Lymphovascular invasion of tumor cells in lymph node metastases has a negative impact on survival in esophageal cancer

Lymphovascular Invasion is an Independent Negative Prognostic Factor in Esophageal Adenocarcinoma

BACKGROUND

The significance of lymphovascular invasion (LVI) in esophageal adenocarcinoma (EAC) has not yet been described. Potential utility as an adjunct to current staging guidelines remains unknown.

METHODS

The National Cancer Database was queried from 2006 to 2020. Univariate and multivariable models, Kaplan Meier method, and log-rank test were used. Subgroup analyses by pN stage were conducted.

RESULTS

Of 9,689 patients, 23.2% had LVI. LVI was an independent prognostic factor (hazard ratio [HR] 1.401, 95% confidence interval [CI] 1.307-1.502, p < 0.0001) with reduction in median survival to 20.0 months (95% CI 18.9-21.4) from 39.7 months (95% CI 37.8-42.3, p < 0.0001). Multivariable survival analysis adjusted on pN and pT stage found that patients with LVI had decreased survival in a given pN stage (p < 0.001). pN0/LVI+ patients had a similar prognosis to the higher staged pN1/LVI- (28.6 months), although pN1/LVI- patients did slightly worse (p = 0.0135). Additionally, patients with pN1/LVI+ had equivalent survival compared with pN2/LVI- (p = 0.178) as did pN2/LVI+ patients compared with pN3/LVI- (p = 0.995).

CONCLUSIONS

In these data, LVI is an independent negative prognostic factor in EAC. LVI was associated with a survival reduction similar to an upstaged nodal status irrespective of T stage. Patients with LVI may be better classified at a higher pN stage.

High microvessel and lymphatic vessel density predict poor prognosis in patients with esophageal squamous cell carcinoma

Background

Microangiogenesis and lymphangiogenesis are essential for tumor growth in the tumor microenvironment, contributing to tumor invasion and metastasis. Limited literature exists on these processes in esophageal squamous cell carcinoma (ESCC). Therefore, the purpose of this study is to explore the impacts of microangiogenesis and lymphangiogenesis on the occurrence, progression, and prognosis assessment of ESCC.

Methods

Surgical specimens and paraffin-embedded human tissues were procured from ESCC patients, encompassing 100 ESCC tissues and 100 cancer-adjacent normal (CAN) tissues. CD34 and D2-40 were utilized as markers for microvessel endothelial cells and lymphatic vessel endothelial cells, respectively. Microvascular density (MVD) and lymphatic vessel density (LVD) were evaluated through immunohistochemical quantification.

Results

We found that tumor tissues in ESCC patients had significantly higher MVD and LVD than cancer-adjacent normal (CAN) tissues. High MVD and LVD were associated with lymph node metastasis and advanced tumor clinical stages. Additionally, both high MVD and high LVD were strongly linked to poorer prognosis among cancer patients. Furthermore, a positive correlation was found between high MVD and high LVD (p < 0.05). The presence of these markers individually indicated a worse prognosis, with their combined assessment showcasing enhanced prognostic value.

Conclusions

Overall, the increased MVD and LVD indicates higher invasion and metastasis of ESCC, closely correlating with unfavorablefor poor prognosis of ESCC patients.

Expression of SOX4 Significantly Predicts the Risk of Lymph Node Metastasis for Patients With Early-Stage Esophageal Squamous Cell Carcinoma

Esophageal squamous cell carcinoma stands as a notably aggressive malignancy within the digestive system. In cases of early esophageal cancer without lymph node metastasis, endoscopic surgical resection offers a viable alternative, often resulting in improved patient quality of life. However, the paucity of methods to preoperatively ascertain lymph node involvement complicates surgical planning. SOX4 gene was previously found to be highly associated with invasive metastasis in our work through single-cell RNA sequencing on 5 paired tumor/peritumor tissues. This research included the collection of 124 tissue samples from 106 patients (106 tumor and 18 lymph node specimens). Samples were methodically arranged into a tissue microarray and treated with immunohistochemical staining. Statistical analysis was conducted to assess the relationship between them. In the univariate analysis, 3 factors were identified as statistically significant in relation to lymph node metastasis: T category (P = .014), vascular invasion (P < .001), and SOX4 intensity (P = .001). Additionally, when evaluating SOX4 intensity alongside other clinical indicators, SOX4 was shown to independently influence lymph node metastasis. Further, the multivariate analysis revealed that vascular invasion (P < .001) and SOX4 intensity (P = .003) were significantly associated with lymph node metastasis, exhibiting hazard ratios of 10.174 and 7.142, respectively. The results of our study indicate that both SOX4 expression and vascular invasion serve as predictors of lymph node metastasis in patients diagnosed with category T1 esophageal squamous cell carcinoma, underscoring the potential utility of SOX4 in prognostic evaluations.

A radiomics nomogram based on contrast-enhanced CT for preoperative prediction of Lymphovascular invasion in esophageal squamous cell carcinoma

Background and purpose

To develop a radiomics nomogram based on contrast-enhanced computed tomography (CECT) for preoperative prediction of lymphovascular invasion (LVI) status of esophageal squamous cell carcinoma (ESCC).

