereas NSM demonstrated a poor prognostic factor (P = 0.01) for ESCC. Subgroup analysis according to anatomical criterion, NSM was a favorable factor for OS in middle thoracic ESCC (P = 0.003). Pathological N1 status was found to be a risk factor for NSM (P < 0.00001) according to JSED criterion and middle thoracic ESCC was identified as a predictor for NSM (P = 0.0003) according to anatomical compartment criterion. According to JSED criterion, NSM demonstrated poor prognosis on ESCC and N1 status was a risk factor for NSM. Concerning the anatomical compartment criterion, a favorable prognosis of NSM was found in middle thoracic ESCC and NSM was prone to occur in middle thoracic ESCC. CRD42021219333.

Role of nodal skip metastasis in patients with mid-thoracic oesophageal squamous cell carcinoma: a propensity score matching study

OBJECTIVES

Nodal skip metastasis (NSM) is a common phenomenon in mid-thoracic oesophageal squamous cell carcinoma (MT-OSCC); however, the prognostic implications of NSM in patients with MT-OSCC remain unclear.

METHODS

This retrospective study enrolled 300 patients with MT-OSCC who underwent radical oesophagectomy and who had pathologically confirmed lymph node metastasis from January 2014 to December 2016. The patients were divided into 2 groups according to the presence or absence of NSM. Propensity score matching was applied to minimize patient selection bias. The impact of NSM on overall survival (OS) was assessed by Kaplan-Meier and multiple Cox proportional hazards analyses. The median follow-up time was 57 months.

RESULTS

The NSM rate in the entire cohort was 22.0% (66/300). Pathological N (pN) stage (P < 0.001) and sex (P = 0.001) were identified as significant independent risk factors for NSM. NSM was more frequent in pN1 compared with pN2 patients (87.9% vs 12.1%, P < 0.001) and no NSM was found in pN3. NSM(+) patients had better prognoses than NSM(-) patients (Kaplan-Meier; 3-year OS, 62.1% vs 34.1%, P < 0.001). Propensity score matching produced 51 matched pairs, and the 3-year OS was still better in the NSM(+) compared with the NSM(-) group (66.7% vs 40.0%, P = 0.025). Multivariable Cox analysis confirmed NSM(+) as an independent factor favouring OS in patients with MT-OSCC.

CONCLUSIONS

NSM usually occurs at pN1 stage in patients with MT-OSCC, and is associated with a favourable prognosis.

A Specific Predicting Model for Screening Skip Metastasis From Patients With Negative Central Lymph Nodes Metastasis in Papillary Thyroid Cancer

Skip metastasis is a specific type of papillary thyroid cancer lymph node metastasis (LNM). The present study aimed to clarify the typical clinical characteristics of skip metastasis and optimize the prediction model, so as to provide a more individual treatment mode for skip metastasis. We retrospectively analyzed 1075 PTC patients with different lymph node metastasis statuses from two clinical centers. Comparisons have been made between patients with skip metastasis and other types of LNM. Univariate and multivariate analyses were performed to detect the risk factors for skip metastasis with negative LNM, and a nomogram for predicting skip metastasis was established. The rate of skip metastasis was 3.4% (37/1075). Compared with other types of LNM, significant differences showed in tumor size, upper portion location, thyroid capsular invasion, and ipsilateral nodular goiter with the central lymph node metastasis (CLNM) group, and in age and gender with the lateral lymph node metastasis (LLNM) group. Four variables were found to be significantly associated with skip metastasis and were used to construct the model: thyroid capsular invasion, multifocality, tumor size > 1 cm, and upper portion. The nomogram had good discrimination with a concordance index of 0.886 (95% confidence interval [CI], 0.823 to 0.948). In conclusion, the significant differences between skip metastasis and other types of LNM indicated that the lymph node drainage pathway of skip metastasis is different from either CLNM or LLNM. Furthermore, we established a nomogram for predicting risk of skip metastasis, which was able to effectively predict the potential risk of skip metastasis in patients without preoperative LNM clue.

