Prognostic and Clinical Evaluation of Axillary Lymph Node Metastasis in Esophageal Cancer

Double primary recurrent human epidermal growth factor receptor 2-positive breast cancer and esophageal cancer that responded well to chemotherapy

Double primary breast and esophageal cancer have been no reported cases in which treatment methods other than surgery were selected because of multiple metastasis or advanced cancer. The patient was a 52-year-old woman who had received left pectoral muscle-preserving mastectomy and axillary lymph node dissection (level 2) 7 years prior, following the diagnosis of left breast cancer. The postoperative diagnosis was pT2 N3a M0 stage IIIC and luminal human epidermal growth factor receptor 2 (HER2) phenotype. After the surgery, six courses of triple chemotherapy with 5-fluorouracil (5-FU), epirubicin, and cyclophosphamide and four courses of docetaxel (DTX) were administered, and letrozole was administered for 5 years. Seven years after the surgery, swelling of her left axillary, supra-, and subclavicular lymph nodes, and sternum osteolysis were observed on computed tomography (CT). Radioisotope uptake was observed in the esophagus on positron emission tomography. An esophageal cancer was observed in the upper thoracic esophagus on esophagogastroscopy. The patient was administered a local treatment for esophageal cancer and systemic chemotherapy for both cancers. As a primary therapy, double chemotherapy with 5-FU and cisplatin (FP) (two courses) + radiotherapy on the esophagus and left supraclavicular lymph nodes (total target dose of radiotherapy was 60 Gy /30 fractions) was performed with the concomitant use of trastuzumab and zoledronate. Marked shrinkage [complete response (CR)] of the esophageal cancer was observed on esophagogastroscopy and shrinkage (partial response) of the left axillary and supra- and subclavicular lymph nodes were observed on CT. The secondary treatment included pertuzumab + trastuzumab + DTX. Bilateral pleural effusions were observed in the eighth course; therefore, DTX was withdrawn and the treatment was continued with only the molecularly targeted drugs. Two years have passed since the initiation of treatment. The individual lymph node metastatic foci have disappeared or markedly shrunk (CR) on CT scans and the sternal metastases have remained hard without change. In addition, CR for esophageal cancer has been maintained. We report a case of double primary recurrent HER2-positive breast cancer and esophageal cancer that responded well to radiotherapy and chemotherapy.

Understanding the Association of Axillary Lymph Node Metastasis in Esophageal Cancers

Lymph node metastasis is widely believed to be one of the most powerful prognostic factors influencing the outcomes of many solid cancers, including esophageal cancers. The left supraclavicular node, famously described as the Virchow's node, is occasionally involved in patients with advanced gastrointestinal cancers. Virchow node involvement is considered “nonregional” in all the gastrointestinal cancers, except in esophageal cancers. On the other hand, axillary lymph node metastases (ALNMs) are considered “nonregional” in all gastrointestinal cancers, including esophageal cancers. Exceptionally, some experts share a contrarian view and consider ALNM and supraclavicular lymph node metastasis to represent a contiguous regional dissemination of esophageal cancer. The clinical presentation of ALNM in the vast majority of the patients with esophageal cancers has been reported to be metachronous. Synchronous presentation is exceedingly rare, and our patient is possibly the second case to be reported in the English language literature. The increasing role of ¹⁸F-fluorodeoxyglucose positron emission tomography computed tomography scans in aiding the staging workup in patients with esophageal cancers and ultimately influencing the choice of management in such rare scenarios is further discussed.

Unusual lymph node metastasis from cancer of the thoracic esophagus

A 76-year-old male received concurrent chemoradiotherapy, at a dose of 60 Gy with low-dose 5-fluorouracil, for cT1bN0M0 squamous cell carcinoma of the mid-thoracic esophagus. Because his primary tumor relapsed with mediastinal and right supraclavicular node metastasis 4 months after completion of chemoradiotherapy, right transthoracic esophagectomy with mediastinal and right cervical lymphadenectomy was performed. However, metastatic tumors developed deep beneath the anterior border of the trapezius muscle 2 months after esophagectomy. En bloc dissection of the adipose tissue including the tumor and the transverse cervical artery was performed, followed by adjuvant radiotherapy of 50.4 Gy to the area of dissection. The patient died of pneumonia 11 months after metastasectomy, with locally recurrent disease. We have had three cases of this unusual lymph nodes metastasis from cancer of the thoracic esophagus to date and here present the characteristic imaging findings and the possible mechanism of this unusual lymph node metastasis.

