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

Risk factors and prognosis for supraclavicular lymph node metastasis in patients with thoracic esophageal cancer. Distant or regional metastasis?

We aimed to determine the frequency and prognosis of supraclavicular (#104) lymph node (LN) metastasis compared with other LN stations in patients with advanced thoracic esophageal cancer and to identify risk factors for metastasis to delineate the indications for three-field lymphadenectomy (3FL). The study cohort of 567 eligible patients with esophageal cancer had undergone subtotal esophagectomy from 2003 to 2020. LN metastasis was defined as pathologically proven metastasis or positron emission tomography-positive LNs. The efficacy index (EI), calculated from the frequency of LN metastases and survival rates, was used as prognostic value of each LN station dissection for patient survival. Risk factors for #104 LN metastasis were determined by multivariable logistic regression. The frequency of #104 LN metastasis was 11.6% overall, 31.7% in upper and 8.3% in middle/lower third lesion. Neoadjuvant chemotherapy was administered to 71% of patients and chemo-radiation to 11%. The 5-year overall survival was 45.8%. The EI for #104 LNs (5.3) was similar to that for #101 LNs. Risk factors were age < 65 years, upper third lesion, clinical N2-3, #101/106rec LN metastasis and poorly differentiated carcinoma. The 5-year overall survival of patients with middle/lower lesions was 38% (EI 3.1), similar to that for #101 and #8/9/11 LNs. The prognosis of patients with #104 LN metastases is similar to that of patients with metastases in other regional LN stations. Therefore, we recommend 3FL exclusively for patients at a high risk of #104 LN metastasis due to the overall metastatic rate not being high.

Clinical and Pathologic Supraclavicular Lymph Node Metastases in Esophageal Squamous Cell Carcinoma Treated by Esophagectomy with Three-Field Lymph Node Dissection

BACKGROUND

This study investigated the survival outcomes for surgically treated esophageal squamous cell carcinoma (ESCC) patients based on clinically suspicious supraclavicular lymph node (SCN) metastasis (cSCN+) and pathologically confirmed SCN metastasis (pSCN+).

METHODS

Using an institutional registry between 1994 and 2018, this study retrospectively analyzed 611 patients who received curative-intent esophagectomy with 3-field lymph node dissection for ESCC. The study used computed tomography and positron emission tomography to define cSCN+.

RESULTS

Among 611 patients, 24.4% had cSCN+ and 12.2% had pSCN+. The 5-year overall survival (OS) rates were 68.2% for cN0, 43.5% for cN+ without cSCN+, and 30.3% for cN+ with cSCN+ (p = 0.018). Although the univariable analysis showed that cSCN+ was associated with poorer survival than cN0 or cN+ with cSCN- (hazard ratio [HR], 1.818; p < 0.001), the multivariable analysis did not support this finding (HR, 1.281; p = 0.681). The 5-year OS rates were 64.2% for pN0, 41.5% for pN+ without pSCN+, and 25.6% for pN+ with pSCN+ (p = 0.054). Univariable analysis showed an association of pSCN+ with poor OS (HR, 1.830; p < 0.001), but the difference in the multivariable analysis was not significant (HR, 0.912; p = 0.587).

CONCLUSIONS

The presence of SCN metastasis did not have a significant impact on the OS of ESCC patients with 3-field lymph node dissection regardless of clinical suspicion or pathologic confirmation.

Two-year outcomes of clinical N2-3 esophageal squamous cell carcinoma after neoadjuvant chemotherapy and immunotherapy from the phase 2 NICE study

OBJECTIVE

This study aims to report the 2-year outcomes of patients with clinical stage N2-3 esophageal squamous cell carcinoma who received neoadjuvant chemotherapy and immunotherapy followed by surgery from a phase 2 NICE trial.

METHODS

Eligible patients with clinical stage N2-3 esophageal squamous cell carcinoma were screened and enrolled, then treated with regimen of nab-paclitaxel (100 mg/m2, days 1, 8, 15), carboplatin (area under the curve = 5, day 1), camrelizumab (200 mg, day 1) of two 21-day cycles and esophagectomy 4 to 6 weeks after the last chemotherapy. Oncologic outcomes, recurrence patterns, overall survival (OS), and recurrence-free survival (RFS) were explored.

RESULTS

From November 20, 2019, to December 22, 2020, 60 patients were recruited. After a median follow-up of 27.4 months, disease recurrence was observed in 19 (37.3%) patients, with 5 (9.8%) locoregional recurrence, 9 (17.6%) distant metastasis, and 5 (9.8%) combined recurrence. Lung was the most commonly involved metastatic site. The median time to recurrence was 10.8 months (interquartile range, 7.5-12.7 months). The 2-year OS and RFS rates were 78.1% and 67.9%, respectively. Patients who achieved major pathologic response (MPR) had a significantly greater 2-year OS rate (91.4% vs 47.7%; P < .001) and RFS rate (77.1% vs 45.9%; P = .003). On multivariable analysis, MPR was indicated as an independent prognostic factor for disease recurrence (hazard ratio, 0.39; 95% confidence interval, 0.21-0.82; P = .029).

CONCLUSIONS

In patients receiving neoadjuvant chemotherapy and immunotherapy, distant metastasis remains the predominant recurrence pattern. MPR is associated with lower recurrence and better survival. Long-term results derived from randomized controlled trials are further required.

TRIAL REGISTRATION NUMBER

ChiCTR1900026240.

Impact of thoracic duct resection during radical esophagectomy on oncological and survival outcomes: Systematic review

Practice is variable in the inclusion or exclusion of the thoracic duct (TD) as part of the resected specimen and associated lymphadenectomy in radical esophagectomy for esophageal cancer. While some surgeons believe that the removal of TD-associated nodes may improve radicality and survival, others suggest this represents systemic disease and resection may increase morbidity without survival benefit. A systematic review was performed up to March 2023 using the search terms 'esoph∗' AND 'thoracic duct' for relevant articles which compared thoracic duct preservation (TDP) to resection (TDR) in esophagectomy for esophageal cancer. Included studies were required to report relevant oncological outcomes including at least one of overall survival (OS), disease free survival (DFS) and nodal yield. Seven cohort studies were included in data synthesis, including data for 5926 patients. None of the reported studies were randomised controlled trials. All studies originated from Japan or South Korea with almost exclusively squamous cell-type cancer. Nodal yield was higher in TDR groups. TDR was equivalent or inferior to TDP with reference to clinical outcomes (length of stay, morbidity, mortality). A single study reported increased OS in the TDR group while the remaining studies reported no significant difference. Overall study quality was moderate to poor. While an increased nodal yield may be associated with TDR, this may also be associated with higher morbidity, and currently available data does not suggest any survival benefit.

