Recurrence pattern of squamous cell carcinoma of the thoracic esophagus after extended radical esophagectomy with three-field lymphadenectomy

CT-guided 125I brachytherapy for mediastinal metastatic lymph nodes recurrence from esophageal carcinoma: effectiveness and safety in 16 patients

OBJECTIVES

To retrospectively evaluate effectiveness and safety of CT-guided (125)I brachytherapy in 16 patients with mediastinal metastatic lymph nodes recurrence from esophageal carcinoma.

MATERIALS AND METHODS

Sixteen metastatic lymph nodes in 16 patients were percutaneously treated in 19 (125)I brachytherapy sessions. Each metastatic lymph node was treated with computed tomographic (CT) guidance. Follow-up contrast material-enhanced CT or positron emission tomographic (PET) scans were reviewed and the treatment's effectiveness was evaluated.

RESULTS

Months are counted from the first time of (125)I brachytherapy and the median duration of follow-up was 11 months (range, 5-16 months). The local control rates after 3, 6, 10 and 15 months were 75.0, 50.0, 42.9 and 33.3% respectively. At the time of writing, four patients are alive without evidence of recurrence at 16, 9, 16 and 9 months. The 4 patients presented good control of local tumor and no systemic recurrence, and survived throughout the follow-up period. The other 12 patients died of multiple hematogenous metastases 5-15 months after brachytherapy. A small amount of local hematoma occurred in 2 patients that involved applicator insertion through the lung. Two patients presented pneumothorax with pulmonary compression of 30 and 40% after the procedure and recovered after drainage. One patient had minor displacement of radioactive seeds. Severe complications such as massive bleeding and radiation pneumonitis did not occur.

CONCLUSION

(125)I radioactive seed implantation is effective and may be safely applied to mediastinal metastatic lymph nodes recurrence from esophageal carcinoma.

Metachronous pulmonary metastasis after radical esophagectomy for esophageal cancer: prognosis and outcome

Background

Few reports discuss the outcome of pulmonary metastasis after radical esophagectomy for esophageal cancer. To clarify the data from such cases, we conducted a retrospective study on the clinical outcome of patients who developed pulmonary metastasis after undergoing radical esophagectomy.

Methods

We retrospectively reviewed the prognosis and clinical outcome of 25 patients who developed metachronous pulmonary metastasis after esophagectomy for esophageal cancer.

Results

The site of recurrence was pulmonary without extrapulmonary metastasis in 14 patients and extrapulmonary metastasis was observed in 11. Nineteen patients had multiple pulmonary metastasis and 6 had solitary pulmonary metastasis. Twenty-four of patients underwent systemic chemotherapy during initial treatment for metastatic lesions. Pulmonary metastasectomy was indicated in 5 patients with solitary metastasis. The actual 1-, 2- and 4-year survival rates were 60%, 36% and 27%, respectively. Gender, operative procedure, and postoperative morbidity were not significant prognostic factors. However, pathological staging of primary esophageal cancer was a significant prognostic factor. Survival was significantly worse in patients who did not undergo resection than in those who did. The number of pulmonary metastasis, complicated extrapulmonary metastasis and the time of recurrence were also significant prognostic factors.

Conclusions

Multiple pulmonary metastases or complicated extrapulmonary metastasis were unfavorable prognostic factors for patients with pulmonary metastasis arising from esophageal cancer. Although, surgical intervention is not recommended in such cases, metastasectomy is an acceptable choice of treatment for solitary pulmonary metastasis.

Characteristics of recurrence after radical esophagectomy with two-field lymph node dissection for thoracic esophageal cancer

Postoperative radiotherapy has shown positive efficacy in lowering the recurrence rate and improving the survival rate in cases involving lymph node (LN) metastasis. However, the radiotherapy target volume remains controversial. Certain published studies have paid more attention to LNs found to be affected during surgery, while little effort has been made to study the LN metastatic pattern following surgery and its influence on the determination of the target volume of postoperative radiotherapy. In this study, the locoregional recurrence of esophageal squamous cell cancer was examined in 134 patients receiving radical surgery with two-field lymph node dissection from 2004 to 2009. In the 134 cases of recurrence, LN metastasis occurred in 126 patients (94.0%) while 13 patients (9.7%) developed anastomotic recurrence and 5 patients (3.7%) experienced tumor bed recurrence. The difference among the groups was statistically significant (P= 0.000). In the 126 cases with lymph node metastasis, the mediastinal metastasis rate (80.2%) was significantly higher compared with the rate of supraclavicular metastasis and abdominal metastasis (P= 0.000). A significant difference was identified between right and left supraclavicular LN metastasis (31.7% vs 16.7%, P= 0.005). Furthermore, the difference between the metastatic rates in the upper (73.8%), middle (39.7%) and lower mediastinum (1.6%) was statistically significant (P=0.000). Nevertheless, no significant correlation between the rate of LN metastasis was observed in the supraclavicular, mediastinal and abdominal regions for upper, middle and lower thoracic carcinomas (P= 0.404, P= 0.718 and P= 0.169, respectively). Based on our data, LN metastasis is the major locoregional recurrence pattern for esophageal squamous cell cancer following radical surgery. The high-risk lymphatic drainage areas include the supraclavicular nodes, recurrent laryngeal nerve nodes, azygos nodes and subcarinal nodes.

The number of pathologic lymph nodes involved is still a significant prognostic factor even after neoadjuvant chemoradiotherapy in esophageal squamous cell carcinoma

BACKGROUND

The correlation between the number of pathologic metastatic LNs in patients with esophageal squamous cell carcinoma (ESCC) after neoadjuvant chemoradiotherapy (NACRT) and surgical outcome has rarely been reported. We evaluated the correlation between the number of pathologic metastatic lymph nodes (LNs) and the surgical outcome in ESCC after NACRT.

