Prediction of prognosis by the extent of lymph node involvement in squamous cell carcinoma of the thoracic esophagus

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Critical number of lymph node involvement in esophageal and gastric cancer and its impact on long-term survival-A single-center 8-year study

BACKGROUND

Nodal disease in esophageal and gastric cancer is associated with poor survival.

OBJECTIVES

To determine the critical level of lymph node involvement where survival becomes significantly compromised.

METHODS

Survival analyses using multivariable Cox regression and receiver operator characteristics (ROC) were undertaken to determine what number of positive lymph nodes were most sensitive and specific in predicting survival.

RESULTS

A total of 317 patients underwent esophagectomy (n = 190, 59.9%) and gastrectomy (n = 127, 40.1%) for adenocarcinoma. At multivariable analyses, four nodes positivity (irrespective of T-category) was associated with nearly a fivefold increased risk of mortality when compared to node-negative patients (hazard ratio [HR], 4.9; interquartile range 2.0-11.5; P < .001). A positive ratio of up to 50.0% was not associated with worse survival than having four nodes positive (HR, 4.6; 95% confidence interval, 2.6-8.1; P < .001). ROC analysis demonstrated four lymph nodes positive to have a sensitivity of 80.5%, a specificity of 60.1%, and an accuracy of 77.8 (P < .001).

CONCLUSION

The absolute number of nodes positive for cancer is more important than the proportion of positive nodes in predicting survival in esophageal/gastric cancer. Four positive lymph nodes are associated with a fivefold increase in mortality. Beyond this, increasing numbers of positive lymph nodes make no appreciable difference to survival.

Clinical outcomes of elderly patients (≥70 years) with resectable esophageal squamous cell carcinoma who underwent esophagectomy or chemoradiotherapy: A retrospective analysis from a single cancer institute

A retrospective analysis was conducted to investigate outcomes of elderly patients with resectable esophageal squamous cell carcinoma (ESCC) who underwent surgery or chemoradiotherapy (CRT).We performed a retrospective review of the records of elderly patients (≥70 years) with resectable ESCC who underwent esophagectomy or CRT between January 2009 and March 2013. According to the main treatment strategy, patients were allocated into either surgery group or CRT group. Overall survival (OS), cancer-specific survival and progression-free survival were calculated by the Kaplan-Meier method. Univariate and multivariate survival analyses were performed by the Kaplan-Meier method and Cox proportional hazards model, respectively.A total of 188 patients were enrolled. Eighty-eight patients underwent esophagectomy, and 100 patients underwent CRT. The median age of the patients was 73 years (range, 70-81 years) in the surgery group and 76 years (range, 70-88 years) in the CRT group. The median survival time (MST) for the whole cohort was 25.6 months, and 1-, 3-, and 5-year survival rates were 69.2%, 36.1%, and 21.9%, respectively. The MST in the surgery group and the CRT group was 36 months and 15 months, respectively. The 1-, 3-, and 5-year survival rates in the surgery group were 82.4%, 49.0%, and 33.3%, compared to 58.0%, 24.1%, and 7.8% in the CRT group (P < 0.0001). Multivariate analysis revealed that lymph node status (hazard ratio [HR] = 0.598, P = 0.011) and treatment strategies (HR = 0.538, P = 0.001) were independent and significant prognostic factors for OS in elderly patients.Surgery was the main treatment strategy for elderly patients with ESCC. Advanced age and comorbidities should not be the cause for elderly patients to avoid aggressive regimens. Delivered therapeutic approaches should be individualized on the basis of carefully evaluating the balance of benefits, risks, and life expectancy.

Proposed Modification of Nodal Staging as an Alternative to the Seventh Edition of the American Joint Committee on Cancer Tumor-Node-Metastasis Staging System Improves the Prognostic Prediction in the Resected Esophageal Squamous-Cell Carcinoma

INTRODUCTION

The 7th American Joint Committee on Cancer (AJCC) tumor-node-metastasis staging system for esophageal cancer defined N classification based on the number of metastatic lymph nodes (LNs). However, this classification might neglect the extent of LNs metastasis. This study aimed to revise N classification based on the extent of LNs metastasis and propose a modification to the current AJCC staging system for better representing the prognostic characteristics of Chinese esophageal squamous-cell carcinoma (ESCC).

METHODS

We retrospectively reviewed 1993 ESCC patients who underwent curative resection. The proposed N categories based on the number of LNs metastasis stations were compared with the current staging system by univariate and multivariate Cox regression analyses. Homogeneity, discriminatory ability, and monotonicity of gradients of two staging systems were compared using likelihood ratio χ statistics and Akaike information criterion calculations.