Comparison of TNM AJCC/UICC 8th with JES 11th staging systems for prognostic prediction in patients with esophageal squamous cell carcinoma who underwent radical (chemo) radiotherapy in China

OBJECTIVE

The aim of the study was to compare the prognostic prediction performances of the American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) 8th staging system and the Japan Esophageal Society (JES) 11th staging system for patients with esophageal squamous cell carcinoma who underwent radical (chemo) radiotherapy.

METHODS

In total, 574 patients were enrolled and categorized according to the tumor, node metastasis (TNM) AJCC/UICC 8th and JES 11th editions. Survival rates and disease-free survival were computed using the Kaplan-Meier technique. The log-rank test was used for survival difference analysis.

RESULTS

(1) The 8th AJCC/UICC N staging exhibited significant stratification for overall survival (OS) and progression-free survival (PFS). JES 11th showed significant OS stratification, but PFS was not well-stratified for N2-N4. (2) Both staging systems demonstrated significant stratification for OS and PFS. (3) AJCC/UICC 8th TNM staging yielded significantly well-stratified OS and PFS in the differing staging group. JES 11th failed to stratify OS and PFS for stages III and IVA. (4) AJCC/UICC 8th TNM stratified OS and PFS significantly well for lower and middle region tumors, whereas JES 11th inadequately stratified stages III and IVA. (5) Significant multivariable analysis results indicated that AJCC/UICC 8th independently predicted poor OS and PFS.

CONCLUSIONS

In Chinese patients with esophageal squamous cell carcinoma who underwent radical (chemo) radiotherapy, the AJCC/UICC 8th edition exhibited superior prognostic prediction capabilities compared with the JES 11th edition.

Abdominal lymph node metastasis in non-surgical esophageal squamous cell carcinoma: prognostic significance and a novel staging strategy

Purpose

This study aimed to evaluate the feasibility of a combination of abdominal lymph node (LN) metastasis and the number of LNs in esophageal squamous cell carcinoma (ESCC) patients to optimize its clinical nodal staging.

Methods

A retrospective study, including a total of 707 ESCC patients treated with definitive radiotherapy, was conducted at two participating institutes. Different combinations of LN variables, including abdominal LN metastasis (R1: no-abdominal LN metastasis; R2: abdominal LN metastasis), were further analyzed to propose a potential revised nodal (rN) staging.

Results

The multivariate analyses showed that the number of metastatic LN and abdominal LN metastasis were independent prognostic factors for the overall survival (OS). The results showed no significant differences in the OS between the N2 patients with abdominal LN metastasis and N3 patients. The OS of the stage III patients with abdominal LN metastasis was not significantly different from those with stage IVa. The N3R1 and N1-2R2 had similar hazard ratios (HRs). The N1R1 subset was defined as rN1, the N2R1 subset was defined as rN2, and the N3R1-2 and N1-2R2 subsets were defined as rN3. The HRs of OS of the rN2 and rN3 groups increased subsequently. The rN stage could identify the differences in the OS times of each subgroup based on the 8th AJCC cN staging or the 11th JES N staging.

Conclusions

The rN staging, including the number of metastatic LNs and abdominal LN metastasis, might serve as a potential prognostic predictor for non-surgical patients with ESCC.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The prognostic value of 11th Japanese classification and 8th AJCC staging systems in Chinese patients with esophageal squamous cell carcinoma

BACKGROUND

Two staging systems, the 8th staging system by the American Joint Committee on Cancer (AJCC) and the 11th Japanese classification by Japan Esophageal Society (JES), are currently applied in the clinic for predicting the prognosis of patients with esophageal squamous cell carcinoma (ESCC). The differences between the two staging systems have been widely researched. However, little studies focus on the differences in specific staging between the two systems. Therefore, we aimed to compare the performance of different staging in predicting overall survival (OS) of Chinese patients with ESCC.

METHODS

This retrospective study included 268 patients who underwent radical esophagectomy and mediastinal lymph node dissection for ESCC between January 2008 and December 2013. Patients were staged by the 8th AJCC and 11th JES staging systems. OS was estimated using the Kaplan-Meier method and compared between N stages and between stage groupings using the log-rank test. Cox proportional hazards regression analysis was performed to identify factors independently related to outcome. Further, we compared the concordance indexes (C-indexes) of the two staging systems.

RESULTS

The mean age was 61.25 ± 7.056 years, median follow-up was 44.82 months, and 5-year OS rate was 47%. The OS was well predicted by the 8th AJCC N staging (P < 0.001) and the 11th JES N staging (P < 0.001), with a c-index of 0.638 (95% CI: 0.592-0.683) for AJCC N staging and 0.627 (95% CI: 0.583-0.670) for JES N staging (P = 0.13). In addition, the OS was also well predicted by stage groupings of the 8th AJCC (P < 0.001) and the 11th JES systems (P < 0.001), with a c-index of 0.658 (95% CI: 0.616-0.699) for 8th AJCC stage grouping and 0.629 (95% CI: 0.589-0.668) for the11th JES stage grouping (P = 0.211).

CONCLUSIONS

The prognostic effect of 11th JES staging system is comparable with that of AJCC 8th staging system for patients with ESCC. Therefore, both systems are applicable to clinical practice.

Safety and Feasibility of Robot-Assisted Minimally Invasive Esophagectomy (RAMIE) with Three-Field Lymphadenectomy and Neoadjuvant Chemoradiotherapy in Patients with Resectable Esophageal Cancer and Cervical Lymph Node Metastasis

BACKGROUND

In the West, patients with cervical lymph node metastasis of resectable esophageal cancer at diagnosis are generally precluded from curative treatment. This study prospectively explored the safety and feasibility of neoadjuvant chemoradiotherapy followed by robot-assisted minimally invasive esophagectomy (RAMIE) with three-field lymphadenectomy for these patients.

METHODS

Between 2015 and 2021, patients with resectable thoracic esophageal cancer and cervical lymph node metastasis were recruited nationwide in the Netherlands. Patients without interval metastasis following neoadjuvant chemoradiotherapy and good physical condition underwent RAMIE with bilateral three-field lymphadenectomy. Safety was predefined as ≤50% Clavien-Dindo grade ≥3b postoperative complications.

RESULTS

Neoadjuvant chemoradiotherapy was administered to 29 patients (19 (66%) adenocarcinoma and 10 (34%) squamous cell carcinoma). After restaging, nine (31%) patients were excluded (interval metastasis, clinical deterioration, or withdrawn consent). RAMIE was performed in 20 patients (R0-rate 95%). A median of 42 [range 21-71] lymph nodes were resected of which 13 [range 2-35] were cervical. Only 1 (5%) patient had an unexpected contralateral cervical lymph node metastasis. Complications grade ≥3b occurred in 50%. Most frequent complications of any grade were recurrent laryngeal nerve palsy (45%) and pneumonia (40%). Overall survival at 1 year was 85% and quality of life at 6 months was comparable to esophageal cancer patients treated with curative intent.

