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

Clinical and Pathologic Supraclavicular Lymph Node Metastases in Esophageal Squamous Cell Carcinoma Treated by Esophagectomy with Three-Field Lymph Node Dissection

BACKGROUND

This study investigated the survival outcomes for surgically treated esophageal squamous cell carcinoma (ESCC) patients based on clinically suspicious supraclavicular lymph node (SCN) metastasis (cSCN+) and pathologically confirmed SCN metastasis (pSCN+).

METHODS

Using an institutional registry between 1994 and 2018, this study retrospectively analyzed 611 patients who received curative-intent esophagectomy with 3-field lymph node dissection for ESCC. The study used computed tomography and positron emission tomography to define cSCN+.

RESULTS

Among 611 patients, 24.4% had cSCN+ and 12.2% had pSCN+. The 5-year overall survival (OS) rates were 68.2% for cN0, 43.5% for cN+ without cSCN+, and 30.3% for cN+ with cSCN+ (p = 0.018). Although the univariable analysis showed that cSCN+ was associated with poorer survival than cN0 or cN+ with cSCN- (hazard ratio [HR], 1.818; p < 0.001), the multivariable analysis did not support this finding (HR, 1.281; p = 0.681). The 5-year OS rates were 64.2% for pN0, 41.5% for pN+ without pSCN+, and 25.6% for pN+ with pSCN+ (p = 0.054). Univariable analysis showed an association of pSCN+ with poor OS (HR, 1.830; p < 0.001), but the difference in the multivariable analysis was not significant (HR, 0.912; p = 0.587).

CONCLUSIONS

The presence of SCN metastasis did not have a significant impact on the OS of ESCC patients with 3-field lymph node dissection regardless of clinical suspicion or pathologic confirmation.

A novel web-based dynamic nomogram for recurrent laryngeal nerve lymph node metastasis in esophageal squamous cell carcinoma

Background

Patients with esophageal squamous cell carcinoma (ESCC) are liable to develop recurrent laryngeal nerve (RLN) lymph node metastasis (LNM). We aimed to assess the predictive value of the long diameter (LD) and short diameter (SD) of RLN lymph node (LN) and construct a web-based dynamic nomogram for RLN LNM prediction.

Methods

We reviewed 186 ESCC patients who underwent RLN LN dissection from January 2016 to December 2018 in the Affiliated Hospital of North Sichuan Medical College. Risk factors for left and right RLN LNM were determined by univariate and multivariate analyses. A web-based dynamic nomogram was constructed by using logistic regression. The performance was assessed by the area under the curve (AUC) and Brier score. Models were internally validated by performing five-fold cross-validation.

Results

Patients who underwent left and right RLN LN dissection were categorized as left cohort (n = 132) and right cohort (n = 159), with RLN LNM rates of 15.9% (21/132) and 21.4% (34/159), respectively. The AUCs of the LD (SD) of RLN LN were 0.663 (0.688) in the left cohort and 0.696 (0.705) in the right cohort. The multivariate analysis showed that age, the SD of RLN LN, and clinical T stage were significant risk factors for left RLN LNM (all P < 0.05), while tumor location, the SD of RLN LN, and clinical T stage were significant risk factors for right RLN LNM (all P < 0.05). The dynamic nomograms showed reliable performance after five-fold cross-validation [(left (right), mean AUC: 0.814, range: 0.614–0.891 (0.775, range: 0.084–0.126); mean Brier score: 0.103, range: 0.084–0.126 (0.145, range: 0.105–0.206)], available at https://mpthtw.shinyapps.io/leftnomo/ and https://mpthtw.shinyapps.io/rightnomo/.

Conclusion

The LD and SD of RLN LN are inadequate to predict RLN LNM accurately, but online dynamic nomograms by combined risk factors show better prediction performance and convenient clinical application.

Lymph node dissection and recurrent laryngeal nerve protection in minimally invasive esophagectomy

Until now, neoadjuvant therapy plus surgical resection of the primary tumor and potential metastatic lymph nodes (LNs) has been the current optimal treatment for locally advanced thoracic esophageal cancer (EC). LN metastasis is one of the most negative prognostic factors for thoracic esophageal squamous cell carcinoma (ESCC). However, the extent of LN dissection for thoracic ESCC has long been controversial worldwide. LNs along the recurrent laryngeal nerve (RLN) were reported to have the highest frequency of metastases in thoracic ESCC, so lymphadenectomy along the bilateral RLN is necessary but quite challenging because of a high frequency of recurrent nerve palsy and related postoperative complications. With the development of minimally invasive devices and techniques in recent years, minimally invasive esophagectomy (MIE) has been widely applied in EC surgery. The topics of what the optimal extent of lymphadenectomy is and how the recurrent nerve should be well protected during MIE have been debated in recent years. The purpose of our review is specifically to address the patterns of LN metastasis, the extent of LN dissection, and the protection of the RLN in MIE for thoracic ESCC.