RESULTS

The survival differences were not significant for N2 versus N3 category (p = 0.231) and stages IIIB versus IIIC (p = 0.713) based on the 7th AJCC staging system. When the modified staging system was adopted, the survival difference for N2 versus N3 and IIIB versus IIIC could be well discriminated. Statistical analysis showed that the modified staging system had higher likelihood ratio χ scores and smaller Akaike information criterion values than the 7th AJCC staging system, which represented the optimum prognostic stratification.

CONCLUSIONS

The modified staging system with the revised N categories based on the number of LNs metastasis stations better predicts the survival of Chinese ESCC population than the 7th AJCC staging system. Further studies are required to confirm this result.

Validation of T Stage According to Depth of Invasion and N Stage Subclassification Based on Number of Metastatic Lymph Nodes for Distal Extrahepatic Bile Duct (EBD) Carcinoma

According to the current AJCC staging system, the T stage of distal extrahepatic bile duct carcinoma (EBD) is classified according to the extent of the tumor within or beyond the bile duct wall. However many invasive carcinoma accompany stromal desmoplasia that obscure lower boundary of bile duct wall; it is frequently difficult to clearly define the extent of tumors using the current T classification system. In this study, we validated an alternative T classification system by depth of invasion (DoI; T1: < 5  mm, T2: 5 to 12  mm, and T3: ≥ 12  mm). Specifically, we evaluated DoI in 114 cases of distal EBD carcinoma using digital scan images to achieve more objective measurements of tumor DoI. In addition, we evaluated the effect of the number of metastatic lymph nodes (LNs) as well as the number of total examined LNs on the survival rate in the same patient group, and performed a comparative analysis of these data to assess patient survival. We also analyzed 114 cases of distal EBD carcinoma using the current T and N classification of the AJCC staging system (7th edition). The T stage of the current AJCC staging system was not associated with significant differences in patient survival, especially between T2 and T3. However, T staging by DoI was associated with statistically significant differences in patient survival (P < 0.001 in DoI-1, P = 0.002 in DoI-2). With respect to N stage, we divided patients into 3 tiers comprising class 1 (no nodal metastasis), class 2 (1-3 nodal metastases), and class 3 (4 or more nodal metastases). In 3-tier classification analysis, the median survival times for classes 1, 2, and 3 were 79.2, 28.8, and 10.9 months, respectively. The difference in survival among the 3 classes was statistically significant (P < 0.001). We found the cut-off value of 11 LNs (1 to 10 vs  ≥ 11) for N0 stage showed most significant difference (P = 0.007). We think at least 11 LNs should be examined for more accurate evaluation of N stage in distal EBD carcinoma. We propose an alternative T classification using DoI and 3-tier sub-classification of N stage for distal EBD carcinoma.

Prognostic Nomogram for Thoracic Esophageal Squamous Cell Carcinoma after Radical Esophagectomy

Nomogram has demonstrated its capability in individualized estimates of survival in diverse cancers. Here we retrospectively investigated 1195 patients with esophageal squamous-cell carcinoma (ESCC) who underwent radical esophagectomy at Zhejiang Cancer Hospital in Hangzhou, China. We randomly assigned two-thirds of the patients to a training cohort (n = 797) and one-third to a validation cohort (n = 398). Cox proportional hazards regression analyses were performed using the training cohort, and a nomogram was developed for predicting 3-year and 5-year overall survival rates. Multivariate analysis identified tumor length, surgical approach, number of examined lymph node, number of positive lymph node, extent of positive lymph node, grade, and depth of invasion as independent risk factors for survival. The discriminative ability of the nomogram was externally determined using the validation cohort, showing that the nomogram exhibited a sufficient level of discrimination according to the C-index (0.715, 95% CI 0.671–0.759). The C-index of the nomogram was significantly higher than that of the sixth edition (0.664, P-value<0.0001) and the seventh edition (0.696, P-value<0.0003) of the TNM classification. This study developed the first nomogram for ESCC, which can be applied in daily clinical practice for individualized survival prediction.

The expression of cytokeratin 19 in lymph nodes was a poor prognostic factor for hepatocellular carcinoma after hepatic resection

BACKGROUND

The expression of CK19 in primary hepatocellular carcinoma (HCC) is associated with a poor outcome. However, few studies have investigated the expression profile of CK19 in regional lymph nodes (LNs) of HCC after hepatic resection. The purpose of this study was to evaluate the expression of CK19 in primary liver tumor and regional LNs of HCC with and without lymph node metastasis (LNM).