Materials and methods

The clinical and imaging data of 258 patients with ESCC who underwent surgical resection and were confirmed by pathology from June 2017 to December 2021 were retrospectively analyzed.The clinical imaging features and radiomic features were extracted from arterial-phase CECT. The least absolute shrinkage and selection operator (LASSO) regression model was used for radiomics feature selection and signature construction. Multivariate logistic regression analysis was used to develop a radiomics nomogram prediction model. The receiver operating characteristic (ROC) curve and decision curve analysis (DCA) were used to evaluate the performance and clinical effectiveness of the model in preoperative prediction of LVI status.

Results

We constructed a radiomics signature based on eight radiomics features after dimensionality reduction. In the training cohort, the area under the curve (AUC) of radiomics signature was 0.805 (95% CI: 0.740-0.860), and in the validation cohort it was 0.836 (95% CI: 0.735-0.911). There were four predictive factors that made up the individualized nomogram prediction model: radiomic signatures, TNRs, tumor lengths, and tumor thicknesses.The accuracy of the nomogram for LVI prediction in the training and validation cohorts was 0.790 and 0.768, respectively, the specificity was 0.800 and 0.618, and the sensitivity was 0.786 and 0.917, respectively. The Delong test results showed that the AUC value of the nomogram model was significantly higher than that of the clinical model and radiomics model in the training and validation cohort(P<0.05). DCA results showed that the radiomics nomogram model had higher overall benefits than the clinical model and the radiomics model.

Conclusions

This study proposes a radiomics nomogram based on CECT radiomics signature and clinical image features, which is helpful for preoperative individualized prediction of LVI status in ESCC.

The Advantage of Immunohistochemical Staining for Evaluating Lymphovascular Invasion Is Limited for Patients with Esophageal Squamous Cell Carcinoma Invading the Muscularis Mucosa

The cumulative metastasis rate of esophageal squamous cell carcinoma (ESCC) pathologically invading the muscularis mucosae (pT1a-MM), based on lymphovascular invasion (LVI) evaluated by immunohistochemical (IHC) staining is unknown. This retrospective study included patients with endoscopically resected pT1a-MM ESCC. The primary endpoint was the metastasis rate of pT1a-MM based on LVI, evaluated using IHC and additional prophylactic therapy. The secondary endpoint was the identification of independent factors for metastasis based on lesion characteristics. The prognosis was also analyzed considering the impact of head and neck cancer. A total of 104 patients were analyzed, with a median follow-up of 74 months. The positive rate for LVI was 43.3% (45/104). In 33 patients, IHC was not performed at the time of clinical evaluation, 8 of whom exhibited LVI. However, these patients did not exhibit metastasis. The metastasis rates of patients without LVI, those with LVI and additional therapy, and those with LVI without additional therapy were 5.1%, 20.8%, and 0%, respectively. Lesion size ≥ 25 mm was the only independent factor for metastasis in multivariate analysis. The advantage of IHC for determining additional prophylactic therapy is limited for patients with pT1a-MM ESCC.

Risk factors of lymph node metastasis or lymphovascular invasion for superficial esophageal squamous cell carcinoma: A practical and effective predictive nomogram based on a cancer hospital data

Background

Lymphovascular invasion (LVI) is mostly used as a preoperative predictor to establish lymph node metastasis (LNM) prediction models for superficial esophageal squamous cell carcinoma (SESCC). However, LVI still needs to be confirmed by postoperative pathology. In this study, we combined LNM and LVI as a unified outcome and named it LNM/LVI, and aimed to develop an LNM/LVI prediction model in SESCC using preoperative factors.

Methods

A total of 512 patients who underwent radical resection of SESCC were retrospectively collected. Logistic regression and least absolute shrinkage and selection operator (LASSO) regression were adopted to identify the predictive factors of LNM/LVI. Integrated discrimination improvement (IDI) and net reclassification improvement (NRI) were calculated to select the potential predictive factors from the results of LASSO and logistic regression. A nomogram for predicting LNM/LVI was established by incorporating these factors. The efficacy, accuracy, and clinical utility of the nomogram were, respectively, assessed with the area under the curve (AUC), calibration curve, and decision curve analysis (DCA). Finally, the random forest (RF) algorithm was used to further evaluate the impact of these factors included in the nomogram on LNM/LVI.

Results

Tumor size, tumor location, tumor invasion depth, tumor differentiation, and macroscopic type were confirmed as independent risk factors for LNM/LVI according to the results of logistic regression, LASSO regression, IDI, and NRI analyses. A nomogram including these five variables showed a good performance in LNM/LVI prediction (AUC = 0.776). The calibration curve revealed that the predictive results of this nomogram were nearly consistent with actual observations. Significant clinical utility of our nomogram was demonstrated by DCA. The RF model with the same five variables also had similar predictive efficacy with the nomogram (AUC = 0.775).