CONCLUSIONS

RAMIE with three-field lymphadenectomy following neoadjuvant chemoradiotherapy for patients with resectable esophageal cancer presenting with cervical lymph node metastasis is feasible in a Western population. Because contralateral cervical metastasis is rare, a unilateral neck dissection would suffice in the majority of cases.

CLINICAL TRIAL

gov Identifier: NCT02426879. Dutch trial register Identifier: NTR 4552.

Clinical outcomes of salvage radiotherapy in patients with supraclavicular lymph node metastases after esophagectomy

Purpose

To evaluate the clinical outcomes of salvage radiotherapy in patients with supraclavicular lymph node (SCLN) metastases after esophagectomy.

Methods

After initial esophagectomy (R0 resection), clinical outcomes in patients with esophageal squamous cell carcinoma with SCLN metastases during follow-up were retrospectively analyzed.

Results

A total of 114 patients were split into two groups: the salvage radiotherapy (SR) (n=89) and the control (NSR) (without salvage radiotherapy, n=25). The overall survival rates of 1 year, 3 years and 5 years were 81.6%, 31.4% and 8.6%, accordingly. The 1-year and 3-year survival after SCLN metastases (SASM) rates were 40.2% and 14.5%, respectively; the median SASM time was 10 months. In the SR group, the SASM rates of 1-year and 3-year were 48.1% and 18.9%, compared to 12.0% and 0% in the NSR group (p<0.001). Patients in the SR group who received combined radiochemotherapy experienced 1-year and 3-year SASM rates of 62.6% and 33.4%, compared to 41.9% and 16.5% with single radiotherapy (p<0.001). The salvage radiation dose revealed that the 1-year and 3-year SASM rates turned out to be 56.5% and 23.4% in group of ≥60 Gy, and 29.2% and 7.5% in group of <60 Gy (p<0.001). According to multivariate analysis, combined visceral metastases (CVM), combined mediastinal failure (CMF), salvage radiotherapy, salvage radiation dose and salvage treatment method possibly were identified as important prognostic variables. After propensity score matching (PSM), the above results were similar to those before PSM, except for that only salvage radiotherapy is possibly independent prognostic variables for survival after SCLN metastases in multivariate analysis.

Conclusion

It is possible that salvage radiotherapy can increase the survival rate of patients who receive SCLN metastases following esophagectomy.

Significance of dissection in each regional lymph-node station of esophageal cancer based on efficacy index and recurrence patterns after curative esophagectomy

BACKGROUND

The optimal extent of lymph-node (LN) dissection in esophageal cancer has not been established. Although the frequency and patterns of recurrence in each regional LN station after radical dissection are important in determining the regional LNs of thoracic esophageal cancer to be routinely dissected, this information has not been investigated sufficiently. We studied the significance of dissection at each LN station based on their recurrence patterns.

METHODS

Six hundred and twelve patients with esophageal cancer who underwent curative esophagectomy were studied. The incidence and pattern of recurrence (systemic or non-systemic) at each regional LN station were analyzed. To compare the significance of dissection among regional LNs, the efficacy index (EI) was also calculated.

RESULTS

Regional LN recurrence was diagnosed in 101 (16.5%) patients. Among the regional LNs, recurrent laryngeal nerve, paraesophageal, and perigastric LNs showed higher EIs (3.1-6.7). Pretracheal and posterior thoracic para-aortic LNs showed low EIs (0-0.2). Supraclavicular LNs had moderate EIs (1.7-2.0). The recurrence rate was highest in the pretracheal LN, followed by the supraclavicular LNs. The majority (81.8%) of the pretracheal LN had a systemic recurrence, while about half (right: 60.0%, left: 43.8%) of the supraclavicular LNs had a systemic recurrence.

CONCLUSION

Due to the high incidence of systemic recurrence or low EI for pretracheal and posterior thoracic para-aortic LNs, we suggest that these LN stations be regarded as non-regional LNs and be excluded from routine dissection. Supraclavicular LNs may also be excluded from routinely dissected stations.

Prognostic significance of sex determining region Y-box 2, E-cadherin, and vimentin in esophageal squamous cell carcinoma

BACKGROUND

Sex determining region Y-box 2 (SOX2) can promote squamous cell carcinoma (SSC) because it regulates the migration and invasion of several different types of squamous carcinoma cells. However, few studies have examined the prognostic value of SOX2 and its effect on the epithelial-mesenchymal transition (EMT) in esophageal SSC (ESCC), a cancer characterized by high invasion and rapid metastasis.

AIM

To verify the relationship of SOX2 and the EMT in ESCC and determine the prognostic value and significance of SOX2 and protein markers of the EMT in ESCC.

METHODS

One hundred and eighty-five postsurgical ESCC patients were retrospectively examined. Immunohistochemistry was used to detect SOX2, E-cadherin, and vimentin in ESCC tissues. The chi-square test was used to determine the relationships of the expression of these proteins with clinical data. Kaplan-Meier survival curves were used to evaluate factors associated with overall survival (OS).

RESULTS

SOX2 and vimentin had high expression in ESCC tissues and correlated with the depth of local carcinoma invasion. SOX2 expression had positive correlations with tumor size, vimentin expression, and the EMT, and a negative correlation with E-cadherin expression. Expression of SOX2 and vimentin had negative correlations with OS. SOX2 expression was an independent prognostic risk factor for poor OS in patients with ESCC.

CONCLUSION

SOX2 expression was an independent risk factor for OS in patients with ESCC and its expression had a positive correlation with the expression of vimentin, a classic marker of the EMT. SOX2 promoted the migration and invasion of ESCC, and this may related to its effect on vimentin in promoting the EMT.