METHODS

The expression of CK19 in patients with (n = 16) and without LNM (n = 26) was examined using immunohistochemical staining. Both the primary tumor and LN specimen were studied for their CK19 expression. Clinico-pathological variables and prognostic significance were analyzed.

RESULTS

Immunopositivity of CK19 in primary liver tumor was significantly correlated with LNM (P = 0.005) and tumor non-encapsulation (P <0.005). Univariate analysis showed that CK19 expression in primary liver tumor, CK19 expression in regional LN, vascular invasion, daughter nodules, positive resection margin and American Joint Committee on Cancer (AJCC) tumor stage significantly decreased overall survival. Multivariate analysis demonstrated that daughter nodules (P = 0.001) and CK19 expression in regional LN (P = 0.002) were independent prognostic factors for overall survival.

CONCLUSIONS

This study showed that CK19 expression in regional LN of HCC was associated with LNM and an extremely poor outcome after operation. It is of clinical significance to identify these patients at risk for more aggressive HCC, and multi-modality treatment could be helpful to improve their dismal outcome.

Radiofrequency ablation of retroperitoneal metastatic lymph nodes from hepatocellular carcinoma

RATIONALE AND OBJECTIVES

To retrospectively evaluate effectiveness and safety of radiofrequency (RF) ablation with retroperitoneal metastatic lymph nodes from hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Thirty-two patients with retroperitoneal metastatic lymph node recurrence from HCC were enrolled in our study and the patients stratified into two groups based on the treatment. Nineteen patients in Group A were percutaneously treated and each metastatic lymph node was ablated with computed tomographic (CT) guidance. Thirteen patients in Group B only underwent RF ablation for hematogenous metastases, but did not undergo RF ablation or any other treatment for metastatic lymph nodes. Follow-up contrast material-enhanced CT or positron emission tomographic scans were reviewed and Kaplan-Meier survival estimates were analyzed.

RESULTS

There were no significant differences between characteristics of the two groups. Kaplan-Meier analysis indicated the patients of Group A had an overall survival of 26.3% at 1 year compared with 7.7% for those of Group B. Mantel-Cox log rank test showed the 1-year survival rate of Group A was significantly higher than that of Group B (P = .029). In Group A, the local control rate of 3, 6, 10, and 15 months was 78.9%, 73.3%, 41.7%, and 25.0%, respectively. Sixteen, 12, 6, and 2 patients showed no evidence of local progression for 3, 6, 10, and 15 months, respectively. There was no thermal injury of gastrointestinal tract or bile duct during RF ablation in all the 19 patients of Group A.

CONCLUSION

RF ablation is effective and may be safely applied to retroperitoneal metastatic lymph nodes from HCC.

Hepatic resection for hepatocellular carcinoma with lymph node metastasis: clinicopathological analysis and survival outcome

OBJECTIVE

Lymph node metastasis (LNM) rarely occurs in hepatocellular carcinoma (HCC). Few studies have reported the potential risk factors of LNM and the influence of LNM on the progression and prognosis of HCC. The purposes of this study were to explore the clinicopathological characteristics of operable HCC with LNM and to demonstrate the effects of LNM on HCC prognosis.

METHODS

A retrospective review of 2,034 HCC patients undergoing surgery from 1982 to 2005 was performed. The influence of LNM was assessed by clinicopathological factors, tumour recurrence, and overall survival. A total of 66 randomly selected patients matched for clinicopathological variables were used to analyse the difference in survival.

RESULTS

A total of 25 patients (1.23%) were reported to have LNM. Higher preoperative carcinoembryonic antigen levels (> 10 ng/mL) were significantly associated with a higher incidence of LNM than were low preoperative carcinoembryonic antigen levels (≤ = 10 ng/mL) (15.38%vs. 3.79%, p = 0.042). Furthermore, HCC with LNM (N1 disease) was larger in size (mean, 9.44 vs. 5.85 cm, p = 0.016) and significantly associated with vascular invasion, worse histological grade, and nonencapsulation (p = 0.002, < 0.001, and < 0.001, respectively). Finally, patients with HCC accompanied by LNM had shorter mean disease-free survival and overall survival (p = 0.001 and < 0.001, respectively).

CONCLUSION

This study identified the worst prognosis of HCC in a population with LNM. HCC with LNM tends to be the infiltrating type with larger tumour size (> 5 cm), presence of microvascular invasion, and worse histological grade. Liver resection with lymphadenectomy is possibly beneficial for patients with HCC accompanied by LNM.