Conclusion

The nomogram was adopted as a final tool for predicting LNM/LVI because its risk score system made it more user-friendly and clinically useful than the random forest model, which can help clinicians make optimal treatment decisions for patients with SESCC.

Development and validation of a nomogram for preoperative prediction of lymph node metastasis in pathological T1 esophageal squamous cell carcinoma

Endoscopic resection is increasingly used to treat patients with pathological T1 (pT1) esophageal squamous cell carcinoma (ESCC) because of its small surgical trauma. However, reports of the risk factors for lymph node metastasis (LNM) have been controversial. Therefore, we aim to build a nomogram to individually predict the risk of LNM in pT1 ESCC patients, to make an optimal balance between surgical trauma and surgical income.One hundred seventy patients with pT1 esophageal cancer in our hospital were analyzed retrospectively. Logistic proportional hazards models were conducted to find out the risk factor associated with LNM independently, and those were imported into R library "RMS" for analysis. A nomogram is generated based on the contribution weights of variables. Finally, decision analysis and clinical impact curve were used to determine the optimal decision point.Twenty-five (14.7%) of the 170 patients with pT1 ESCC exhibited LNM. Multivariable logistic regression analysis showed that smoking, carcinoembryonic antigen, vascular tumor thromboembolus, and tumor differentiation degree were independent risk factors for LNM. The nomogram had relatively high accuracy (C index of 0.869, 95% confidence interval: 0.794-0.914, P < .0001). The decision curve analysis provided the most significant clinical benefit for the entire included population, with scores falling just above the total score of 85 in the nomogram.Smoking, carcinoembryonic antigen, vascular tumor thromboembolus, and tumor differentiation degree may predict the risk of LNM in tumor 1 ESCC. The risk of LNM can be predicted by the nomogram.

Can lymphovascular invasion be predicted by contrast-enhanced CT imaging features in patients with esophageal squamous cell carcinoma? A preliminary retrospective study

Background

To investigate the value of contrast-enhanced CT (CECT)-derived imaging features in predicting lymphovascular invasion (LVI) status in esophageal squamous cell carcinoma (ESCC) patients.

Methods

One hundred and ninety-seven patients with postoperative pathologically confirmed esophageal squamous cell carcinoma treated in our hospital between January 2017 and January 2019 were enrolled in our study, including fifty-nine patients with LVI and one hundred and thirty-eight patients without LVI. The CECT-derived imaging features of all patients were analyzed. The CECT-derived imaging features were divided into quantitative features and qualitative features. The quantitative features consisted of the CT attenuation value of the tumor (CTV_Tumor), the CT attenuation value of the normal esophageal wall (CTV_Normal), the CT attenuation value ratio of the tumor-to-normal esophageal wall (TNR), the CT attenuation value difference between the tumor and normal esophageal wall (ΔTN), the maximum thickness of the tumor measured by CECT (Thickness), the maximum length of the tumor measured by CECT (Length), and the gross tumor volume measured by CECT (GTV). The qualitative features consisted of an enhancement pattern, tumor margin, enlarged blood supply or drainage vessels to the tumor (EVFDT), and tumor necrosis. For the clinicopathological characteristics and CECT-derived imaging feature analysis, the chi-squared test was used for categorical variables, the Mann–Whitney U test was used for continuous variables with a nonnormal distribution, and the independent sample t-test was used for the continuous variables with a normal distribution. The trend test was used for ordinal variables. The association between LVI status and CECT-derived imaging features was analyzed by univariable logistic analysis, followed by multivariable logistic regression and receiver operating characteristic (ROC) curve analysis.

Results

The CTV_Tumor, TNR, ΔTN, Thickness, Length, and GTV in the group with LVI were higher than those in the group without LVI (P < 0.05). A higher proportion of patients with heterogeneous enhancement pattern, irregular tumor margin, EVFDT, and tumor necrosis were present in the group with LVI (P < 0.05). As revealed by the univariable logistic analysis, the CECT-derived imaging features, including CTV_Tumor, TNR, ΔTN and enhancement pattern, Thickness, Length, GTV, tumor margin, EVFDT, and tumor necrosis were associated with LVI status (P < 0.05). Only the TNR (OR 8.655; 95% CI 2.125–37.776), Thickness (OR 6.531; 95% CI 2.410–20.608), and tumor margin (OR 4.384; 95% CI 2.004–9.717) were independent risk factors for LVI in the multivariable logistic regression analysis. The ROC curve analysis incorporating the above three CECT-derived imaging features showed that the area under the curve obtained by the multivariable logistic regression model was 0.820 (95% CI 0.754–0.885).

Conclusion

The CECT-derived imaging features, including TNR, Thickness, tumor margin, and their combination, can be used as predictors of LVI status for patients with ESCC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12880-022-00804-7.

Can Lymphovascular Invasion be Predicted by Preoperative Contrast-Enhanced CT in Esophageal Squamous Cell Carcinoma?