Prophylactic supraclavicular lymph node dissection for esophageal squamous cell carcinoma: a systematic review and meta-analysis

The supraclavicular lymph nodes (SCLNs) have been regarded as regional nodes for esophageal squamous cell carcinoma (ESCC) in Japan and eastern Asian countries, whereas their involvement has been regarded as distant metastasis in Western countries. The importance of thorough dissection of the lymphatic chain along the recurrent laryngeal nerve, including the cervical paraesophageal nodes, has become well understood; therefore, the contemporary clinical question is whether prophylactic SCLN dissection (SLND) in addition to cervical paraesophageal node dissection is beneficial for patients with ESCC. We analyzed studies comparing esophagectomy with SLND vs. esophagectomy without SLND, in both of which cervical paraesophageal node dissection had been completed, based on a comprehensive literature search of the PubMed, Scopus, and Cochrane databases. Our meta-analysis focused on two long-term outcomes: 3-year and 5-year overall survival (OS) rates; and three short-term outcomes: pneumonia, recurrent nerve palsy, and anastomotic leakage. Four studies, with a collective total of 1584 patients were included in the review. No significant differences were found between esophagectomy with SLND vs. esophagectomy without SLND in the meta-analysis of both long-term (3-year and 5-year OS; risk ratio 1.09, 95% CI 0.94-1.26, P = 0.28, and risk ratio 1.14, 95% CI 0.96-1.35, P = 0.15, respectively) and short-term outcomes. Based on our analysis, no clear data support prophylactic SLND on the cervical paraesophageal node dissection.

Should the Supraclavicular Lymph Nodes be Considered Regional Lymph Nodes in Cervical Esophageal Cancer?

BACKGROUND

The importance of supraclavicular lymph node (SCLN) metastases in esophageal cancer (EC) remains unknown. Few studies have reported on the prognostic impact of SCLN metastases on patients with cervical EC (CEC). This study aimed to investigate whether SCLNs should be considered regional lymph nodes and be dissected in patients with CEC.

METHODS

This retrospective study enrolled 835 consecutive patients who underwent radical esophagectomy. Of these patients, 67 underwent radical surgery for CEC. These 67 patients were divided into three groups based on the presence of lymph node metastases with or without metastatic SCLNs or the absence of lymph node metastases.

RESULTS

Of the 67 patients, 23 (34.3%) did not have metastatic lymph nodes (pN-negative group), 27 (40.3%) had metastatic lymph nodes except for metastatic SCLNs (pN-positive group without metastatic SCLN), and 17 (25.4%) had metastatic lymph nodes including metastatic SCLNs (pN-positive group with metastatic SCLNs). The 5-year overall survival rate was 58.4% for the pN-negative group, 46.2% for the pN-positive group without metastatic SCLNs, and 7.8% for the pN-positive group with metastatic SCLNs. The pN-positive group with metastatic SCLNs tended to show residual tumor cells and complications after surgery. The presence of metastatic SCLNs was a significantly poor prognostic factor (p = 0.004). The efficacy index was lowest for the lymph nodes in the supraclavicular region.

CONCLUSIONS

The prognosis of the CEC patients with metastatic SCLNs was dismal. Although the cervical esophagus is located adjacent to the SCLNs, the SCLNs may be considered extra-regional lymph nodes in patients with CEC.

Prognostic Significance of the Number and Extent of Metastatic Lymph Nodes in Patients with Esophageal Cancer: Comparison of the Union for International Cancer Control 8th Edition and Japan Esophageal Society Japanese Classification of Esophageal Cancer 11th Edition Classifications for Esophageal Cancer

BACKGROUND

The tumor, node, metastasis staging system of the Union for International Cancer Control (UICC) has been used worldwide for esophageal cancer, and, in Japan, the Japan Esophageal Society Japanese Classification of Esophageal Cancer (JES) has also been used; however, there is a big difference between the two classifications with regard to node staging. We hypothesized that these two node staging systems may lead to different outcome predictions in terms of tumor location.

METHODS

This study enrolled 409 patients who underwent esophagectomy at Keio University Hospital, Tokyo, Japan, between January 2005 and December 2017. We included those who underwent R0 or R1 resection or esophagectomy with additional organ excision, and excluded those who underwent salvage surgery. Thereafter, we investigated how the number or spread of metastatic lymph nodes affected the prognosis.

RESULTS

For all 409 patients, the 5-year overall survival rate was 64.1% and the 5-year recurrence-free survival rate was 58.4%. The concordance indices were 0.756 for UICC 8th edition pathological node staging and 0.732 for JES 11th edition pathological node staging (p = 0.06). Based on tumor location, the difference in the concordance indices between these two classifications was greatest for lower thoracic esophageal tumors (p = 0.02).

CONCLUSIONS

For all patients, the UICC 8th edition node staging system tended to reflect survival more precisely than that of the JES 11th edition. For lower thoracic esophageal tumors in particular, the former node staging system could be more useful.

Neoadjuvant Chemoradiotherapy Followed by Esophagectomy with Three-Field Lymph Node Dissection for Thoracic Esophageal Squamous Cell Carcinoma Patients with Clinical Stage III and with Supraclavicular Lymph Node Metastasis

Simple Summary

This study aimed to clarify the efficacy of neoadjuvant chemoradiotherapy (NACRT) followed by esophagectomy with three-field lymph node (LN) dissection for clinical Stage III patients and for clinical Stage IVB patients with supraclavicular LN metastasis as the only distant metastatic factor. We observed that NACRT followed by esophagectomy with three-field lymph node dissection is feasible and offers the potential for long-term survival of these patients. It is also suggested that supraclavicular LNs should be treated as regional LNs at least in patients with upper and middle thoracic esophageal squamous cell carcinoma (ESCC).

Abstract

Background: Neoadjuvant chemoradiotherapy (NACRT) followed by esophagectomy is now the standard treatment for patients with resectable advanced thoracic esophageal squamous cell carcinoma (ESCC) worldwide. However, the efficacy of NACRT followed by esophagectomy with three-field lymph node dissection for clinical Stage III patients and for clinical Stage IVB patients with supraclavicular LN metastasis has not yet been determined. Methods: Between 2008 and 2018, 94 ESCC patients diagnosed as clinical Stage III and 18 patients diagnosed as clinical Stage IVB with supraclavicular LN metastasis as the only distant metastatic factor were treated with NACRT followed by esophagectomy with extended lymph node dissection at Akita University Hospital. Long-term survival and the patterns of recurrence in these 112 patients were analyzed. Results: The median follow-up period of censored cases was 60 months. The five-year OS and DSS rates among the clinical Stage III patients were 57.6% and 66.6%, respectively. The five-year OS and DSS rates among the clinical Stage IVB patients were 41.3% and 51.6%, respectively. The most frequent recurrence pattern was distant metastasis (69.2%) in the Stage III patients and LN metastasis (75.0%) in the Stage IVB patients. Conclusion: NACRT followed by esophagectomy with three-field LN dissection is feasible and offers the potential for long-term survival of clinical Stage III ESCC patients and even clinical Stage IVB patients with supraclavicular LN metastasis as the only distant metastatic factor. At least in patients with upper and middle thoracic ESCC, treating supraclavicular LNs as regional LNs seems to be appropriate.