Distribution of Lymph Node Metastases in Esophageal Carcinoma Patients Undergoing Upfront Surgery: A Systematic Review

Metastatic lymphatic mapping in esophageal cancer is important to determine the optimal extent of the radiation field in case of neoadjuvant chemoradiotherapy and lymphadenectomy when esophagectomy is indicated. The objective of this review is to identify the distribution pattern of metastatic lymphatic spread in relation to histology, tumor location, and T-stage in patients with esophageal cancer. Embase and Medline databases were searched by two independent researchers. Studies were included if published before July 2019 and if a transthoracic esophagectomy with a complete 2- or 3-field lymphadenectomy was performed without neoadjuvant therapy. The prevalence of lymph node metastases was described per histologic subtype and primary tumor location. Fourteen studies were included in this review with a total of 8952 patients. We found that both squamous cell carcinoma and adenocarcinoma metastasize to cervical, thoracic, and abdominal lymph node stations, regardless of the primary tumor location. In patients with an upper, middle, and lower thoracic squamous cell carcinoma, the lymph nodes along the right recurrent nerve are often affected (34%, 24% and 10%, respectively). Few studies describe the metastatic pattern of adenocarcinoma. The current literature is heterogeneous in the classification and reporting of lymph node metastases. This complicates evidence-based strategies in neoadjuvant and surgical treatment.

Clinical significance and prognosis of supraclavicular lymph node metastasis in patients with thoracic esophageal cancer

Background

Although most studies proved that thoracic esophageal cancer surgery with supraclavicular lymph nodes (SCLNs) metastasis could benefit, less than 30% of the 5-year survival rate remained controversy on its surgical treatment. In this study, we aimed to analyze the prognosis of SCLNs on the different segments of thoracic esophageal cancer, which will supply a reference for the treatment of this disease.

Methods

Retrospectively collected the clinical data of 163 patients with thoracic esophageal squamous cancer (ESCC) and compared the effects of SCLNs on prognosis in different segments.

Results

Patients with SCLNs metastasis had a worse prognosis than the negative group (P<0.001). In the upper thoracic group, there was no significant difference in OS between SCLNs positive group and negative group (P=0.077); however, in the middle and lower thoracic group, SCLNs positive group had a worse prognosis than the negative group (P<0.001) and lymph nodes positive in other sites (except for SCLNs) (P=0.039). Multivariate analysis found that SCLNs metastasis was an independent risk factor affecting the prognosis of ESCC in the middle and lower thoracic segments (P=0.007).

Conclusions

For patients with upper thoracic ESCC, SCLNs appear to be regional nodes. For the middle and lower thoracic ESCC, SCLNs should be defined as distant metastasis, and neoadjuvant therapy first may be an available therapy.

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.

Negative lymph node at station 108 is a strong predictor of overall survival in esophageal cancer

A negative lymph node (NLN) may represent a stronger predictor for the overall survival (OS) rate of patients with esophageal squamous cell carcinoma (ESCC), when compared with a positive LN (PLN). The present study aimed to investigate which LN station, containing the NLN, was associated with OS rate. A retrospective review was conducted in 216 patients with ESCC and a forward stepwise Cox regression model analysis was used to assess the relationship between clinical parameters and OS rate. Patients were divided into subgroups according to the status of the LN at station 108. Survival analysis was performed using the Kaplan-Meier method. The ratio of albumin-to-globulin (AGR), and of lymphocytes to neutrophil granulocytes (LNR) in the subgroups were also investigated. Overall, 105p (the PLN number at station 105), 108p, 109p and 7p were confirmed to be risk factors for OS rate (all P<0.05). Conversely, 108n (the NLN number at station 108) was identified as a protective factor for OS rate [hazard ratio (HR) 0.457, P=0.001]. Survival analysis demonstrated that patients with an NLN identified at the station 108 had an improved OS rate compared with those with a PLN identified at station 108 (P=0.006). Patients with only an NLN identified at station 108 had the best OS rate among all the sub-groups examined, and the AGR of this group of patients was higher than those of the other groups. The LN status at station 108 may indicate the prognosis of patients with ESCC, and an NLN may reflect the reaction of the immune system to tumor metastasis in these patients.