The N-classification for esophageal cancer staging: should it be based on number, distance, or extent of the lymph node metastasis?

BACKGROUND

The recently published AJCC-TNM staging system for esophageal carcinoma made an obvious modification on N-classification based on the number of metastatic regional lymph nodes (LN). However, this classification might ignore the site at which these LNs occur, a factor that might be even more important in reflecting patients' prognosis.

METHODS

A retrospective study of 236 patients with carcinoma of thoracic esophagus who underwent esophagectomy between 1984 and 1989 with each at least six LNs removed was conducted, with a 10-year follow-up rate of 92.4%. The proposed scheme for N-classification according to the number (0, 1-2, 3-6, ≥7; N0-3), distance (0, 1, 2, 3 stations; S0-3), or extent (0, 1, and 2 fields; F0-2) of LN involvement was evaluated by univariate and multivariate survival analysis.

RESULTS

The LN metastasis was identified in 112 patients, revealing a poorer 5-year survival in this patient group when compared to patients without node involvement. Cox regression analysis revealed that the number and distance of LN metastases and the number of metastasis fields were factors significantly influencing survival. When these factors were further analyzed by univariate log-rank test, no significant difference in survival existed between N2 and N3 patients, or among S1, S2, and S3 patients. When patients were grouped according to the extent of LN metastasis, significant differences in survival were observed overall and between each subgroup.

CONCLUSIONS

Refining the current N-classification for esophageal cancer according to the extent of LN metastasis, rather than by number alone, might be a better means of staging that could subgroup patients more effectively and result in different rates of survival.

Clinical significance of lymph node metastasis in patients undergoing partial hepatectomy for hepatocellular carcinoma

BACKGROUND

There are few detailed clinical reports about perihepatic lymph node (LN) assessment of hepatocellular carcinoma (HCC). The purpose of the present study was to evaluate the incidence, site, and impact on survival of LN metastasis in patients with HCC amenable to curative liver resection and routine regional lymphadenectomy.

METHODS

From January 2001 to June 2004, a total of 523 HCC patients undergoing curative hepatic resection and routine regional lymphadenectomy were included in this study. The incidence, site of LN metastasis in HCC patients, and its influence on survival were analyzed.

RESULTS

A total of 3433 lymph nodes were dissected from the 523 patients enrolled in this study and examined by pathologists. Among these patients, LN metastasis was found in 39 (7.45%) patients. Hepatic pedicle, retropancreatic space, and common hepatic artery stations were conventionally removed. The incidence of LN metastasis in the hepatic pedicle station was higher than that in the other stations (p < 0.01) The overall cumulative survival rate was significantly worse for patients with LN metastasis than for those without LN metastasis (p < 0.01). The median survival time was 28 months among the patients with LN metastasis and 53 months among those without LN metastasis. Tumors had recurred in 82.05% (32/39) of patients with LN metastasis and in 57.64% (279/484) of those without LN metastasis (p < 0.01). Regional lymphadenectomy was considerably safe with a low intraoperative complication rate (0.95%).

CONCLUSIONS

Lymph node metastasis in patients with HCC is closely related to a lower survival rate. Regional lymph node dissection should always be performed to determine the precise stage of the disease. Hepatic resection with regional lymphadenectomy is a safe procedure in patients with HCC.

Clinical significance of lymph node metastasis in patients undergoing partial hepatectomy for hepatocellular carcinoma

BACKGROUND

There are few detailed clinical reports about perihepatic lymph node (LN) assessment of hepatocellular carcinoma (HCC). The purpose of the present study was to evaluate the incidence, site, and impact on survival of LN metastasis in patients with HCC amenable to curative liver resection and routine regional lymphadenectomy.

METHODS

From January 2001 to June 2004, a total of 523 HCC patients undergoing curative hepatic resection and routine regional lymphadenectomy were included in this study. The incidence, site of LN metastasis in HCC patients, and its influence on survival were analyzed.

RESULTS

A total of 3433 lymph nodes were dissected from the 523 patients enrolled in this study and examined by pathologists. Among these patients, LN metastasis was found in 39 (7.45%) patients. Hepatic pedicle, retropancreatic space, and common hepatic artery stations were conventionally removed. The incidence of LN metastasis in the hepatic pedicle station was higher than that in the other stations (p < 0.01) The overall cumulative survival rate was significantly worse for patients with LN metastasis than for those without LN metastasis (p < 0.01). The median survival time was 28 months among the patients with LN metastasis and 53 months among those without LN metastasis. Tumors had recurred in 82.05% (32/39) of patients with LN metastasis and in 57.64% (279/484) of those without LN metastasis (p < 0.01). Regional lymphadenectomy was considerably safe with a low intraoperative complication rate (0.95%).

