Influence of celiac axis lymph nodes in the definitive treatment of esophageal cancer

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evolving role of endoscopic ultrasonography-guided fine-needle aspiration in tumor staging and treatment of patients with carcinomas of the upper gastrointestinal tract

INTRODUCTION

Treatments such as neoadjuvant chemotherapy and endoscopic mucosal resection for upper gastrointestinal carcinomas (UGC) necessitates preoperative staging evaluation of lymph nodes. Endoscopic ultrasonography (EUS)-guided fine-needle aspiration (FNA) of lymph nodes provides more accurate staging than EUS alone. Our study investigates the role of EUS-FNA in the staging/treatment of patients with UGC.

MATERIALS AND METHODS

We searched our database for patients who had EUS-FNA staging of lymph nodes for UGC over 1 year. The cytologic diagnoses were compared with clinical, radiographic, EUS-determined staging, and patient follow-up data. All EUS/EUS-FNA procedures used a standard radial and/or linear echo endoscope. Direct smears from the aspirated material were stained by Papanicolaou and Diff-Quik methods.

RESULTS

We studied 84 patients with esophageal or gastroesophageal junction carcinomas and 15 patients with gastric carcinomas. EUS-FNA confirmed N0 status for 100% of patients with T1 and T2 tumors and for 93% of patients with T3 tumors. Patients with T1N0 carcinomas confirmed by EUS were selected for endoscopic mucosal resection. All patients with gastric carcinomas had EUS-determined stage T3 and above tumors. Based on primary tumor stage, all patients with gastric carcinomas received neoadjuvant chemotherapy.

CONCLUSIONS

Cytologic diagnosis by EUS-FNA agreed with EUS nodal staging in 77% of the patients with UGC. EUS-FNA was useful to select patients with T1N0 esophageal or gastroesophageal junction carcinomas for endoscopic mucosal resection. EUS-FNA did not contribute significantly in treatment of patients with higher stage tumors whose disease was down-staged to N0 by EUS-FNA. These patients received neoadjuvant chemotherapy based on the status of the primary tumor.

The impact of endoscopic ultrasonography with fine needle aspiration (EUS-FNA) on esophageal cancer staging: a survey of thoracic surgeons and gastroenterologists

Accurate staging of esophageal cancer is critical to achieving optimal treatment outcomes. End-oscopic ultrasound with fine needle aspiration (EUS-FNA) has emerged as a valuable tool for locoregional staging. However, it is unclear how different physician specialties perceive the benefit of EUS-FNA for esophageal cancer staging, and thus utilize this modality in clinical practice. A survey regarding utilization of EUS-FNA in esophageal cancer was distributed to 211 thoracic surgeons and 251 EUS-capable gastroenterologists. Seventy-six thoracic surgeons (36%) and 78 gastroenterologists (31%) responded to the survey. Most surgeons (75%) use EUS to stage potentially resectable esophageal cancer 75% of the time. Surgeons using EUS less often are less likely to have access to high-quality EUS services than their peers. Fewer surgeons believe EUS is the most accurate test for T and N-staging (84% and 71%, respectively) as compared with gastroenterologists (97% and 96%, P < 0.01 for both). Most endosonographers (68%) decide whether to dilate a malignant esophageal stricture to complete the staging exam on a case-by-case basis. Surgeons disagree as to whether involvement of celiac lymph nodes should preclude esophagectomy in distal esophageal cancer. While most thoracic surgeons have embraced EUS-FNA as the most accurate locoregional staging modality in esophageal cancer, this attitude is not fully reflected in utilization patterns due to a lack of quality EUS services in some centers. Controversial areas that warrant further study include dilation of malignant strictures to facilitate EUS staging, and the implication of involved celiac lymph nodes on management.

Celiac lymph nodes: distant or regional for thoracic esophageal carcinoma?

Involvement of celiac nodes is defined as distant metastasis in the TNM classification for thoracic esophageal carcinoma. Some textbooks, however, describe dissection of these nodes as a standard technique. The present study was, therefore, undertaken to clarify which celiac nodes are regional for thoracic esophageal carcinoma and whether or not celiac node dissection would provide a survival benefit. Eight hundred and five patients who underwent R0 resection (no residual tumor) with systematic lymphadenectomy including the celiac axis area for thoracic esophageal carcinoma were retrospectively investigated. The frequency of metastasis and the therapeutic value of dissecting celiac nodes were compared to those associated with the left gastric artery area. The frequencies of left gastric and celiac nodal involvement were 15.4% and 9.6%, respectively, for thoracic esophageal carcinoma. As for tumor location, the incidences of metastasis around left gastric artery and celiac axis from the upper, middle and lower portion were 6.7% and 1.0%; 12.3% and 7.7%; and 25.7% and 17.4%, respectively. The 5-year survivals of patients with celiac but not left gastric metastasis were 36.3% and 41.8% for the middle and lower portions, respectively, while the corresponding values with left gastric involvement but no celiac metastasis were 24.1% and 27.9%. These differences were not significant. The frequency of celiac node involvement was not low. And, their dissection has equivalent therapeutic value to that of left gastric nodes. Revision of the TNM classification to account for celiac node involvement in thoracic esophageal carcinoma, especially of the middle and lower portions, is needed.

Endoscopic ultrasonography-identified celiac adenopathy remains a poor prognostic factor despite preoperative chemoradiotherapy in esophageal adenocarcinoma

OBJECTIVE

We reviewed our experience with preoperative chemoradiotherapy in patients with adenocarcinoma of the distal esophagus and pretreatment endoscopic ultrasonography-identified celiac adenopathy.

METHODS

One hundred eighty-six patients with adenocarcinoma of the distal esophagus were staged with endoscopic ultrasonography before treatment from 1997 through 2004. All patients were treated with concurrent chemoradiotherapy (CRT group) and surgical intervention or induction chemotherapy followed by concurrent chemoradiotherapy (C-->CRT group) and surgical intervention. Survival analysis (excluding operative mortality) evaluated various pretreatment factors.

RESULTS

Multivariable Cox regression analysis showed that pretreatment endoscopic ultrasonography-identified celiac adenopathy was a significant predictor of decreased long-term survival (P = .03). Median and 3-year survivals were 49 months and 54% in the endoscopic ultrasonography-identified cN0 M0 group (n = 65), 45 months and 56% in the endoscopic ultrasonography-identified cN1 M0 group (n = 96), and 19 months and 12% in the endoscopic ultrasonography-identified celiac adenopathy (cM1a) group (n = 18; P = .03). Increased systemic relapse was noted in the endoscopic ultrasonography-identified cM1a group (44% vs 22%, P = .07). The only factor associated with increased survival in the endoscopic ultrasonography-identified cM1a group (27 vs 15 months, P = .02) was the addition of induction chemotherapy before concurrent chemoradiotherapy and surgical intervention.

CONCLUSIONS

Endoscopic ultrasonography-identified celiac adenopathy in patients with adenocarcinoma of the distal esophagus conveys a poor prognosis despite preoperative chemoradiotherapy. These patients should be stratified in future multimodality trials. The investigation of induction chemotherapy before concurrent chemoradiotherapy might be warranted in this high-risk group of patients.