Objective: To explore whether preoperative contrast-enhanced computed tomogrpahy (CT) can predict lymphovascular invasion (LVI) in esophageal squamous cell carcinoma (ESCC), and provide a reliable reference for the formulation of clinical individualized treatment plans. Methods: This retrospective study enrolled 228 patients with surgically resected and pathologically confirmed ESCC, including 36 patients with LVI and 192 patients without LVI. All patients underwent contrast-enhanced CT (CECT) scan within 2 weeks before the operation. Tumor size (including tumor length and maximum tumor thickness), tumor-to-normal wall enhancement ratio (TNR), and gross tumor volume (GTV) were obtained. All clinical features and CECT-derived parameters associated with LVI were analyzed by univariate and multivariate analysis. The independent predictors for LVI were identified, and their combination was built by multivariate logistic regression analysis, using the significant variables from the univariate analysis as inputs. Results: Univariate analysis of clinical features and CECT-derived parameters revealed that age, TNR, and clinical N stage (cN stage) were significantly associated with LVI. The multivariable analysis results demonstrated that age (odds ratio [OR]: 5.32, 95% confidence interval [CI]: 2.224-12.743, P<.001), TNR (OR: 5.399, 95% CI: 1.609-18.110, P  =  .006), and cN stage (cN1: OR: 2.874, 95% CI: 1.182-6.989, P  =  .02; cN2: OR: 6.876, 95% CI: 2.222-21.227) were identified to be independent predictors for LVI. The combination of age, TNR, and cN stage achieved a relatively higher area under the curve (AUC) (0.798), accuracy (ACC) (65.4%), sensitivity (SEN) (69.4%), specificity (SPE) (79.7%), positive predictive value (PPV) (77.4%), and negative predictive value (NPV) (71.6%). Conclusions: The combination of clinical features and CECT-derived parameters may be effective in predicting LVI status preoperatively in ESCC.

Occurrence and Prognostic Value of Perineural Invasion in Esophageal Squamous Cell Cancer: A Retrospective Study

OBJECTIVE

The aim of this study was to explore the occurrence and prognostic value of perineural invasion (PNI) as a classic tumor pathological feature in esophageal squamous cell carcinoma (ESCC).

METHODS

We retrospectively enrolled 794 ESCC patients who underwent radical esophagectomy at Shanghai Chest Hospital from 2017 to 2018. The incidence, associated factors, and prognosis of PNI were analyzed.

RESULTS

PNI was identified in 15.7% (125/794) of patients. The presence of PNI was significantly associated with depth of invasion (p < 0.001), pN stage (p = 0.008), tumor stage (p < 0.001), and lymphovascular invasion (LVI; p < 0.001). Multivariate logistic regression analysis demonstrated that advanced pT stage and LVI were independently associated with the presence of PNI, while multivariate Cox regression analysis demonstrated that PNI was not an independent risk factor for poor overall survival (OS) or recurrence-free survival (RFS) in ESCC patients (OS hazard ratio [HR] 0.688, 95% confidence interval [CI] 0.448-1.056, p = 0.087; RFS HR 0.837, 95% CI 0.551-1.273, p = 0.406). In the PNI-positive patient subgroup, adjuvant therapy was associated with better OS and RFS.

CONCLUSION

PNI correlates with, and may be a concomitant consequence of, LVI and advanced tumor invasion (T3-4) in ESCC patients. Although PNI was not identified as an independent prognostic indicator, our results suggest ESCC patients with PNI should be considered for adjuvant therapy.

Contrast-Enhanced CT-Based Radiomics Analysis in Predicting Lymphovascular Invasion in Esophageal Squamous Cell Carcinoma

Objectives

To develop a radiomics model based on contrast-enhanced CT (CECT) to predict the lymphovascular invasion (LVI) in esophageal squamous cell carcinoma (ESCC) and provide decision-making support for clinicians.

Patients and Methods

This retrospective study enrolled 334 patients with surgically resected and pathologically confirmed ESCC, including 96 patients with LVI and 238 patients without LVI. All enrolled patients were randomly divided into a training cohort and a testing cohort at a ratio of 7:3, with the training cohort containing 234 patients (68 patients with LVI and 166 without LVI) and the testing cohort containing 100 patients (28 patients with LVI and 72 without LVI). All patients underwent preoperative CECT scans within 2 weeks before operation. Quantitative radiomics features were extracted from CECT images, and the least absolute shrinkage and selection operator (LASSO) method was applied to select radiomics features. Logistic regression (Logistic), support vector machine (SVM), and decision tree (Tree) methods were separately used to establish radiomics models to predict the LVI status in ESCC, and the best model was selected to calculate Radscore, which combined with two clinical CT predictors to build a combined model. The clinical model was also developed by using logistic regression. The receiver characteristic curve (ROC) and decision curve (DCA) analysis were used to evaluate the model performance in predicting the LVI status in ESCC.