CONCLUSIONS

Lymph node metastasis in patients with HCC is closely related to a lower survival rate. Regional lymph node dissection should always be performed to determine the precise stage of the disease. Hepatic resection with regional lymphadenectomy is a safe procedure in patients with HCC.

Prognostic significance of perigastric lymph nodes metastases on survival in patients with thoracic esophageal cancer

Several publications have showed that the number of metastatic lymph node (LN) should be taken into consideration in nodal category of esophageal cancer, but seldom considered extent of involved regional LNs. The aim of this study is to evaluate the significance of the extent of regional LN metastasis on survival in patients with esophageal cancer. A total of 245 thoracic esophageal cancer patients underwent transthoracic esophagectomy with standard lymphadenectomy between January 2000 and December 2006 were included in the study. Data including demographic factors, pathologic findings, LN parameters and survival outcomes were collected. The survival experience was depicted using Kaplan-Meier method. A multivariate Cox proportional hazard model was used to screen the significant prognostic factors. The univariate analysis to further explore the significant prognostic factor was done by log-rank test. After a median follow-up of 53.2 months, the 5-year survival rate was 46.3% for the entire cohort. Cox model regression indicated that the LN status and perigastric nodal status, aside from residual tumor status, histological tumor type and depth of invasion, were the independent prognostic factors. Patients without LN metastasis had better 5-year survival than those with positive nodes (64.2% vs. 18.9%, X2=35.875, P<0.001). However, For those patients with nodal involvement, there was no difference in 5-year survival between patients with involved nodes<3 and >or=3 (27.8% vs. 0%, X2=0.925, P=0.336). When considering the location of LN metastasis, patients could be further stratified according to whether the perigastric nodes were involved or not (37.5% vs. 10.0%, X2=4.295, P=0.038). In conclusion, involved LN number had no prognostic implication in nodal involved patients based on our data. Whereas, perigastric nodal involvement should be used to refine the N category (N0, no nodal metastasis, N1, non-perigastric node metastasis, N2, perigastric node metastasis) for the future esophageal cancer staging criteria.

Impact of the number of resected and involved lymph nodes on esophageal cancer survival

BACKGROUND

Using a large data set, we investigated the impact of the number of resected and involved lymph nodes on overall survival for patients with esophageal cancer.

METHODS

From the National Oncology Database, esophageal cancer cases with data available on the total number of resected and involved nodes as well as other variables were evaluated as it relates to overall survival by multivariate analysis using Cox proportional hazards method. Patients with 0, exactly 1 or 1-3 positive nodes were separately studied to determine the association between the number of lymph nodes resected and overall survival.

RESULTS

From 1969 to 2002, 3,144 (17%) of 18,390 esophageal cancer cases with complete data were identified. Increasing number of involved nodes predicted poorer outcome (P < 10(-6)). Results from studying patients with 0, exactly 1 or 1-3 positive nodes showed that survival improved with increasing number of nodes analyzed up to 12. Three-tier nodal grouping with increasing risk of death were identified, 0, 1-3, and >or=4 positive nodes (P < 10(-5)).

CONCLUSIONS

The pathological assessment of minimal 12 lymph nodes provides sufficient prognostic information. Three-tier nodal grouping is suggested for the next version of AJCC staging system for esophageal cancer.

Prognostic variables in thoracic esophageal squamous cell carcinoma

BACKGROUND

Thoracic esophageal squamous cell carcinoma (TESCC) is an aggressive malignancy with a poor prognosis. The current American Joint Committee on Cancer (AJCC) TNM cancer staging system focusing on the effect of regional (N1) and nonregional lymph node (M1a and M1b) metastasis may need reappraisal. We investigated the role of the number of dissected and positive nodes in TESCC patients.

METHODS

A total of 109 TESCC patients (97 men; mean age of 62.3 years) who underwent surgical resection were retrospectively analyzed. The current AJCC TNM system and other lymph node classifications were used to subgroup these patients and analyze survival differences. Previously reported prognostic factors were evaluated.

RESULTS

Patients with positive lymph node metastasis had a poor prognosis (p < 0.001). There was a significant difference in survival among the 67 node-positive patients subdivided into subgroups with 1 to 3 and 4 or more positive nodes (p = 0.004). Multivariable Cox proportional hazard regression analysis identified four independent prognostic factors: difficulty in swallowing (p = 0.024), cigarette smoking (p = 0.003), number of positive lymph nodes (0, 1 to 3, and > or = 4; p < 0.001), and gastric cardia invasion (p = 0.012). Total dissection of at least 20 lymph nodes was the minimal requirement to achieve accurate nodal staging.

