Influence of Metastatic Status and Number of Removed Lymph Nodes on Survival of Patients With Squamous Esophageal Carcinoma

Resected lymph nodes and survival of patients with esophageal squamous cell carcinoma: an observational study

BACKGROUND

The incidence and mortality of esophageal cancer are high. Therefore, the authors aimed to investigate how the number of dissected lymph nodes (LNs) during esophagectomy for esophageal squamous cell carcinoma impacts overall survival (OS), particularly that of patients with positive LNs.

MATERIALS AND METHODS

Data from 2010 to 2017 were obtained from the Sichuan Cancer Hospital and Institute Esophageal Cancer Case Management Database. Participants were divided into two groups: patients with negative lymph nodes (N0) and patients with positive lymph nodes (N+). The median number of resected LNs during surgery was 24; therefore, patients with 15-23 and those with 24 or more resected LNs were assigned to subgroups A and B, respectively.

RESULTS

After a median follow-up of 60.33 months, 1624 patients who underwent esophagectomy were evaluated; 60.53 and 39.47% had a pathological diagnosis of N+ or N0, respectively. The median OS was 33.9 months for the N+ group; however, the N0 group did not achieve the median OS. The mean OS was 84.9 months. In the N+ group, the median OS times of subgroups A and B were 31.2 and 37.1 months, respectively. The OS rates at 1, 3, and 5 years were 82, 43, and 34%, respectively, for subgroup A of the N+ group; they were 86, 51, and 38%, respectively, for subgroup B of the N+ group. Subgroups A and B of the N0 group exhibited no statistically significant differences.

CONCLUSION

Increasing the number of LNs harvested during surgery to 24 or more could improve the OS of patients with positive LNs but not that of patients with negative LNs.

Impact of increasing lymph node yield on staging, morbidity and survival after esophagectomy for esophageal adenocarcinoma

BACKGROUND

Extended lymphadenectomy during esophagectomy for esophageal cancer may increase survival, but also increase morbidity. This study analyses the influence of lymph node yield after transthoracic esophagectomy for esophageal adenocarcinoma on the number of positive lymph nodes, pathological N-stage, complications and survival.

MATERIALS AND METHODS

Consecutive patients undergoing transthoracic esophagectomy for esophageal adenocarcinoma between 2010 and 2020 were prospectively recorded (follow-up until January 2022). Lymph node yield was analyzed as continuous and dichotomous variable (≤30 vs. ≥31 nodes). The effect of lymph node yield on number of positive lymph nodes, complications, disease-free (DFS) and overall survival (OS) was assessed in multivariable regression analyses.

RESULTS

585 patients were included. Median lymph node yield increased from 25 (IQR 20-34) in 2010 to 39 (IQR 32-50) in 2020. Higher lymph node yield was associated with more positive lymph nodes (≥31 vs. ≤30 IRR 1.39, 95%CI 1.11-1.75). In 258 (y)pN + patients, the percentage of (y)pN3-stage increased with 14% between patients with ≤30 and ≥ 31 lymph nodes examined (p 0.014). Higher lymph node yield was not associated with more complications. Superior survival was seen in patients with ≥31 vs. ≤30 lymph nodes examined [DFS: HR 0.73, 95%CI 0.58-0.93, OS: HR 0.71, 95%CI 0.55-0.93)].

CONCLUSIONS

A lymph node yield of 31 or higher was associated with upstaging and superior survival after esophagectomy for esophageal adenocarcinoma, without increasing morbidity. Extended lymphadenectomy may therefore be regarded as an important part of the multimodal treatment of esophageal cancer.

Optimal settings of near-infrared fluorescence imaging with indocyanine green for intraoperative detection of lymph node metastasis in esophageal cancer

Lymphatic flow mapping using near-infrared fluorescence (NIR) imaging with indocyanine green (ICG) has been used for intraoperative diagnosis of lymph node metastasis (LNM) in various cancers. Accurate prediction of LNM intraoperatively may allow minimization of the extent of lymphadenectomy. However, a consistent method and diagnostic ability, allowing application of NIR-guided lymphatic flow mapping to esophageal cancer (EC), have not been established due to the multidirectional and complex characteristics of lymphatic flow in the esophagus. Herein, we present a novel NIR-guided surgical technique for predicting lymph node stations potentially containing LNM in EC with high diagnostic accuracy derived from appropriately adjusting the ICG injection setting.