Results

In the radiomics model, Sphericity and gray-level non-uniformity (GLNU) were the most significant radiomics features for predicting LVI. In the clinical model, the maximum tumor thickness based on CECT (cThick) in patients with LVI was significantly greater than that in patients without LVI (P<0.001). Patients with LVI had higher clinical N stage based on CECT (cN stage) than patients without LVI (P<0.001). The ROC analysis showed that both the radiomics model (AUC values were 0.847 and 0.826 in the training and testing cohort, respectively) and the combined model (0.876 and 0.867, respectively) performed better than the clinical model (0.775 and 0.798, respectively), with the combined model exhibiting the best performance.

Conclusions

The combined model incorporating radiomics features and clinical CT predictors may potentially predict the LVI status in ESCC and provide support for clinical treatment decisions.

Risk factors for lymph node metastasis in T1 esophageal squamous cell carcinoma: A systematic review and meta-analysis

BACKGROUND

Lymph node metastasis (LNM) affects the application and outcomes of endoscopic resection in T1 esophageal squamous cell carcinoma (ESCC). However, reports of the risk factors for LNM have been controversial.

AIM

To evaluate risk factors for LNM in T1 ESCC.

METHODS

We searched Embase, PubMed and Cochrane Library to select studies related to LNM in patients with T1 ESCC. Included studies were divided into LNM and non-LNM groups. We performed a meta-analysis to examine the relationship between LNM and clinicopathologic features. Odds ratio (OR), mean differences and 95% confidence interval (CI) were assessed using a fixed-effects or random-effects model.

RESULTS

Seventeen studies involving a total of 3775 patients with T1 ESCC met the inclusion criteria. After excluding studies with heterogeneity based on influence analysis, tumor size (OR = 1.93, 95%CI = 1.49-2.50, P < 0.001), tumor location (OR = 1.46, 95%CI = 1.17-1.82, P < 0.001), macroscopic type (OR = 3.17, 95%CI = 2.33-4.31, P < 0.001), T1 substage (OR = 6.28, 95%CI = 4.93-8.00, P < 0.001), differentiation (OR = 2.11, 95%CI = 1.64-2.72, P < 0.001) and lymphovascular invasion (OR = 5.86, 95%CI = 4.60-7.48, P < 0.001) were found to be significantly associated with LNM. Conversely, sex, age and infiltrative growth pattern were not identified as risk factors for LNM.

CONCLUSION

A tumor size > 2 cm, lower location, nonflat macroscopic type, T1b stage, poor differentiation and lymphovascular invasion were associated with LNM in patients with T1 ESCC.

D2-40 A Helpful Marker in Assessment of Lymphatic Vessel Invasion in Carcinoma of Breast

Background & Objective:

Breast cancer is the most common malignancy among Iranian women and worldwide. Lymphatic vessel invasion (LVI) was found to be an independent prognostic factor in many carcinomas, including invasive carcinoma of the breast. The aim of this study was to compare the hematoxylin and eosin (H&E) staining method and use of the immunohistochemical (IHC) marker ofD2-40, for evaluation of LVI in breast carcinoma specimens.

Methods:

The study was conducted on 50 patients undergone surgery between the years 2010 and 2015 in Rohani Hospital, Babol, Iran with invasive carcinoma of the breast with Census sampling method. LVI was assessed by two surgical pathologists, using H&E- stained sections and two IHC markers, i.e., D2-40 and CD31.

Results:

LVI was detected in 25 (50%) patients by H&E and in 14 (28%) patients by D2-40. Twelve out of 25 patients with positive LVI in H&E were confirmed by D2-40 and 2 out of 25 patients with negative lymphatic vessel in H&E. Only one case showed weak staining of CD31 proving LVI. These results showed a significant difference between the H&E staining and D2-40 IHC study for LVI detection (P=0.004).

Conclusion:

The D2-40 IHC marker is helpful in the diagnosis and confirmation of LVI in invasive carcinoma of the breast. CD31 is not suitable for the evaluation of lymphatic vessels.

Linking Circulating Serum Proteins with Clinical Outcomes in Esophageal Adenocarcinoma-An Emerging Role for Chemokines

Simple Summary

Cancer of the esophagus (food pipe) is an aggressive type of cancer with poor prognosis and rates are increasing. Current treatments help to prolong survival but only for a minority of patients, therefore there is an urgent need to discover why some people do not respond and to develop new and improved treatments. Newer treatments targeting the immune system show promise but the anti-tumor immune response in esophageal cancer is not well understood. This study measured levels of 54 immune markers in serum of patients with esophageal cancer and evaluated a link with patient clinical outcomes, e.g., survival time, response to treatment, and adverse events. We found that certain chemokines, proteins which control immune cell trafficking, were particularly high in patients who survived longer (CCL22 and CCL26) and responded to treatment (CCL4), suggesting the importance of immune cell movement in orchestrating an effective immune response to esophageal cancer.