CONCLUSIONS

Dissection of more than 20 lymph nodes is mandatory in TESCC patients to achieve accurate staging. Positive lymph node metastasis of 4 or higher is a significant independent prognostic factor.

Impact of solitary involved lymph node on outcome in localized cancer of the esophagus and esophagogastric junction

Node-positive esophageal cancer is associated with a dismal prognosis. The impact of a solitary involved node, however, is unclear, and this study examined the implications of a solitary node compared with greater nodal involvement and node-negative disease. The clinical and pathologic details of 604 patients were entered prospectively into a database from1993 and 2005. Four pathologic groups were analyzed: node-negative, one lymph node positive, two or three lymph nodes positive, and greater than three lymph nodes positive. Three hundred and fifteen patients (52%) were node-positive and 289 were node-negative. The median survival was 26 months in the node-negative group. Patients (n=84) who had one node positive had a median survival of 16 months (p=0.03 vs node-negative). Eighty-four patients who had two or three nodes positive had a median survival of 11 months compared with a median survival of 8 months in the 146 patients who had greater than three nodes positive (p=0.01). The survival of patients with one node positive [number of nodes (N)=1] was also significantly greater than the survival of patients with 2-3 nodes positive (N=2-3) (p=0.049) and greater than three nodes positive (p<0001). The presence of a solitary involved lymph node has a negative impact on survival compared with node-negative disease, but it is associated with significantly improved overall survival compared with all other nodal groups.

The prognostic importance of the number of involved lymph nodes in esophageal cancer: implications for revisions of the American Joint Committee on Cancer staging system

OBJECTIVE

The American Joint Committee on Cancer (AJCC) staging system for esophageal cancer is controversial because it relies on arbitrary definitions of the anatomic location of lymph nodes to establish N and M status. It has been proposed that the number of involved lymph nodes may better predict survival. We reviewed our experience to determine the prognostic impact of the number of involved nodes and the extent of lymphadenectomy on the current staging system.

METHODS

Records of all patients who underwent resection of previously untreated adenocarcinoma and squamous cell carcinoma of the esophagus and gastroesophageal junction were reviewed. Overall survival according to the AJCC staging system and the number of involved lymph nodes was analyzed by the method of Kaplan and Meier and by recursive partitioning methods.

RESULTS

Data were available on 336 patients operated on between January 1996 and September 2003. Recursive partitioning analysis using AJCC staging variables reproduced the AJCC staging system. When the number of involved lymph nodes is added, patients with more than 4 involved lymph nodes have survival similar to that of patients with M1 disease, and patients with no involved lymph nodes have the best prognosis. Recursive partitioning analysis identified 18 lymph nodes as the minimal number required for accurate staging. In patients who have 18 or more lymph nodes removed, survival is only predicted by the presence of nodal involvement and M1 disease.

CONCLUSION

Our analysis suggests that revisions of the current AJCC staging system for esophageal cancer should include N staging based on the number of involved lymph nodes and minimal requirements for the extent of lymphadenectomy.

Protein clusters associated with carcinogenesis, histological differentiation and nodal metastasis in esophageal cancer

We examined the proteomic background of esophageal cancer. We used laser microdissection to obtain tumor tissues from 72 esophageal squamous cell carcinoma cases and adjacent normal tissues in 57 of these cases. The 2D-DIGE generated quantitative expression profiles with 1730 protein spots. Based on the intensity of the protein spots, unsupervised classification distinguished the tumor tissues from their normal counterparts, and subdivided the tumor tissues according to their histological differentiation. We identified 498 protein spots with altered intensity in the tumor tissues, which protein identification by LC-MS/MS showed to correspond to 217 gene products. We also found 41 protein spots that were associated with nodal metastasis, and identified 33 proteins corresponding to the spots, including cancer-associated proteins such as alpha-actinin 4, hnRNP K, periplakin, squamous cell carcinoma antigen 1 and NudC. The identified cancer-associated proteins have been previously reported to be individually involved in a range of cancer types, and our study observed them collectively in a single type of malignancy, esophageal cancer. As the identified proteins are involved in important biological processes such as cytoskeletal/structural organization, transportation, chaperon, oxidoreduction, transcription and signal transduction, they may function in a coordinate manner in carcinogenesis and tumor progression of esophageal cancer.