Application of Indocyanine Green Enhanced Fluorescence in Esophageal Surgery: A Mini Review

Despite recent technological innovations and the development of minimally invasive surgery, esophagectomy remains an operation burdened with severe postoperative complications. Fluorescence imaging, particularly using indocyanine green (ICG), offers the ability to address a number of issues faced during esophagectomy. The three main indications for the intraoperative use of ICG during esophagectomy are visualization of conduit vascular supply, allow identification of sentinel nodes and visualization of the thoracic duct. The purpose of this mini review is to present an overview of current practice in fluorescence imaging utilizing ICG during esophagectomy, as well as to demonstrate how this technology can guide lymphadenectomy and reduce surgical morbidity such as anastomotic leaking and chylothorax.

Performance of Indocyanine-Green Imaging for Sentinel Lymph Node Mapping and Lymph Node Metastasis in Esophageal Cancer: Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Lymphatic mapping with indocyanine-green (ICG) and near-infrared light fluorescent imaging is widely used for sentinel lymph node staging in different types of cancer but is not fully accepted for all procedures because studies have reported heterogeneous results. This study aimed to assess the detection rate (DR) of ICG imaging for sentinel lymph node mapping (SLNM) and lymph node metastases (LNMs) in esophageal cancer.

METHODS

A systematic search was performed to identify relevant studies examining the use of ICG imaging for SLNM in patients with esophageal cancer. Extracted results were pooled in a single-proportion meta-analysis, with a random-effects model, presented as forest plots.

RESULTS

Six studies were included in the analysis. The ICG DR for SLNM was 89% [95% confidence interval (CI) 71%-96%]. The pooled sensitivity and specificity values for the detection of LNMs were 84% (95% CI 64%-94%) and 15% (95% CI 3%-45%), respectively. A trend towards a lower DR was found with increasing mean latency time between ICG injection and SLNM.

CONCLUSIONS

ICG imaging is a technique that potentially could improve lymph node yield excision and, as a consequence, improve the detection of lymph node metastases.

Combined CT texture analysis and nodal axial ratio for detection of nodal metastasis in esophageal cancer

OBJECTIVE

To assess the accuracy of a combination of CT texture analysis (CTTA) and nodal axial ratio to detect metastatic lymph nodes (LNs) in esophageal squamous cell carcinoma (ESCC).

METHODS

The contrast-enhanced chest CT images of 78 LNs (40 metastasis, 38 benign) from 38 patients with ESCC were retrospectively analyzed. Nodal axial ratios (short-axis/long-axis diameter) were calculated. CCTA parameters (kurtosis, entropy, skewness) were extracted using commercial software (TexRAD) with fine, medium, and coarse spatial filters. Combinations of significant texture features and nodal axial ratios were entered as predictors in logistic regression models to differentiate metastatic from benign LNs, and the performance of the logistic regression models was analyzed using the area under the receiver operating characteristic curve (AUROC).

RESULTS

The mean axial ratio of metastatic LNs was significantly higher than that of benign LNs (0.81 ± 0.2 vs 0.71 ± 0.1, p = 0.005; sensitivity 82.5%, specificity 47.4%); namely, significantly more round than benign. The mean values of the entropy (all filters) and kurtosis (fine and medium) of metastatic LNs were significantly higher than those of benign LNs (all, p < 0.05). Medium entropy showed the best performance in the AUROC analysis with 0.802 (p < 0.001; sensitivity 85.0%, specificity 63.2%). A binary logistic regression analysis combining the nodal axial ratio, fine entropy, and fine kurtosis identified metastatic LNs with 87.5% sensitivity and 65.8% specificity (AUROC = 0.855, p < 0.001).

CONCLUSION

The combination of CTTA features and the axial ratio of LNs has the potential to differentiate metastatic from benign LNs and improves the sensitivity for detection of LN metastases in ESCC.

ADVANCES IN KNOWLEDGE

The combination of CTTA and nodal axial ratio has improved CT sensitivity (up to 87.5%) for the diagnosis of metastatic LNs in esophageal cancer.

Integrated analysis of genomic and transcriptomic profiles identified a prognostic immunohistochemistry panel for esophageal squamous cell cancer

Background

The poor outcome of patients with esophageal squamous cell carcinoma (ESCC) highlights the importance of the identification of novel effective prognostic biomarkers. We aimed to identify a clinically applicable prognostic immunohistochemistry (IHC) panel for ESCC.

Methods

An integrated analysis was performed to screen and establish a prognostic panel using exome sequencing profile from 81 pairs of ESCC samples and RNA expression microarray data from 119 ESCC subjects. Two independent ESCC cohorts were recruited as training and validation groups to test the prognostic value.