Supraclavicular lymph node metastasis in elderly patients undergoing esophageal squamous cell carcinoma radical surgery: construction of risk and prognostic predictive nomograms

Background

Supraclavicular lymph node metastasis (SCLN) is an adverse prognostic determinant of esophageal cancer. However, lymphadenectomy for SCLN is a traumatic procedure, especially in elderly patients, which is associated with more postoperative complications. Currently, identification of risk factors of SCLN metastasis and avoidance of unnecessary lymphadenectomy for SCLN in esophageal squamous cell carcinoma (ESCC) patients has become an unmet clinical need.

Methods

A total of 90 elderly patients with ESCC between January 2008 and December 2013 was eligible for this analysis. Logistic regression was performed to determine risk factors for SCLN metastasis after ESCC radical surgery in elderly patients. A nomogram was constructed to individually predict the risk for SCLN metastasis. The Kaplan-Meier survival curve and cumulative risk curve were further analyzed to evaluate the effect of SCLN metastasis after ESCC radical surgery on survival prognosis and cumulative risk assessment in elderly patients. Finally, the SCLN metastasis group and the independent risk factor group were fitted by drawing a decision curve to evaluate the net benefit of the model.

Results

SCLN developed in 38 patients (42.2%). Postoperative lymph node metastasis (P<0.05), tumor thrombus (P<0.05) and tumor infiltration (P<0.05) were independent risk factors for SCLN metastasis. The influence of SCLN metastasis on postoperative survival in elderly ESCC patients was statistically significant (P=0.028, P <0.05); with the passage of time, the cumulative risk of SCLN metastasis increased, the survival probability decreased, and the survival time was shortened.

Conclusions

Postoperative lymph node metastasis, tumor thrombus and tumor infiltration are independent risk factors for recurrence and metastasis of SCLNs in elderly patients with esophageal squamous cell carcinoma. The nomogram model based on these factors provides a preliminary reference for individualized risk assessment, prognosis guidance and decision-making of SCLN metastasis in elderly patients with esophageal squamous cell carcinoma (ESCC).

Lymph node dissection and recurrent laryngeal nerve protection in minimally invasive esophagectomy

Until now, neoadjuvant therapy plus surgical resection of the primary tumor and potential metastatic lymph nodes (LNs) has been the current optimal treatment for locally advanced thoracic esophageal cancer (EC). LN metastasis is one of the most negative prognostic factors for thoracic esophageal squamous cell carcinoma (ESCC). However, the extent of LN dissection for thoracic ESCC has long been controversial worldwide. LNs along the recurrent laryngeal nerve (RLN) were reported to have the highest frequency of metastases in thoracic ESCC, so lymphadenectomy along the bilateral RLN is necessary but quite challenging because of a high frequency of recurrent nerve palsy and related postoperative complications. With the development of minimally invasive devices and techniques in recent years, minimally invasive esophagectomy (MIE) has been widely applied in EC surgery. The topics of what the optimal extent of lymphadenectomy is and how the recurrent nerve should be well protected during MIE have been debated in recent years. The purpose of our review is specifically to address the patterns of LN metastasis, the extent of LN dissection, and the protection of the RLN in MIE for thoracic ESCC.

Metastatic disease in head & neck oncology

The head and neck district represents one of the most frequent sites of cancer, and the percentage of metastases is very high in both loco-regional and distant areas. Prognosis refers to several factors: a) stage of disease; b) loco-regional relapses; c) distant metastasis. At diagnosis, distant metastases of head and neck cancers are present in about 10% of cases with an additional 20-30% developing metastases during the course of their disease. Diagnosis of distant metastases is associated with unfavorable prognosis, with a median survival of about 10 months. The aim of the present review is to provide an update on distant metastasis in head and neck oncology. Recent achievements in molecular profiling, interaction between neoplastic tissue and the tumor microenvironment, oligometastatic disease concepts, and the role of immunotherapy have all deeply changed the therapeutic approach and disease control. Firstly, we approach topics such as natural history, epidemiology of distant metastases and relevant pathological and radiological aspects. Focus is then placed on the most relevant clinical aspects; particular attention is reserved to tumours with distant metastasis and positive for EBV and HPV, and the oligometastatic concept. A substantial part of the review is dedicated to different therapeutic approaches. We highlight the role of immunotherapy and the potential effects of innovative technologies. Lastly, we present ethical and clinical perspectives related to frailty in oncological patients and emerging difficulties in sustainable socio-economical governance.

Clinical implications of cancer stem cells in digestive cancers: acquisition of stemness and prognostic impact

Digestive system cancers are the most frequent cancers worldwide and often associated with poor prognosis because of their invasive and metastatic characteristics. Recent studies have found that the plasticity of cancer cells can impart cancer stem-like properties via the epithelial-mesenchymal transition (EMT). Cancer stem-like properties such as tumor initiation are integral to the formation of metastasis, which is the main cause of poor prognosis. Numerous markers of cancer stem cells (CSCs) have been identified in many types of cancer. Therefore, CSCs, via their stem cell-like functions, may play an important role in prognosis after surgery. While several reports have described prognostic analysis using CSC markers, few reviews have summarized CSCs and their association with prognosis. Herein, we review the prognostic potential of eight CSC markers, CD133, CD44, CD90, ALDH1A1, EPCAM, SOX2, SOX9, and LGR5, in digestive cancers including those of the pancreas, colon, liver, gastric, and esophagus.

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.

The clinical significance of the intraoperative pathological examination of bilateral recurrent laryngeal nerve lymph nodes using frozen sections in cervical field lymph node dissection of thoracic esophageal squamous cell carcinoma

Background

The aim of this study was to evaluate intraoperative pathological examination of the left and right recurrent laryngeal nerve lymph nodes (LNs) using frozen section as a predictor of cervical LN metastasis.

Methods

Retrospectively collected data from 69 patients with esophageal squamous cell carcinoma who had undergone intraoperative pathological examination of the left and right recurrent laryngeal nerve LNs using frozen sections and three-field LN dissection in the Fujian Medical University Union Hospital from December 2015 to April 2018, was used to explore the relationship between recurrent laryngeal nerve LN metastasis and cervical LN metastasis and to determine whether cervical-field LN dissection should be performed in patients with thoracic esophageal cancer.