Abstract

Esophageal adenocarcinoma (EAC) is an aggressive cancer with poor prognosis and incidence is increasing rapidly in the Western world. Multi-modal treatment has improved survival outcomes but only for a minority of patients. Currently no markers have been identified to predict treatment response. This study investigated the association between clinical outcomes and pre-treatment levels of 54 serum proteins in n = 80 patients with EAC. Low tumor regression grade (TRG), corresponding to a favorable treatment response, was linked to prolonged overall survival (OS). CCL4 was higher in patients with a favorable treatment response, while Tie2 and CRP were higher in poor responders. Elevated CCL22 and CCL26 was associated with improved OS, while elevated IL-10 showed a negative association. CCL3, CCL4, IL-1α and IL-12/IL23p40 were highest in individuals with no adverse features of tumor biology, whereas levels of Tie2 and VEGF were lowest in this cohort. CCL4 was also elevated in patients with high tumor lymphocyte infiltration. Comparison of matched pre- and post-treatment serum (n = 28) showed a large reduction in VEGFC, and a concomitant increase in other cytokines, including CCL4. These data link several serum markers with clinical outcomes, highlighting an important role for immune cell trafficking in the EAC antitumor immune response.

Impact of Lymphovascular Invasion on Survival Outcome in Patients With Gastric Cancer

OBJECTIVES

To evaluate the prognostic significance of lymphovascular invasion (LVI) for patients with gastric cancer (GC).

METHODS

A total of 1,720 consecutive patients who underwent curative gastrectomy were retrospectively identified. The association between LVI and clinicopathologic characteristics was determined and its impact on survival outcome was evaluated.

RESULTS

LVI was detected in 21.3% of GC patients, 5.9% of patients with early GC, 24.0% of patients with advanced GC, and 6.7% of node-negative patients using H&E staining. Tumor size (odds ratio [OR], 1.509; 95% confidence interval [CI], 1.159-1.965; P < .01), differentiated type (OR, 1.817; 95% CI, 1.377-2.398; P < .001), and the depth of tumor invasion (OR, 3.011; 95% CI, 2.174-4.171; P < .001) were independent predictive factors for LVI. LVI-positive patients have a poorer prognosis than LVI-negative patients, irrespective of tumor stage or lymph node metastasis. LVI was an independent prognostic factor for patients with GC (hazard ratio, 1.299; 95% CI, 1.112-1.518; P < .001).

CONCLUSIONS

LVI provided additional prognostic information for GC patients, and LVI-positive patients should be considered candidates for adjuvant chemotherapy.

Lymphatic Invasion Might Be Considered as an Upstaging Factor in N0 and N1 Gastric Cancer

(Background) The aim of this study was to investigate the prognostic impact of lymphatic invasion in gastric cancer, focusing on survival differences between N stage groups. (Methods) A total of 398 consecutive patients who underwent curative gastrectomy for primary gastric adenocarcinoma from January 2006 to December 2015 were analyzed retrospectively using data from a prospectively collected registry database. We compared various clinicopathological features and survival differences between lymphatic invasion-positive and -negative groups. (Results) Of the 398 patients, 141 (35.4%) showed lymphatic invasion. The lymphatic invasion-positive subgroup had poorer prognosis than the lymphatic invasion-negative subgroup in N0 (five-year survival rate: 87.8% vs. 73.6%, p = 0.048) and N1 (87.2% vs. 50%, p = 0.007) stage patients. The odds ratio (OR) of lymphatic invasion to five-year survival rate was 2.078 (95% confidence interval (CI), 1.103-3.916; p = 0.024). The presence of lymphatic invasion had worse effect on survival than age (OR, 1.807; 95% CI, 1.024-2.242; p = 0.029) or tumor depth (OR, 1.286; 95% CI, 1.078-1.897; p = 0.013) in N0 and N1 stage patients. The overall survival of patients with lymphatic invasion was not different from that of patients at a one-higher N stage without lymphatic invasion at any N stage. (Conclusions) The presence of lymphatic invasion may be the most important independent prognostic factor in N0 and N1 gastric cancer and might be an upstaging factor of N stage at any N stage. Therefore, in addition to the number of metastasized lymph nodes, the presence of lymphatic invasion should be included in N stage determination.

Overexpression of VEGF-C and MMP-9 predicts poor prognosis in Kazakh patients with esophageal squamous cell carcinoma

Vascular endothelial growth factor (VEGF) and Matrix metalloproteinases (MMPs) are believed to participate in infiltration of tumors. High mortality of esophageal squamous cell carcinoma (ESCC) related to its primary infiltration; however, it is not clear whether the expression of VEGF and MMPs is involved in this process. Screening of The Cancer Genome Atlas (TCGA) database showed that among the VEGF family and MMP9, VEGF-A, VEGF-C, and MMP-9 mRNA were overexpression in ESCC. This result was verified using the Oncomine database and in Kazakh patients with ESCC. Overexpression of VEGF-C and MMP-9 and positive association with advanced esophageal cancer and invading ESCC cells (Gene Expression Omnibus (GEO): GSE21293). Immunohistochemical staining revealed that VEGF-C and MMP-9 were overexpressed in Kazakh ESCCs. VEGF-C expression was related to invasive depth, tumor-node-metastasis (TNM) staging, lymphatic, and lymph node metastasis of ESCC. The linear association between them was further confirmed in TCGA database and the specimens from Kazakh patients with ESCC. Patients with both proteins expression had tumors with greater aggressiveness, suffered from poor prognosis compared with patients who did not express either protein or expressed protein alone. Both proteins expression predicted high invasiveness of ESCC, which is related to worse prognosis of Kazakh ESCCs.