Clinical significance and prognosis of supraclavicular lymph node metastasis in patients with thoracic esophageal cancer

Background

Although most studies proved that thoracic esophageal cancer surgery with supraclavicular lymph nodes (SCLNs) metastasis could benefit, less than 30% of the 5-year survival rate remained controversy on its surgical treatment. In this study, we aimed to analyze the prognosis of SCLNs on the different segments of thoracic esophageal cancer, which will supply a reference for the treatment of this disease.

Methods

Retrospectively collected the clinical data of 163 patients with thoracic esophageal squamous cancer (ESCC) and compared the effects of SCLNs on prognosis in different segments.

Results

Patients with SCLNs metastasis had a worse prognosis than the negative group (P<0.001). In the upper thoracic group, there was no significant difference in OS between SCLNs positive group and negative group (P=0.077); however, in the middle and lower thoracic group, SCLNs positive group had a worse prognosis than the negative group (P<0.001) and lymph nodes positive in other sites (except for SCLNs) (P=0.039). Multivariate analysis found that SCLNs metastasis was an independent risk factor affecting the prognosis of ESCC in the middle and lower thoracic segments (P=0.007).

Conclusions

For patients with upper thoracic ESCC, SCLNs appear to be regional nodes. For the middle and lower thoracic ESCC, SCLNs should be defined as distant metastasis, and neoadjuvant therapy first may be an available therapy.

Lymphovascular invasion as an independent prognostic indicator in radically resected thoracic esophageal squamous cell carcinoma

Background

The prognostic value of lymphovascular invasion (LVI) in esophageal cancer remains controversial. This study investigated the impact of LVI on prognosis in thoracic esophageal squamous cell carcinoma (ESCC).

Methods

A total of 1586 patients who underwent radical esophagectomy were selected for the study. Correlations between LVI and clinicopathological features were evaluated by χ² test. Univariate analysis of the survival curve was conducted using the Kaplan–Meier method. Multivariate analysis was carried out by Cox regression. The Akaike information criterion (AIC) and the concordance index (c‐index) were employed to assess model prognostic accuracy of different pN staging systems.

Results

The presence of LVI was detected in 406 of 1586 (25.6%) patients. LVI frequency was significantly higher in patients with higher pN classifications (P < 0.001). LVI had independent significant prognostic value in ESCC (P < 0.001). In subgroup analyses, the presence of LVI significantly decreased overall survival in pN0, pN2, and pN3 stage patients. The AIC value of the pN staging system modified by LVI was lower than that of the current pN staging system, while the c‐index of the modified pN staging system was higher than that of the current pN staging system.

Conclusion

Our results suggest that LVI is an independent prognostic indicator in radically resected thoracic ESCC. LVI could potentially supplement the pN ESCC staging system. ESCC patients with LVI could be staged at more advanced pN classifications.

Analysis of definitive chemo-radiotherapy for esophageal cancer with supra-clavicular node metastasis based on CT in a single institutional retrospective study: a propensity score matching analysis

Background

The prognostic value of supra-clavicular lymph node (SCLN) metastases in esophageal cancer (EC) is still not clear.

Method

From January 2009 to December 2015, a survival analysis was performed to retrospectively identify the prognostic value of SCLN metastasis on survival on 751 patients with EC treated with definitive chemo-radiotherapy (dCRT).

Results

The median follow-up duration for living patients was 56.6 months. The median overall survival (OS) for all patients was 16.6 months. Patients with SCLN metastasis had a much poorer prognosis for OS (χ² = 17.342, P < 0.001), distant metastasis-free survival (DMFS) (χ² = 24.793, P < 0.001) and progression-free survival (PFS) (χ² = 25.802, P < 0.001) than those without SCLN metastasis. The same results were found after propensity score matching. Nonetheless, the prognosis of patients with cervical or upper thoracic EC metastasis in SCLN was better than those of patients with middle or lower thoracic EC metastasis in SCLN for OS (χ² = 4.516, P = 0.038), DMFS (χ² = 8.326, P = 0.004) and PFS (χ² = 6.255, P = 0.012). Univariate analysis showed that gender, middle or lower thoracic EC with SCLN metastasis, tumor length, tumor diameter, concurrent chemo-radiotherapy (CCR) and number of lymph nodes were prognostic factors for PFS. Gender, age, middle or lower thoracic EC with SCLN metastasis, tumor diameter, tumor length, and number of lymph nodes were prognostic factors for DMFS. According to the multivariate analysis, only middle or lower thoracic EC with SCLN metastasis and number of lymph nodes were independent prognostic factors for DMFS and PFS.

Conclusion

For patients with cervical or upper thoracic EC, metastasis in SCLN should be considered to be regional lymph nodes and treated with curative intent if the total number of lymph nodes is limited. However, for patients with middle or lower thoracic EC, metastasis should be considered to be a higher level N stage or M1 stage, and it is thus necessary to provide consolidation chemotherapy after dCRT.