Results

In the entire cohort, 15.9% (11/69) of patients had metastasis in the cervical LNs. We detected 1,195 cervical LN, with an average of 17.3 LN dissections per patient; 28 (2.3%) cases had LN metastasis. Patients with recurrent laryngeal nerve LN metastasis tended to have a high incidence of cervical LN metastasis (P=0.017). Multivariate analysis showed that left recurrent laryngeal nerve LN metastasis was the only independent risk factor for cervical LN metastasis (P=0.02). The incidence of postoperative pulmonary infection was 18.8% (13/69), chylothorax was 2.9% (2/69), anastomotic leakage was 2.9% (2/69), and hoarseness was 8.7% (6/69) for the entire cohort. There was no significant increase in complications compared with patients with 2-field LN dissection in our hospital during the same period. Additional studies are necessary to establish postoperative locoregional recurrence rates and long-term survival.

Conclusions

Intraoperative pathological examination of left recurrent laryngeal nerve LN using frozen sections has some prognostic value in predicting cervical LN metastasis and it can be an indicator for the selection of cervical-field dissection in thoracic esophageal carcinoma.

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

Background

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

Methods

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

Results

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

Conclusions

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

The impact of cervical lymph node dissection on acid and duodenogastroesophageal reflux after intrathoracic esophagogastrostomy following transthoracic esophagectomy

PURPOSE

The aim of this study was to evaluate the impact of cervical lymph node dissection on acid reflux and duodenogastroesophageal reflux (DGER) in patients undergoing transthoracic esophagectomy with gastric tube reconstruction and intrathoracic esophagogastrostomy.

METHODS

Thirty-one patients receiving transthoracic esophagectomy with gastric tube reconstruction by intrathoracic esophagogastrostomy were divided into the following two groups: a two-field lymph node dissection group (2F group) and a three-field lymph node dissection group (3F group). All patients underwent 24-h pH and bilirubin monitoring and gastrointestinal endoscopy at 1 year after surgery. The 24-h pH and bilirubin monitoring results, endoscopic findings, and reflux symptoms were compared between the 2 groups.

RESULTS

No acid reflux was observed in the 2F group, whereas it was observed in 6 (40%) patients in the 3F group (p = 0.007). DGER was found in 2 patients (13%) in the 2F group and in 8 (53%) in the 3F group (p = 0.023). Four patients (25%) in the 2F group and 9 (60%) in the 3F group (p = 0.048) had reflux esophagitis.

CONCLUSION

Cervical lymph node dissection increases acid reflux and DGER and can lead to an increase in the incidence of reflux esophagitis in patients undergoing intrathoracic esophagogastrostomy.

Supraclavicular and celiac metastases in squamous cell carcinoma of the middle thoracic esophagus

PURPOSE

Squamous cell carcinoma of the middle thoracic esophagus (SCC-ME) often metastasizes to the neck, mediastinum, and abdomen. This study aims to assess the prognostic impact of supraclavicular (SC) and celiac (CE) lymph node (LN) metastases in patients with SCC-ME.

METHODS

We examined 210 patients who underwent curative esophagectomy with three-field LN dissection for SCC-ME. The clinicopathological features and survival outcomes of patients with and without SC and/or CE metastases were compared to assess the prognostic significance of SC and/or CE metastases.

RESULTS

We observed metastases to SC and CE in 25 (11.9%) and 20 (9.5%) patients, respectively. Seven patients (3.3%) had both SC and CE metastases. Although the survival of patients with SC and/or CE metastases was worse compared with those without, that of patients with SC metastases but without CE metastases was comparable with that of patients with CE metastases but without SC metastases; the 5 year overall survival rates were 35.6% and 46.2%, respectively. However, survival of patients with both SC and CE metastases was the worst among all groups, and all patients with both SC and CE metastases experienced disease recurrence.

CONCLUSIONS

The prognosis of patients with both SC and CE metastases was extremely poor. In contrast, patients with metastasis to either one of these sites could be candidates for surgery as the main modality in a multidisciplinary strategy.

Analysis of definitive chemo-radiotherapy for esophageal cancer with supra-clavicular node metastasis based on CT in a single institutional retrospective study: a propensity score matching analysis

Background

The prognostic value of supra-clavicular lymph node (SCLN) metastases in esophageal cancer (EC) is still not clear.

Method

From January 2009 to December 2015, a survival analysis was performed to retrospectively identify the prognostic value of SCLN metastasis on survival on 751 patients with EC treated with definitive chemo-radiotherapy (dCRT).

Results

The median follow-up duration for living patients was 56.6 months. The median overall survival (OS) for all patients was 16.6 months. Patients with SCLN metastasis had a much poorer prognosis for OS (χ² = 17.342, P < 0.001), distant metastasis-free survival (DMFS) (χ² = 24.793, P < 0.001) and progression-free survival (PFS) (χ² = 25.802, P < 0.001) than those without SCLN metastasis. The same results were found after propensity score matching. Nonetheless, the prognosis of patients with cervical or upper thoracic EC metastasis in SCLN was better than those of patients with middle or lower thoracic EC metastasis in SCLN for OS (χ² = 4.516, P = 0.038), DMFS (χ² = 8.326, P = 0.004) and PFS (χ² = 6.255, P = 0.012). Univariate analysis showed that gender, middle or lower thoracic EC with SCLN metastasis, tumor length, tumor diameter, concurrent chemo-radiotherapy (CCR) and number of lymph nodes were prognostic factors for PFS. Gender, age, middle or lower thoracic EC with SCLN metastasis, tumor diameter, tumor length, and number of lymph nodes were prognostic factors for DMFS. According to the multivariate analysis, only middle or lower thoracic EC with SCLN metastasis and number of lymph nodes were independent prognostic factors for DMFS and PFS.

Conclusion

For patients with cervical or upper thoracic EC, metastasis in SCLN should be considered to be regional lymph nodes and treated with curative intent if the total number of lymph nodes is limited. However, for patients with middle or lower thoracic EC, metastasis should be considered to be a higher level N stage or M1 stage, and it is thus necessary to provide consolidation chemotherapy after dCRT.

Neck Lymph Node Metastasis as A Poor Prognostic Factor in Thoracic Esophageal Squamous Cell Carcinoma Patients Receiving Concurrent Chemoradiotherapy: A Propensity Score-Matched Analysis

The present study investigated the clinical impact of neck lymph node (LN) metastasis in locally advanced inoperable thoracic esophageal squamous cell carcinoma (ESCC) patients who underwent concurrent chemoradiotherapy (CCRT) with a curative intent. There were 404 ESCC patients enrolled, including 35 patients with neck LN metastasis and 369 patients without such metastasis. Through the propensity score matching method, 35 patients of the 369 patients without neck LN metastasis were matched to the 35 patients with neck LN metastasis. Progression-free survival (PFS) and overall survival (OS) were found to be significantly worse in the neck LN metastasis group compared to the full non-neck LN metastasis group (9.8 months versus 5.9 months, P < 0.001, and 18.2 months versus 9.7 months, P = 0.001) and the matched non-neck LN metastasis group (9.9 months versus 5.9 months, P = 0.006, and 19.4 months versus 9.7 months, P = 0.007). In order to determine the difference between neck LN and supraclavicular LN metastasis, seventy patients with supraclavicular LN metastasis were also selected from the 369 patients without neck LN metastasis for comparison. Subsequently, when compared to the ESCC patients with supraclavicular LN metastasis, significantly worse PFS (8.5 months versus 5.9 months, P = 0.026) and OS (17.2 months versus 9.7 months, P = 0.047) were still found in the ESCC patients with neck LN metastasis. Our study indicates that neck LN metastasis is an independent poor prognostic factor for locally advanced inoperable thoracic ESCC patients who have undergone CCRT.