Prognostic value of lymphovascular invasion in patients with esophageal squamous cell carcinoma

Background

Whether lymphovascular invasion (LVI) in esophageal squamous cell carcinoma (ESCC) should be considered an independent prognostic factor for survival is controversial. The aim of this report was to investigate the prognostic value of LVI for patients with ESCC.

Methods

Between October 2010 and July 2011, 152 ESCC patients were retrospectively reviewed. All of the patients underwent curative resection as their primary treatment. Clinicopathological features and overall survival (OS) rate were investigated. Kaplan-Meier curves were used to calculate the OS rate, and the prognostic factors were identified by Cox regression model.

Results

Positive LVI was found in 49 (32.2%) patients. Patients with negative LVI had a significantly better 5-year OS rate than those with positive LVI (52.9% vs. 28.8%; P=0.000). The age, T stage, N stage, tumor differentiation, and LVI were demonstrated to be significant prognostic factors for OS through univariate analyses. LVI was confirmed as an independent prognostic factor for OS through multivariate survival analyses. Subgroup analyses revealed that LVI was associated with a decreased OS in node-negative patients, and no significant difference was observed in node-positive cases.

Conclusions

Our study highlighted that LVI is an independent prognostic factor in patients with resectable ESCC. LVI may facilitate the stratification of patients with poor survival.

Effects of lymph node metastasis of thoracic esophageal squamous cell carcinoma on design of radiotherapy target volume

Objective

To analyze the correlation between lymph node metastasis of thoracic esophageal squamous cell carcinoma (ESCC) and clinical and pathological factors, and to provide a reference for the outline of clinical target volume.

Methods

The pathological characteristics of 1034 thoracic ESCC patients after surgery were described, and the correlations between clinical and pathological factors and lymph node metastasis were studied by univariate and Logistic multivariate analyses.

Results

Lymph node metastasis was significantly correlated with tumor length, invasion depth and differentiation degree (P<0.01), but not gender, age, tumor site or pathological type (P>0.05). Logistic multivariate analysis showed that tumor length, invasion depth and differentiation degree were independent risk factors for thoracic ESCC. The lymph node metastasis rates of mid-thoracic ESCC in the middle mediastinum, lower-thoracic ESCC in the lower mediastinum and abdominal cavity were 18.5%, 35.3% and 19.7% respectively in the T1-T2 stage. In the T3-T4 stage, the lymph node metastasis rates of mid-thoracic ESCC in the middle mediastinum and abdominal cavity were 39.6% and 17.4% respectively, and those of lower-thoracic ESCC in middle and lower mediastina and abdominal cavity were 21.1%, 43.4% and 29.8% respectively. Highly/moderately differentiated mid-thoracic ESCC in the middle mediastinum, lower-thoracic ESCC in middle and lower mediastina and abdominal cavity had the lymph node metastasis rates of 34.7%, 15.1%, 33.5% and 23.7% respectively. Lowly differentiated mid-thoracic ESCC in the middle mediastinum and abdominal cavity had the lymph node metastasis rates of 46.9% a 29.6% respectively, and those of lower-thoracic ESCC in middle and lower mediastina and abdominal cavity were 25.5%, 49.1% and 27.3% respectively.

Conclusion

During the outline of radiotherapy target volume for thoracic ESCC, tumor length, invasion depth and differentiation degree should be comprehensively considered to selectively irradiate the regions prone to lymph node metastasis.

Lymphovascular invasion as a poor prognostic indicator in thoracic esophageal carcinoma: a systematic review and meta-analysis

The ability to further stratify patients with esophageal carcinoma (EC) in the same stage into high-risk patients by the presence of lymphovascular invasion (LVI) may permit refinement of multi-modality therapy. However, the role of LVI in the prognosis of EC is not definite. A meta-analysis was conducted to investigate the relationship between LVI and EC prognosis. We searched PubMed, Embase, Web of Science, and Cochrane Library databases for studies on the association between LVI and prognosis of EC. Only studies with patient survival data related to LVI were included. The effect size for this analysis was the hazard ratio (HR) with 95% confidence intervals (CI) for overall survival (OS) and recurrence-free survival (RFS). Thirty-five studies with 9876 patients were included according to the defined inclusion and exclusion criteria. LVI was a poor indicator for the OS (HR = 1.64, 95% CI: 1.44-1.87, P < 0.001) and RFS (HR = 1.79, 95% CI: 1.38-2.34, P < 0.001). However, the heterogeneity was medium in OS (I2 = 61.2%, P < 0.001) and extreme in RFS (I2 = 77.5%, P < 0.001). In subgroup analysis, heterogeneity was originated from the staining method and proportion of early disease (stage (I + II)). We concluded that LVI was a poor prognostic indicator in patients with EC, especially in those studies with the IHC staining method and a high proportion of early disease (stage (I + II)).