Pattern of lymph node metastasis in thoracic esophageal squamous cell carcinoma with poor differentiation

The aim of the present study was to explore the pattern of lymph node metastasis (LNM) in poorly-differentiated esophageal squamous cell carcinoma (pdESCC) and the implication of postoperative irradiation. A total of 690 patients with pdESCC were retrospectively investigated. The rates of intro-thoracic and extra-thoracic LNM in pdESCC were investigated and compared to previous research on ESCC en bloc. The comparison of the rates between pdESCC and ESCC were performed using the Cochran-Mantel-Haenszel test. The clinicopathological factors associated with LNM in pdESCC were analyzed by Chi-squared tests, and Fisher's exact test was used to assess the rate difference of extra-thoracic LNM. Logistic-regression analysis was used to explore risk factors associated with lymph node (LN) station. Results demonstrated that the distribution pattern of LNM in pdESCC was significantly different compared with that of ESCC (P<0.05). Univariate and multivariate analysis indicated that risk factors associated with LNM were depth and length (P<0.001 and P<0.001) and multivariate analysis also indicated that the location of the tumor (P=0.042) was a risk factor associated with LNM in pdESCC. Metastasis in the abdominal cavity was significantly higher than in the neck in the middle and lower thoracic pdESCC (both P<0.01). LN station 102 and 7 for upper thoracic ESCC, 101 and 105 for middle thoracic ESCC, and 100 for lower thoracic ESCC were identified as high-risk stations for metastases in pdESCC compared to ESCC. Several parameters, including location and neck metastasis, were identified as risk factors of metastasis for the above sites, respectively. In conclusion, postoperative therapy should include more LN stations in pdESCC depending on risk factors of tumor metastasis individually.

Elucidation of the Anatomical Mechanism of Nodal Skip Metastasis in Superficial Thoracic Esophageal Squamous Cell Carcinoma

Background

Lymph node metastasis (LNM) is a standard mechanism of cancer progression in esophageal squamous cell carcinoma (ESCC). We aimed to clarify the anatomical mechanism of skip nodal metastasis to mediastinal zones by analyzing the relationship between LNM to sentinel zones and lymphatic vessel counts in the muscle layer adjacent to the outer esophagus.

Methods

We examined the surgical records of 287 patients with ESCC who underwent potentially curative surgery (three-field lymphadenectomy) and whole esophagi, including pharynges and stomachs from 10 cadavers, to determine the number of lymphatic vessels in the intra-outer longitudinal muscle layer adjacent to the outer esophagus of the cervical (Ce), upper thoracic, middle thoracic (Mt), lower thoracic (Lt), and abdominal esophagi (Ae).

Results

The frequency of LNM to the middle mediastinal and supraclavicular zones, including the Mt and Ce, respectively, was lower than to the upper and lower mediastinal and abdominal zone in patients with superficial and advanced thoracic ESCC. In cadavers, the lymphatic vessel counts of the intra-outer longitudinal muscle layer in the Mt and Ce were significantly lower than those of the Lt and Ae, suggesting that lymphatic flow toward the outside of the Mt and Ce was not more abundant than to other sites.

Conclusion

Our anatomical data suggested that the absence of intra-muscle lymphatic vessels in the middle mediastinal and supraclavicular zones causes skip LNM in patients with thoracic ESCC. Thus, standard esophagectomy with lymph node dissection, including distant zones, may be appropriate for treating patients with superficial thoracic ESCC.

Electronic supplementary material

The online version of this article (10.1245/s10434-018-6390-0) contains supplementary material, which is available to authorized users.

The prognostic value of nodal skip metastasis in resectable thoracic esophageal squamous cell carcinoma

Purpose

This study aimed to investigate the incidence of nodal skip metastasis (NSM) to identify the risk factors that influence NSM and to assess the prognostic value of NSM in patients with thoracic esophageal squamous cell carcinoma (ESCC).

Patients and methods

Between January 2009 and December 2013, 285 patients with ESCC with positive lymph nodes who underwent complete resection were enrolled.

Results

For the entire group, NSM occurred in 32.3% (92/285) of patients. The median survival time and 5-year survival rate in the NSM group were 28 months and 12.0%, respectively, compared with 36.3 months and 25.0%, respectively, in the non-NSM group (P=0.008). Both N stage (P=0.001) and T stage (P=0.014) were associated with the incidence of NSM. NSM (P=0.008), T stage (P=0.000), and N stage (P=0.000) were independent prognostic factors for survival. In the NSM group, T stage (P=0.014) and N stage (P=0.000) were independent prognostic factors for survival.

Conclusion

It was concluded that NSM is common in ESCC and is associated with poor survival.