Oesophagectomy with or without supraclavicular lymphadenectomy after neoadjuvant treatment for squamous cell carcinoma of the oesophagus

Background

Treatment of supraclavicular nodes remains controversial among patients with oesophageal squamous cell carcinoma. This study assessed the outcomes of patients who underwent oesophagectomy with or without supraclavicular lymphadenectomy after neoadjuvant treatment.

Methods

This was a single-centre retrospective cohort study. Patients with oesophageal squamous cell carcinoma and clinically negative supraclavicular nodes who underwent oesophagectomy after neoadjuvant treatment between January 2005 and December 2015 were included. Overall and relapse-free survival were compared between patients who did or did not undergo supraclavicular nodal dissection. Propensity score matching was used to correct for differences in prognostic factors between the groups.

Results

Some 223 patients underwent supraclavicular lymphadenectomy. The prevalence of pathologically confirmed supraclavicular metastasis was 10·3 per cent, and these patients had poor 5-year relapse-free (7 per cent) and overall (14 per cent) survival. Only two of 55 patients who did not undergo supraclavicular lymphadenectomy had recurrent disease in the supraclavicular region without distant metastasis. There was no statistically significant difference between the groups in relapse-free survival (hazard ratio (HR) 0·95, 95 per cent c.i. 0·61 to 1·47; P = 0·821) or overall survival (HR 0·86, 0·52 to 1·40; P = 0·544). Similarly, no significant difference in relapse-free or overall survival was observed between the propensity score-matched groups.

Conclusion

For patients with clinically negative supraclavicular lymph nodes, prophylactic supraclavicular lymphadenectomy may be omitted when neoadjuvant treatment is administered.

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

Background

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

Materials and methods

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

Results

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

Conclusions

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

Proposed modifications of supraclavicular lymph node metastasis in the esophageal squamous cell carcinoma staging system for improved survival stratification

The present study aims to investigate the clinical implication of supraclavicular lymph nodes (SCLNs) in thoracic esophageal squamous cell carcinoma (ESCC). A total of 1156 ESCC patients who underwent three-field lymphadenectomy with node metastasis were analyzed retrospectively. SCLNs were defined as regional nodes in the current system or as distant nodes in the modified system. Survival was analyzed using the Kaplan-Meier method, and values were compared using the log-rank test. Multivariate analysis was performed using the Cox proportional hazard model. The Akaike information criterion (AIC) and the concordance index (c-index) were applied to compare the two prognostic systems. Among 1156 patients, 183 (15.8%) patients were diagnosed with SCLN metastasis. Higher rate of SCLN metastasis was associated with upper tumor location, metastasis involving seven or more nodes, and positive recurrent laryngeal nerve node status. The current staging system was unable to stratify overall survival well in patients with N2, N3, and M1 status using a univariate analysis. In both the current staging system and the modified version, age, gender, pathological T status, and nodal status were independent prognostic factors in a multivariate analysis. The AIC value for the modified version was smaller than that for the current staging system; the c-index value for the modified version was larger than that for the current staging system. Based on the data from our single center, SCLNs should be reclassified as regional lymph nodes in thoracic ESCC for better stratification of overall survival.

Predicting prognosis in resected esophageal squamous cell carcinoma using a clinical nomogram and recursive partitioning analysis

BACKGROUND

Development demand of precise medicine in resectable esophageal squamous cell carcinoma (ESCC) require to recognize patients at high risk treated by surgery alone. Thus, our aim was to construct a clinical nomogram and recursive partitioning analysis (RPA) to predict long-term survival in ESCC treated by surgery alone.

METHODS

Based on the patients with ESCC who treated by three-incisional esophagectomy and two-field lymphadenectomy alone, we identified and integrated significant prognostic factors for survival to build a nomogram. The nomogram was calibrated for overall survival (OS) and the predictive accuracy and discriminative ability was measured by concordance index (c-index) and Akaike information criterion (AIC). Based on the nomogram, the RPA was performed for risk stratification.

RESULTS

A total of 747 patients were included for analysis. Five independent prognostic factors were identified and entered into the nomogram. The calibration curves for probability of 1-, 3-, and 5-year OS showed optimal agreement between nomogram prediction and actual observation. The AIC value of the nomogram was lower than that of the 7th edition staging system, whereas the c-index of the nomogram was higher than that of the 7th edition staging system. The risk groups stratified by RPA allowed significant distinction between survival curves within respective TNM categories.

CONCLUSION

The RPA based on a clinical nomogram appears to be suitable for risk stratification in OS for resected ESCC. This practical system may help clinicians in decision making and design of clinical studies.

Regional hyperthermia combined with radiotherapy for esophageal squamous cell carcinoma with supraclavicular lymph node metastasis

To assess the efficacy and toxicity of Intensity-modulated radiotherapy (IMRT) and hyperthermia for upper and middle thoracic esophageal squamous cell carcinoma (UMT-ESCC) with supraclavicular lymph node metastasis. A total of 50 patients with UMT-ESCC with supraclavicular lymph node metastasis were evaluated in this retrospective study. All patients received IMRT. Hyperthermia was delivered simultaneously with irradiation, in 45 minutes twice a week for 5-6 weeks. Hyperthermia included supraclavicular lymph node metastasis. Forty-four patients (88.0%) received concurrent chemoradiotherapy based on cisplatin regimens. The most common types of hematological toxicities were anemia (62.0%) and leukopenia (60.0%). Most of these events were grade 1-2 and transient. The 3-year progression-free survival (PFS) rate and overall survival (OS) rate were 34.9% and 42.5%, respectively. Cox regression revealed that tumor length and number of supraclavicular lymph node metastasis were two independent predictors of OS (tumor length: HR=3.65, p=0.008; nodal stage: HR=8.07, p=0.019). The IMRT combined with supraclavicular regional hyperthermia has low toxicity and well tolerated with excellent local control in UMT-ESCC with supraclavicular lymph node metastasis.