Successfully treated advanced esophageal cancer with left axillary lymph node metastasis and synchronous right breast cancer: a case report

The incidence of double cancer of the esophagus and breast is rare, and axillary lymph node metastasis (ALM) in esophageal cancer is also very rare. We report a case of advanced esophageal cancer with left ALM and synchronous right breast cancer. A 64-year-old woman was admitted to our hospital with dysphagia. The clinical diagnosis was esophageal cancer (T3N0M1 stage IV) and right breast cancer (T1cN0M0 stage I). She was initially treated with triple chemotherapy with docetaxel, cisplatin, and 5-fluorouracil. The primary lesion in the esophagus achieved almost complete response as assessed by esophageal endoscopy. A computed tomography scan showed that the left ALM reduced in size and that stable disease was achieved for the right breast cancer. She underwent partial mastectomy of the right breast and bilateral axillary lymph node dissection. The histopathological diagnosis of the breast cancer was T1cN1M0 stage IIA. The lymph nodes from the left axilla contained metastatic cells from the squamous cell carcinoma of the esophagus. Complete response was achieved for the primary lesion in the esophagus following chemoradiotherapy (CRT), and the patient has been relapse free 2 years after treatment. Thus, we report the successful treatment of synchronous double cancers of the esophagus with left ALM and right breast by combination therapy with chemotherapy, CRT, and surgery.

Isolated axillary lymph node metastasis in oesophageal adenocarcinoma

Oesophageal adenocarcinoma metastatic to the axilla is a rare occurrence. The authors present a case of a woman who developed an axillary metastasis from a completely excised oesophageal adenocarcinoma with no prior evidence of nodal disease. With aggressive local treatment, including multiple local operations and radiotherapy, she remains alive and disease-free 12 years after her diagnosis following surgical resection of her axillary metastasis with adjuvant radiotherapy. This case report suggests that there are occasions when aggressive local treatment of apparently isolated metastases can result in a cure.

Discovery of the primary site of esophageal squamous cell carcinoma based on axillary lymph nodes metastasis detected with fluorodeoxyglucose positron-emission tomography: report of a case

A 60-year-old Japanese man with no chief complaints underwent 18F-fluorodeoxyglucose positron-emission tomography (FDG-PET) during a medical check-up. FDG-PET revealed high tracer uptake in the left supraclavicular and axillary regions but no significant uptake in the esophageal region. However, upper gastrointestinal endoscopy revealed an ulcerative tumor in the middle third of the esophagus. Endoscopic biopsy revealed moderately differentiated squamous cell carcinoma. The patient underwent chemoradiotherapy. Follow-up FDG-PET and computed tomography after therapy revealed a complete response in the lymph nodes. The patient underwent subtotal esophagectomy with gastric tube reconstruction through the posterior mediastinum. However, metastasis to the axillary lymph nodes was detected 16 months after surgery, and lymph node dissection was performed. To our knowledge, this is the first reported case in which the primary site of esophageal squamous cell carcinoma was discovered on the basis of axillary lymph node metastasis detected with FDG-PET.

Plasma DNA is more reliable than carcinoembryonic antigen for diagnosis of recurrent esophageal cancer

BACKGROUND

Carcinoembryonic antigen (CEA) and plasma DNA are known to be elevated in patients with esophageal cancer and are higher in patients with disseminated disease. The sensitivity and specificity of these markers in the diagnosis of recurrent esophageal cancer have not been compared.

STUDY DESIGN

Plasma DNA was measured using polymerase chain reaction in 45 patients with esophageal cancer and 44 asymptomatic volunteers. The 95(th) percentile (19 ng /mL) in the volunteers was used to define normal. Thirty-nine patients had localized cancer and underwent resection, and six had disseminated disease at operation. Plasma DNA was measured preoperatively in all patients, with serum CEA measured in 31. Plasma DNA was measured sequentially during followup in 21 patients, including 7 who developed recurrence. CEA was measured in 14 of 21 patients who had sequential plasma DNA measured and in 6 of 7 patients with recurrence. CEA levels greater than 5.0 ng/mL were used as cut-off.

RESULTS

Plasma DNA was more sensitive than CEA for detecting unresectable esophageal cancer (100% versus 40%), but it had a lower specificity (22% versus 89%). The positive predictive value (19% versus 40%) and negative predictive value (100% versus 89%) were similar for plasma DNA and serum CEA, respectively. Plasma DNA was also more sensitive than CEA in detecting recurrent esophageal cancer (100% versus 33%). The specificity and positive predictive values were 100% for both tests, but the negative predictive values were higher for plasma DNA. Plasma DNA rose before there was clinical evidence of recurrence in 67% compared with only 17% for CEA.

CONCLUSIONS

Elevated plasma DNA is an extremely reliable indicator of the presence of recurrent disease, and, in the majority of patients, it rises before clinical evidence of recurrence. In contrast, a normal CEA should be interpreted cautiously, because it does not exclude recurrent disease.