Results

Three genes were selected, namely, ANO1, GAL, and MMP3, which were aberrantly expressed in ESCC tumor tissues (P < .001). Among them, ANO1 and MMP3 were reserved for the construction of the prognostic panel due to their significant association with the prognosis of ESCC patients (P = .015 and P < .001). Patients with both ANO1+ and MMP3+ had a poorer prognosis than that with ANO1−/MMP3+, ANO1+/MMP3−, or ANO1−/MMP3 − in both the training set and validation set (P < .001). Receiver operating characteristic analysis showed that the combination of IHC panel and eighth American Joint Commission on Cancer staging yielded a better prognostic predictive efficacy compared with the two indexes alone (P < .001, area under curve: 0.752). Finally, a nomogram was created by integrating the IHC markers and clinicopathological risk factors to predict prognosis with a C‐index of 0.695 (95% confidence interval: 0.657‐0.734).

Conclusion

Using an integrated multistage screening strategy, we identified and validated a valuable prognostic IHC panel for ESCC.

Prognostic Value of Lymph Node Yield on Overall Survival in Esophageal Cancer Patients: A Systematic Review and Meta-analysis

OBJECTIVE

This meta-analysis determines whether increased lymph node yield improves survival in patients with esophageal cancer undergoing esophagectomy with or without neoadjuvant therapy.

BACKGROUND

Esophagectomy involves resection of the esophagus and surrounding lymph nodes, which are commonly the first stations of cancer spread. The extent of lymphadenectomy during esophagectomy remains controversial, with several studies publishing conflicting results, especially in the era of neoadjuvant therapy.

METHODS

An electronic literature search was undertaken using Embase, Medline, and the Cochrane library databases (2000 to 2017). Articles with esophageal cancer patients undergoing esophagectomy with lymphadenectomy and investigating the effects of low and high lymph node yield on overall survival and disease-free survival were included. Meta-analysis of data was conducted using a random effects model. If the study divided the cohort into multiple groups based on lymph node yield, survival was compared between the lowest and highest lymph node yield groups. In addition to analysis of the entire cohort, subset analysis of only those patients receiving neoadjuvant therapy was also performed.

RESULTS

A total of 26 studies were included in this meta-analysis with a follow-up ranging from 15 to 94 months. For the analysis of overall survival, 23 studies were included. A meta-analysis showed that overall survival significantly improved in the high lymph node yield group [hazard ratio (HR) = 0.81; 95% confidence interval (95% CI) = 0.74-0.87; P < 0.01]. In the 10 studies describing disease-free survival, this was significantly improved in the high lymph node yield group (HR = 0.72; 95% CI = 0.62-0.84; P < 0.01). Subset analysis of neoadjuvant-treated patients demonstrated a survival benefit of high lymph node yield on overall survival (HR = 0.82; 95% CI = 0.73-0.92; P < 0.01).

CONCLUSION

This meta-analysis demonstrates the benefit of an increased lymph node yield from esophagectomy on overall and disease-free survival. In addition, a survival benefit of a high lymph node yield was demonstrated in patients receiving neoadjuvant therapy followed by esophagectomy.

Comparison of Ivor Lewis esophagectomy and Sweet esophagectomy for the treatment of middle-lower esophageal squamous cell carcinoma

Background

For cancer of the middle and/or lower segment of thoracic esophagus, the Ivor Lewis esophagectomy is the mainstream standard surgery, whereas the Sweet procedure is widely used in China. As no consensus has been reached about the choice of different thoracic approaches, we designed this retrospective study to investigate and compare oncological benefits of the two surgical approaches.

Methods

After propensity score matching, 150 patients who underwent the Sweet or Ivor Lewis esophagectomy from August 2003 to December 2009 in the Beijing Cancer Hospital were reviewed. We compared the postoperative recovery, nutritional parameters, and survival of the two different surgical approaches.

Results

The 5-year overall survival (OS) rate for the whole group was 48.5%, and the 10-year OS rate was 35.6%. The Ivor Lewis group had a longer operation time, longer duration of chest tube drainage, and a larger volume of total thoracic drainage. No significant differences were found between the two groups in terms of the duration of systemic inflammatory response syndrome (SIRS), length of postoperative hospital stay, duration of postoperative nasogastric tube use, incidence of major complications, and nutritional status after the esophagectomy. The OS rates were similar in both groups.