Comparison of two major staging systems of esophageal cancer-toward more practical common scale for tumor staging

The latest 8th edition of TNM Classification of Malignant Tumours by Union for International Cancer Control (UICC) and 11th edition of Japanese Classification of Esophageal Cancer by Japan Esophageal Society (JES) are the two major classifications widely accepted as tools for clinical staging of esophageal cancer. Both systems consist of three main categories, i.e., T, N, and M, but large difference exists between the two. JES system has more detailed sub-classification of T1 tumors reflecting meticulous work by Japanese investigators on superficial esophageal cancer. N-category shows the largest difference. UICC defines the N-category according to only the number of the metastatic regional lymph nodes. The definition of regional nodes in UICC system is static and uniform, and supraclavicular nodes are definitely excluded. In JES system, regional nodes are subgrouped into five different patterns according to the main tumor location, and the supraclavicular nodes are always regional nodes for thoracic esophageal cancer. Japanese surgeons have described the evidence that regional nodes should be dynamically defined according to tumor location and supraclavicular nodes should be included in regional nodes. Compared to the simplified N-category, the staging matrix of UICC system is somewhat complicated. The clinical stage and pathological stage of UICC system are not identical and difference exists also between squamous cell carcinoma (SCC) and adenocarcinoma. It has another system of pathological prognostic grouping. We can imagine several reasons for the difference occurred between the two systems. One is the difference of major pathology. Another reason is the difference of basic concept of cancer treatment. The relative "dependence" on radical surgery in Japan has required the detailed definition of each lymph node station and the evaluation of "efficacy index" of each station. The strict and detailed definition of lymph node stations has been regarded as an obstacle to those who are not familiar with it. Some simplification can be done but maintaining dynamic definition of regional lymph nodes linked to tumor location. If UICC system can accept this concept, I think the two systems can be unified to realize more practical and useful staging system as an international common language.

Clinical Significance of the Pre-therapeutic Nodal Size in Patients Undergoing Neo-Adjuvant Treatment Followed by Esophagectomy for Esophageal Squamous Cell Carcinoma

BACKGROUND

The clinical significance of pre-therapeutic nodal size in patients with esophageal squamous cell carcinoma (ESCC) is not clear. We investigated whether nodal size was correlated with survival in patients undergoing neo-adjuvant treatment followed by esophagectomy for ESCC.

METHODS

In 2009-2013, 222 patients who underwent neo-adjuvant treatment followed by esophagectomy for ESCC were enrolled in this retrospective study. Nodal size was measured along the short axis of the largest node using pre-therapeutic CT images. Patients were then stratified based on this short axis, and nodal size was correlated with clinicopathological factors and survival.

RESULTS

Patients with larger nodes were likely to have deeper cT, higher cN status, and poorer survival. Among the clinical factors cT, cN, cM, and nodal size, only cT and nodal size were independent prognostic factors in multivariate analysis [hazard ratio (HR) 2.0, 95 % confidence interval (CI) 1.1-3.5, p = 0.025 and HR 1.5, 95 % CI 1-2.3, p = 0.036, respectively]. In addition, nodal size was significantly associated with hematological recurrence (p = 0.007), but not lymphatic relapse (p = 0.272).

CONCLUSIONS

The short axis of the largest node before neo-adjuvant treatment in patients with ESCC is a prognostic factor.

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

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

Prognostic value of supraclavicular nodes and upper abdominal nodes metastasis after definitive chemoradiotherapy for patients with thoracic esophageal squamous cell carcinoma

The purpose of this study is to assess the prognostic value of supraclavicular nodes, left gastric nodes, celiac nodes and common hepatic nodes metastasis in esophageal squamous cell carcinoma (ESCC) treated with definitive radiotherapy. A total of 293 ESCC patients treated with radiotherapy or chemoradiotherapy entered the study. The results showed that the presence of supraclavicular nodes (χ² = 0.075, P = 0.785) and left gastric nodes (χ² = 3.603, P = 0.058) metastasis had no significant influence on survival, while celiac nodes (χ² = 33.775, P < 0.001) and common hepatic nodes (χ² = 42.350, P < 0.001) metastasis were associated with significantly shorter survival, regardless of the sites of primary tumor. Multivariate analysis showed that celiac nodes (HR: 0.457, 95% CI: 0.256-0.816; P = 0.008) and common hepatic nodes (HR: 0.241, 95% CI: 0.092-0.630; P = 0.004) metastasis were independently adverse indicator of survival in upper ESCC. While in the middle and lower ESCC, only the common hepatic nodes (middle ESCC: HR: 0.345, 95% CI: 0.161-0.738, P = 0.006; lower ESCC: HR: 0.377, 95% CI: 0.160-0.890, P = 0.026) metastasis was an independently adverse indicator of survival. In conclusion, our study demonstrated that in ESCC treated with definitive radiotherapy, both of celiac nodes and common hepatic nodes metastasis were adverse indicator of survival in upper ESCC, and common hepatic nodes metastasis were adverse indicator of survival in middle and lower ESCC. Supraclavicular nodes an left gastric nodes metastasis is not associated with patients survival in ESCC.

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

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

Supraclavicular node disease is not an independent prognostic factor for survival of esophageal cancer patients treated with definitive chemoradiation

BACKGROUND

The prognostic value of supraclavicular lymph node (SCN) metastases in esophageal cancer is not well established. We analyzed the prognostic value of SCN disease in patients after definitive chemoradiation (dCRT) for esophageal cancer.

METHODS

We retrospectively analyzed 207 patients treated between 2003 and 2013 to identify the prognostic value of metastasis in the SCN on treatment failure and survival. All patients were treated with external beam radiotherapy (50.4 Gy in 28 fractions) combined with weekly concurrent paclitaxel 50 mg/m² and carboplatin AUC2.

RESULTS

Median follow-up for patients alive was 43.3 months. The median overall survival (OS) for all patients was 17.5 months. OS at one, three and five years was 67%, 36% and 21%, respectively. For patients with metastasis in a SCN, OS was 23.6 months compared to 17.1 months for patients without metastasis in the SCN (p = .51). In multivariate analyses, higher cT status, cN status and adenocarcinoma were found to be prognostically unfavorable, but a positive SCN was not (p = .67). Median OS and median disease-free survival for tumors with SCN involvement and N0/1 disease was 49.0 months and 51.6 months, respectively, compared to 14.2 months and 8.2 months, respectively, in patients with N2/3 disease.

CONCLUSION

In esophageal cancer treated with dCRT, the number of affected lymph nodes is an important independent prognostic factor, whereas involvement of a SCN is not. Supraclavicular lymph nodes should be considered as regional lymph nodes and treated with curative intent if the total number of involved lymph nodes is limited.