Neck Lymph Node Metastasis as A Poor Prognostic Factor in Thoracic Esophageal Squamous Cell Carcinoma Patients Receiving Concurrent Chemoradiotherapy: A Propensity Score-Matched Analysis

The present study investigated the clinical impact of neck lymph node (LN) metastasis in locally advanced inoperable thoracic esophageal squamous cell carcinoma (ESCC) patients who underwent concurrent chemoradiotherapy (CCRT) with a curative intent. There were 404 ESCC patients enrolled, including 35 patients with neck LN metastasis and 369 patients without such metastasis. Through the propensity score matching method, 35 patients of the 369 patients without neck LN metastasis were matched to the 35 patients with neck LN metastasis. Progression-free survival (PFS) and overall survival (OS) were found to be significantly worse in the neck LN metastasis group compared to the full non-neck LN metastasis group (9.8 months versus 5.9 months, P < 0.001, and 18.2 months versus 9.7 months, P = 0.001) and the matched non-neck LN metastasis group (9.9 months versus 5.9 months, P = 0.006, and 19.4 months versus 9.7 months, P = 0.007). In order to determine the difference between neck LN and supraclavicular LN metastasis, seventy patients with supraclavicular LN metastasis were also selected from the 369 patients without neck LN metastasis for comparison. Subsequently, when compared to the ESCC patients with supraclavicular LN metastasis, significantly worse PFS (8.5 months versus 5.9 months, P = 0.026) and OS (17.2 months versus 9.7 months, P = 0.047) were still found in the ESCC patients with neck LN metastasis. Our study indicates that neck LN metastasis is an independent poor prognostic factor for locally advanced inoperable thoracic ESCC patients who have undergone CCRT.

The clinical impact of supraclavicular lymph node metastasis in patients with locally advanced esophageal squamous cell carcinoma receiving curative concurrent chemoradiotherapy

Background

To evaluate the clinical significance of supraclavicular lymph node (SCLN) in patients with locally advanced esophageal squamous cell carcinoma (ESCC) receiving curative concurrent chemoradiotherapy (CCRT).

Materials and methods

We retrospectively analyzed all 369 locally advanced ESCC patients treated with CCRT between 2000 and 2015, including 70 patients with SCLN metastasis and 299 patients without SCLN metastasis.

Results

For these locally advanced ESCC patients treated with curative CCRT, N0-2 were significantly associated with superior progression-free survival (PFS) and overall survival (OS) in univariate and multivariable analyses. However, there were no significant differences in PFS and OS between the SCLN metastasis and non-SCLN metastasis groups; a subgroup analysis also revealed there was no significant differences in PFS and OS between patients with and without SCLN metastasis either in the N0-2 or in the N3 subgroup analysis.

Conclusions

Our study suggests that SCLN metastasis is not a prognostic factor in locally advanced ESCC patients receiving curative CCRT, and that SCLNs should be considered to be regional LNs and treated with curative intent.

Prognostic value of supraclavicular nodes and upper abdominal nodes metastasis after definitive chemoradiotherapy for patients with thoracic esophageal squamous cell carcinoma

The purpose of this study is to assess the prognostic value of supraclavicular nodes, left gastric nodes, celiac nodes and common hepatic nodes metastasis in esophageal squamous cell carcinoma (ESCC) treated with definitive radiotherapy. A total of 293 ESCC patients treated with radiotherapy or chemoradiotherapy entered the study. The results showed that the presence of supraclavicular nodes (χ² = 0.075, P = 0.785) and left gastric nodes (χ² = 3.603, P = 0.058) metastasis had no significant influence on survival, while celiac nodes (χ² = 33.775, P < 0.001) and common hepatic nodes (χ² = 42.350, P < 0.001) metastasis were associated with significantly shorter survival, regardless of the sites of primary tumor. Multivariate analysis showed that celiac nodes (HR: 0.457, 95% CI: 0.256-0.816; P = 0.008) and common hepatic nodes (HR: 0.241, 95% CI: 0.092-0.630; P = 0.004) metastasis were independently adverse indicator of survival in upper ESCC. While in the middle and lower ESCC, only the common hepatic nodes (middle ESCC: HR: 0.345, 95% CI: 0.161-0.738, P = 0.006; lower ESCC: HR: 0.377, 95% CI: 0.160-0.890, P = 0.026) metastasis was an independently adverse indicator of survival. In conclusion, our study demonstrated that in ESCC treated with definitive radiotherapy, both of celiac nodes and common hepatic nodes metastasis were adverse indicator of survival in upper ESCC, and common hepatic nodes metastasis were adverse indicator of survival in middle and lower ESCC. Supraclavicular nodes an left gastric nodes metastasis is not associated with patients survival in ESCC.