Staging of esophageal carcinoma: length of tumor and number of involved regional lymph nodes. Are these independent prognostic factors?

BACKGROUND AND OBJECTIVES

New potential prognostic indicators aside from the TNM classification have been proposed. The aim of this study was to analyze the prognostic relevance of tumor length as well as number of involved regional lymph nodes (LNM) in patients with esophageal carcinoma.

METHODS

Two hundred thirteen patients with esophageal carcinoma (116 squamous cell- and 97 adenocarcinoma) were included in this study. Treatment of choice was subtotal en bloc esophagectomy including "2-field" lymphadenectomy. The median number of examined lymph nodes (LNs) was 28. Eighty patients (38%) received preoperative radio-chemotherapy according to a standardized protocol. Histopathology consisted of tumor stage, residual tumor, grading, and number of examined and involved LN. Univariate and multivariate prognostic values were calculated.

RESULTS

Length of tumor correlated with pT/ypT-category (P<0.01). Univariate but not multivariate analysis showed better survival for tumors<or=3 cm (P<0.05). Patients with 1-5 LNM had significantly better prognoses than those with more than 5 LNM (Hazard ratio 2.7, 95% CI=1.7-4.2) (P<0.01). Patients without LNM and more than 15 examined LN showed significantly better prognosis than those with fewer examined LN (Hazard ratio=0.3, 95% CI=0.1-0.6) (P<0.01).

CONCLUSIONS

A revision of the TNM classification for esophageal carcinoma should subdivide the pN1-category according to the number of LNM.

The number of lymph nodes with metastasis predicts survival in patients with esophageal or esophagogastric junction adenocarcinoma who receive preoperative chemoradiation

BACKGROUND

The survival of patients with locoregional adenocarcinoma of the esophagus or the esophagogastric junction (EGJ) who receive preoperative chemoradiation is reported to be better among patients who achieve a pathologic complete response than among patients who have residual tumor, including lymph node (LN) metastasis. However, the prognostic significance of the number of LNs with residual metastasis remains unclear.

METHODS

The authors studied 187 consecutive patients who received chemoradiation followed by an esophagectomy. The number of positive LNs and the size of metastatic tumor in each positive LN were examined with regard to overall survival (OS) and recurrence-free survival (RFS).

RESULTS

A pathologic complete response was achieved by 29% of patients. No LN metastasis (posttherapy pathologic negative LN status [ypN0]) was present in 49% of patients who had residual carcinoma, and LN metastasis (ypN1) was present in 51% of patients. The 5-year OS and 2-year RFS rates achieved by patients who had 1 positive LN (34% and 45%, respectively) were similar to the rates achieved by patients in the ypN0 group (38% [P = 0.84] and 50% [P = 0.77], respectively) but were significantly better than the rates achieved by patients who had > or = 2 positive LNs (6% [P = 0.02] and 18% [P = 0.01], respectively). The size of metastatic tumor in LNs among patients who had 1 positive LN was a prognostic factor (> or = 4 mm vs. < 4 mm; P = 0.04). In multivariate analysis, OS was better in patients who had 1 LN metastasis among patients in the ypN1 group (P = 0.02) independent of their posttherapy pathologic tumor status.

CONCLUSIONS

The current results suggested that the number of LNs with metastasis is an independent prognostic factor in patients with residual adenocarcinoma of the esophagus or the EGJ after preoperative chemoradiation. The authors suggest modification of the tumor-lymph node-metastasis (TNM) staging classification (ypTNM) to include the number of positive LNs in the ypN1 category.

Pre-tracheal lymph node metastasis in squamous cell carcinoma of the thoracic esophagus

AIMS

To clarify the incidence of pre-tracheal lymph node metastasis in squamous cell carcinoma of the esophagus, and their impact on survival.

METHODS

A cohort of 101 patients with squamous cell carcinoma of the thoracic esophagus who underwent esophagectomy together with 2-field lymphadenectomy including the pre-tracheal region was analysed, retrospectively. The p-TNM staging included stage I in 9, stage IIa in 33, stage IIb in 4, stage III in 43, and stage IV in 12 cases.

RESULTS

Nodal metastases were identified in 56 patients (55.4%). Subcarinal lymph node and pre-tracheal lymph-node metastases were found in 24 patients (23.8%) and 15 patients (14.9%), respectively. The 5-year cumulative survival rates were 26.5 and 2.5% in nodal negative and nodal positive patients, respectively. Patients with pre-tracheal nodal metastasis all died within 2 years. Cox proportional hazards model in patients with nodal involvement revealed T-factor (p=0.0017), pre-tracheal nodal involvement (p=0.0055) and distant metastasis (p=0.0024) as independent prognostic factors.

