Therapy of advanced esophageal malignancy

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

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

The relationship between quality of life (EORTC QLQ-C30) and survival in patients with gastro-oesophageal cancer

It remains unclear whether any aspect of quality of life has a role in predicting survival in an unselected cohort of patients with gastro-oesophageal cancer. Therefore the aim of the present study was to examine the relationship between quality of life (EORTC QLQ-C30), clinico-pathological characteristics and survival in patients with gastro-oesophageal cancer. Patients presenting with gastric or oesophageal cancer, staged using the UICC tumour node metastasis (TNM) classification and who received either potentially curative surgery or palliative treatment between November 1997 and December 2002 (n=152) participated in a quality of life study, using the EORTC QLQ-C30 core questionnaire. On univariate analysis, age (P<0.01), tumour length (P<0.0001), TNM stage (P<0.0001), weight loss (P<0.0001), dysphagia score (P<0.001), performance status (P<0.1) and treatment (P<0.0001) were significantly associated with cancer-specific survival. EORTC QLQ-C30, physical functioning (P<0.0001), role functioning (P<0.001), cognitive functioning (P<0.01), social functioning (P<0.0001), global quality of life (P<0.0001), fatigue (P<0.0001), nausea/vomiting (P<0.01), pain (P<0.001), dyspnoea (P<0.0001), appetite loss (P<0.0001) and constipation (P<0.05) were also significantly associated with cancer-specific survival. On multivariate survival analysis, tumour stage (P<0.0001), treatment (P<0.001) and appetite loss (P<0.0001) were significant independent predictors of cancer-specific survival. The present study highlights the importance of quality of life (EORTC QLQ-C30) measures, in particular appetite loss, as a prognostic factor in these patients.

Ultrasound, computed tomography, or the combination for the detection of supraclavicular lymph nodes in patients with esophageal or gastric cardia cancer: a comparative study

BACKGROUND AND OBJECTIVES

Both ultrasound (US) and computed tomography (CT) can be used to detect supraclavicular lymph node metastases. Aim was to compare US, US plus fine-needle aspiration (US-FNA), CT, US + CT, and US-FNA + CT for the detection of these metastases in esophageal or gastric cardia cancer patients.

METHODS

Between 1994 and 2004, 567 patients underwent US and CT for esophageal or gastric cardia cancer staging. Gold standard was postoperative detection of lymph nodes in the resected specimen, FNA, or a radiological result with follow-up.

RESULTS

Sensitivities of US (75%), US-FNA (72%), US + CT (80%), and US-FNA + CT (79%) were higher than sensitivity of CT alone (25%) (P < 0.001). Specificities were high for US-FNA (100%), CT (99%), and US-FNA + CT (99%), whereas those of US alone (91%) and US + CT (91%) were lower (P < 0.001). In 4/65 (6%) patients with true-positive malignant lymph nodes, CT was positive with US and/or US-FNA being negative. However, in 36/65 (55%) patients, US and/or US-FNA were positive with CT being negative.

CONCLUSION

US-FNA seems the preferred diagnostic modality for the detection of supraclavicular lymph node metastases in patients with esophageal or gastric cardia cancer. Sensitivity of metastases detection only slightly improves if US-FNA is combined with CT. A prospective, comparative study is however needed.