Contrast-enhanced computed tomography combined with Chitosan-Fe3O4 nanoparticles targeting fibroblast growth factor receptor and vascular endothelial growth factor receptor in the screening of early esophageal cancer

Esophageal cancer is a malignant tumor with a relatively high invasiveness, metastatic potential and worldwide incidence among human cancers. The majority of patients with esophageal cancer are diagnosed in a late tumor stage due to a lack of advanced and sensitive protocols for the diagnosis of patients with early-stage esophageal cancer. In the current study, contrast-enhanced computerized tomography (CECT) combined with Chitosan-Fe₃O₄ nanoparticles targeting fibroblast growth factor receptor (FGFR) and vascular endothelial growth factor receptor (VEGFR; CECT-CNFV) were used to diagnose patients with suspected esophageal cancer. A Chitosan-Fe₃O₄-parceled bispecific antibody targeting FGFR and VEGFR was produced and its affinity to esophageal cancer cells was determined both in vitro and in vivo. A total of 320 patients with suspected esophageal cancer were voluntarily recruited to evaluate the efficacy of CECT-CNFV in the diagnosis of early-stage esophageal cancer. All participants were subjected to CT and CECT-CNFV to detect whether tumors were present in the esophageal area. A Chitosan-Fe₃O₄ nanoparticles contrast agent was orally administered at 20 min prior to CT and CECT-CNFV. The results demonstrated that CECT-CNFV improved diagnostic sensitivity and provided a novel protocol for the diagnosis of tumors in patients with suspected gastric cancer at an early-stage. Furthermore, the resolution ratio of images was enhanced by CECT-CNFV, which enabled the visualization of tiny tumor nodules in esophageal tissue. Clinical data demonstrated that CECT-CNFV diagnosed 200 patients with suspected early-stage esophageal cancer and 120 patients as tumor free. In addition, CECT-CNFV exhibited higher signal enhancement of tumor nodules than CT, suggesting a higher accuracy and accumulation of nanoparticle contrast agent within the tumor nodules of esophageal tissue. Notably, the survival rate of patients with esophageal cancer diagnosed at an early-stage by CECT-CNFV was higher than the mean five-year survival rate (P<0.01). In conclusion, CECT-CNFV enhanced the sensitivity and accuracy of CT in the diagnosis of early-stage esophageal cancer. Thus, CECT-CNFV may improve the accuracy of CT in the diagnosis of mural enhancement in patients with esophageal cancer.

Growth and Immune Evasion of Lymph Node Metastasis

Cancer patients with lymph node (LN) metastases have a worse prognosis than those without nodal disease. However, why LN metastases correlate with reduced patient survival is poorly understood. Recent findings provide insight into mechanisms underlying tumor growth in LNs. Tumor cells and their secreted molecules engage stromal, myeloid, and lymphoid cells within primary tumors and in the lymphatic system, decreasing antitumor immunity and promoting tumor growth. Understanding the mechanisms of cancer survival and growth in LNs is key to designing effective therapy for the eradication of LN metastases. In addition, uncovering the implications of LN metastasis for systemic tumor burden will inform treatment decisions. In this review, we discuss the current knowledge of the seeding, growth, and further dissemination of LN metastases.

Strategies of nodal staging of the TNM system for esophageal cancer

The 8^th edition of UICC/AJCC TNM staging for esophageal cancer will start in use since 2018. The nodal staging in this version of TNM system remains unchanged from the 7^th edition that based on the number of lymph nodes (LN) involved, except the limited revision of the regional LN map. In this review, N staging revision was evaluated from its initially simple definition of negative (N0) and positive (N1) LN(s) to the current positive node number based proposal. Meanwhile the disadvantages of current N staging were discussed. The refined nodal staging system in view of the number of metastatic node stations was introduced; as well as the extent and station of metastatic node could better reflect the disease progression and prognosis. The controversy on N staging of esophagogastric junction cancer was also discussed. Other reported N staging associated elements including LN ratio and lymphatic vessel invasion were reviewed and evaluated.

Microvessel density as a prognostic factor in esophageal squamous cell cancer patients: A meta-analysis

BACKGROUND

To date, literature has emerged that shows contradictory results about the prognostic role of microvessel density (MVD) in esophageal squamous cell cancer (ESCC). The aim of the study set out to evaluate the correlation between MVD and the prognosis of ESCC.

METHODS

Identified publications from various databases were obtained and reviewed. A meta-analysis was performed to evaluate the prognostic role of MVD among ESCC patients.

RESULTS

A total of 11 eligible studies containing 891 ESCC cases were included in the meta-analysis. The pooled hazard ratio for overall survival was 2.39 (95% confidence interval 1.92-2.96, P < .001). Heterogeneity among the studies was not significant, and publication bias was not found. Subgroup analyses were also performed on different issues, such as districts, antibodies, and median age.

CONCLUSION

High MVD is a prognostic factor among ESCC that indicated worse prognosis in these patients. More studies are needed, and through abundant evidence, the topic could be re-evaluated by then.