CONCLUSIONS

Our findings suggest that pre-tracheal lymph node metastasis indicates a dismal prognosis. Its occurrence is not unusual, especially in tumour of upper or middle thoracic esophagus. The subcarinal node cannot be regarded as a sentinel node of the pre-tracheal nodal station. Complete lymphadenectomy excluding the pre-tracheal lymph nodes in treating esophageal cancers is only a myth.

The Number of Metastatic Lymph Nodes in Extrahepatic Bile Duct Carcinoma as a Prognostic Factor

The number of lymph nodes with metastases is known to be an important prognostic factor in carcinomas of many organs. The insufficient sampling of lymph nodes has also been associated with worse outcome in several types of carcinoma. However, the prognostic significance of lymph node dissection is not well characterized in extrahepatic bile duct (EBD) carcinomas. For 209 patients with EBD carcinoma, the total number of retrieved lymph nodes and the number of metastatic lymph nodes were evaluated, and other clinicopathologic variables were correlated with patient survival. The number of retrieved lymph nodes was not significantly correlated with survival in this study. The presence of metastasis to lymph nodes significantly decreased survival of patients with EBD carcinoma. The patients with 5 or more metastatic lymph nodes had significantly worse survival than those with 4 or less metastatic lymph nodes. To evaluate the prognosis of the patients with EBD carcinomas more precisely, the number of metastatic lymph nodes as well as the status of metastasis to lymph nodes should be examined and reported. Based on the present data, we propose that nodal classification should be divided into N1 (metastasis in 1 to 4 regional lymph nodes) and N2 (metastasis in 5 or more regional lymph nodes).

The role of lymphadenectomy for liver tumors: further considerations on the appropriateness of treatment strategy

OBJECTIVE

To evaluate the role of regional lymphadenectomy in patients with liver tumors.

BACKGROUND

Lymph node status is 1 of the most important prognostic factors in oncologic surgery; however, the role of lymph node dissection remains unclear for hepatic tumors.

METHODS

A total of 120 consecutive patients undergoing liver resections for primary and secondary hepatic tumors were prospectively enrolled in the study. "Regional" lymphadenectomy was carried out routinely after specimen removal. Incidence, site, and influence on survival of node metastases were analyzed.

RESULTS

Only 1 postoperative complication (intra-abdominal bleeding) was related to lymph node excision. Median number of dissected nodes was 6.8 +/- 3.6. Periportal, pericholedochal, and common hepatic artery stations were always removed. Lymph node metastases were found in 17 (16.5%) patients. The percentage rises to 20.3% when considering only noncirrhotic patients. The incidence of lymph node metastases was 7.5% for hepatocellular carcinoma, 14% for colorectal metastases, 40% for noncolorectal metastases, and 40% for intrahepatic cholangiocarcinoma (P < 0.002). Median survival time was 486 +/- 93.2 days among all patients with node metastases and 725 +/- 29.7 among patients without node metastases. The 2-year survival was 37.1% and 86.7%, in the 2 groups (P < 0.05). The 2-year recurrence rate was 77.6% and 45.3%, respectively (P < 0.05).

CONCLUSIONS

Regional lymphadenectomy is a safe procedure after liver resection, and it should be routinely applied in patients with primary and secondary hepatic tumors, particularly in those without chronic disease. A careful evaluation of node status is nevertheless advisable also in patients with hepatocellular carcinoma on cirrhosis.

Response to preoperative chemotherapy affects prognosis in esophageal cancer

The effect of preoperative chemotherapy on prognosis is still controversial. We have investigated the relationship between responses to preoperative chemotherapy and prognosis after curative operations in patients with esophageal squamous cell carcinoma. Thirty-nine patients received preoperative chemotherapy with continuous infusion of 500 mg/m2 of 5-fluorouracil (5-FU) and intravenous injection of 20 mg/m2 of leucovorin every 12 hours for 5 days. On the 5th day alone, 70 mg/m2 of cisplatin was also infused. The effect was evaluated approximately 14 days after the end of one course of chemotherapy. The rates of responders and non-responders were 64.1% and 35.9%, respectively. After an interval of 21-28 days, transthoracic esophagectomy was performed. Significant histological effect by chemotherapy was found in responders compared to non-responders (P < 0.05). Responders had a significantly better prognosis than non-responders by Log-rank test (P < 0.01). This suggests that preoperative chemotherapy may contribute to better prognosis when the tumor is sensitive to chemotherapy.