Conclusions

The Sweet and Ivor Lewis esophagectomy are both safe and effective. A change of the surgical incision may not be the best way to increase survival, and the choice of surgical procedure should depend on the preference of the thoracic surgeon to secure the safety of the operation.

Long-term outcomes of 530 esophageal squamous cell carcinoma patients with minimally invasive Ivor Lewis esophagectomy

BACKGROUND AND OBJECTIVES

The short-term benefits of minimally invasive esophagectomy (MIE) Ivor Lewis were proved, but 6-year outcomes in esophageal squamous cell carcinoma (ESCC) patients remain unclear. We sought to investigate perioperative outcomes, quality of life (QOL), survival and impact of adjuvant therapy in ESCC patients who underwent MIE Ivor Lewis.

METHODS

We conducted a retrospective review of 530 ESCC patients treated with MIE Ivor Lewis from 2011 to 2016. Relevant variables were collected and assessed. Overall survival (OS) and disease-free survival (DFS) was analyzed by Kaplan-Meier or Cox proportional hazards modeling.

RESULTS

Median operation duration was 266 min. The median number of lymph nodes was 28. The 30-day postoperative mortality was 1.7%. At a median follow-up of 41 months, the 6-year OS and DFS were 44.7% and 46.1%. Adjuvant chemoradiotherapy offered survival advantages in advanced stage patients. Pathological tumor-node-metastasis stage, postoperative complications, and recurrent laryngeal nerve lymphadenectomy were independent prognostic factors based on multivariate analysis. Generalized estimating equation analysis showed a rapid postoperative QOL improvement.

CONCLUSIONS

MIE Ivor Lewis is a safe and feasible procedure in ESCC patients. It offers satisfactory perioperative outcomes, rapid QOL improvement, and acceptable long-term oncologic survival. Adjuvant chemoradiotherapy may improve OS and DFS in advanced stage patients.

Essential role of Na+/Ca2+ exchanger 1 in smoking-induced growth and migration of esophageal squamous cell carcinoma

Tobacco-derived carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) is a major environmental risk factor for the pathogenesis of human esophageal squamous cell carcinoma (ESCC). However, the molecular mechanisms by which tobacco induces ESCC are not well understood. Na+/Ca2+ exchanger 1 (NCX1) is a plasma membrane transporter protein that plays an essential role in maintaining cytosolic Ca²⁺ ([Ca²⁺]_cyt) homeostasis under physiological conditions and is implicated in tumorigenesis as well. In this study, we found that NCX1 expression was significantly higher in ESCC primary tissues compared to the noncancerous tissues and was overexpressed in tumor samples from the smoking patients. The expression of NCX1 proteins was also significantly higher in human ESCC cell lines compared to normal esophageal epithelial cell line. Moreover, NNK potentiated the [Ca²⁺]_cyt signaling induced by removal of extracellular Na⁺, which was abolished by KB-R7943 or SN-6. NNK dose-dependently promoted proliferation and migration of human ESCC cells induced by NCX1 activation. Therefore, NCX1 expression correlates with the smoking status of ESCC patients, and NNK activates the Ca²⁺ entry mode of NCX1 in ESCC cells, leading to cell proliferation and migration. Our findings suggest NCX1 protein is a novel potential target for ESCC therapy.

Identification of the Lymphatic Drainage Pattern of Esophageal Cancer with Near-Infrared Fluorescent Imaging

OBJECTIVE

Nodal status is one of the most important long-term prognostic factors for esophageal cancer. The aim of this study was to evaluate the ability of near-infrared (NIR) light fluorescent imaging to identify the lymphatic drainage pattern of esophageal cancer.

METHODS

Patients with distal esophageal cancer or esophagogastric junction cancer scheduled for esophagectomy were enrolled in this study. Before surgery, an endoscopy was performed with submucosal injection of 2 cc of indocyanine green (ICG) around the tumor. Real-time NIR images from the surgical field were obtained for each patient to visualize the lymphatic ICG drainage.

RESULTS

A total of nine patients were included in this study. Ivor Lewis esophagectomy was performed in all cases. ICG drainage was visualized to first drain along the left gastric nodes in eight patients (88.9%) and toward the diaphragmatic nodes in one patient (11.1%). The median number of resected nodes was 32. Three patients (33.3%) presented nodal involvement. All of them had positive nodes in the first nodal station identified with ICG.

CONCLUSIONS

Evaluation of the lymphatic drainage pattern with real-time NIR light fluorescent technique is feasible. Distal and esophagogastric junction tumors showed to drain first in the left gastric nodes in most of the cases.