METHODS

Eighty-eight patients with ESCC who underwent NACRT followed by surgery were evaluated. The clinical response of NACRT was evaluated and surgical specimens of the primary tumor and resected LNs were analyzed clinicopathologically.

RESULTS

Fewer pathologic metastatic LNs was associated with better survival. According to the number of metastatic LNs, the difference in the median survival was the largest between the groups when patients were divided into those with 2 and 3 metastatic LNs (χ(2) : 13.694, P < 0.001). With regard to clinical factors, the initial N status prior to treatment had the most significant impact on survival by a univariate analysis (P = 0.064), and the number of pathologic metastatic LNs was a risk factor for poor survival, with a hazard ratio of 5.128 (95% C.I.: 1.438-18.285, P = 0.012) by a multivariate analysis.

CONCLUSIONS

Of the various factors, the number of pathologic metastatic LNs was the strongest indicator to predict the patients' survival.

A meta-analysis of lymph node metastasis rate for patients with thoracic oesophageal cancer and its implication in delineation of clinical target volume for radiation therapy

OBJECTIVES

The objective of this study was to pool the lymph node metastasis rate (LNMR) in patients with thoracic oesophageal cancer (TOC) and to determine which node level should be included when undergoing radiation therapy.

METHODS

Qualified studies were identified on Medline, Embase, CBM and the Cochrane Library through to the end of April 2011. Pooled estimates of LNMR were obtained through a random-effect model. Possible effect modifiers which might lead to the statistical heterogeneity were identified through meta-regression, and further subgroup analyses of factors influencing LNMR were performed.

RESULTS

45 observational studies with a total of 18 415 patients were included in the meta-analysis. The pooled estimates of LNMR in upper, middle and lower TOC were 30.7%, 16.8% and 11.0% cervical, 42.0%, 21.1% and 10.5% upper mediastinal, 12.9%, 28.1% and 19.6% middle mediastinal, 2.6%, 7.8% and 23.0% lower mediastinal, and 9%, 21.4% and 39.9% abdominal, respectively. Lymph node metastasis most frequently happened to paratracheal, paraoesophageal, perigastric 106recR and station 7. The most obvious difference (≥15%) of LNMR between two-field and three-field lymphatic dissection occurred in cervical, paratracheal, 106recR and 108.

CONCLUSIONS

Through the meta-analysis, more useful information was obtained about clinical target volume (CTV) delineation of TOC patients treated with radiotherapy. However, our study is predominantly a description of squamous carcinoma and the results may not be valid for adenocarcinoma.

A case of long-term survival after pulmonary resection for metachronous pulmonary metastasis of basaloid squamous cell carcinoma of the esophagus

INTRODUCTION

Basaloid squamous cell carcinoma of the esophagus (BSCE) is a rare malignancy among esophageal cancers. We reported a case of 63-year-old woman with metachronous pulmonary metastasis of BSCE, successfully treated by metastasectomy of the left lung.

PRESENTATION OF CASE

Biopsy specimens of upper gastrointestinal fiberscopy led to diagnosis of poorly differentiated squamous cell carcinoma of the esophagus. Computed tomography revealed metastatic lymph nodes surrounding the bilateral recurrent laryngeal nerve and no evidence of metastasis to distant organs. Curative esophagectomy with three-field lymph node dissection was performed through thoracoscopic approach. Pathological examination of the resected specimens led to diagnosis of BSCE with invasion into the submucosal layer of the esophageal wall. Two years later, a solitary oval-shaped pulmonary lesion of approximately 10mm was detected in the left lung. Wedge resection of the left upper lobe was performed via thoracoscopic approach. The postoperative course was uneventful. Histologically, the pulmonary lesion was diagnosed as metastatic BSCE. Follow-up indicated no recurrence 9 years after the initial surgery.

DISCUSSION

Surgical intervention was acceptable on this case of solitary pulmonary metastasis. However, data are lacking about the efficacy of pulmonary resection for metachronous pulmonary metastasis of BSCE because the postoperative outcome is usually poor. The efficacy of surgical intervention for metastatic lesions of BSCE is debatable and requires further examination.

CONCLUSION

Although the usefulness of surgical intervention for metastatic lesions from BSCE is controversial, the patients with metachronous solitary metastasis to the lung and without extrapulmonary metastasis would be good candidate for pulmonary resection.

CCR7 and VEGF-C: molecular indicator of lymphatic metastatic recurrence in pN0 esophageal squamous cell carcinoma after Ivor-Lewis esophagectomy?

BACKGROUND

Esophageal squamous cell carcinoma (ESCC) is a malignant tumor with a high incidence of lymph node metastasis. This study was undertaken to investigate the expression of CCR7 and VEGF-C in pN0 ESCC and its relationship with lymphatic metastatic recurrence.

METHODS

The expression of CCR7 and VEGF-C was examined by RT-PCR and immunohistochemistry. The recurrence rates were calculated by the Kaplan-Meier method and their difference was determined by log rank analysis. Cox regression analysis was performed to determine the independent risk factors.

RESULTS

In 99 patients, CCR7 mRNA expression was observed in 42 patients with a 3 year recurrence rate of 57.1%; VEGF-C mRNA expression was observed in 52 patients with a 3 year recurrence rate of 53.8%; and coexpression of CCR7 mRNA and VEGF-C mRNA was observed in 22 patients with a 3 year recurrence of 63.6%. Neither CCR7 mRNA nor VEGF-C mRNA expression was observed in 27 patients with a 3 year recurrence rate of 22.2%. The recurrence rates of patients with positive expression of CCR7 mRNA and/or VEGF-C mRNA were significantly higher than in patients without expression of both CCR7 mRNA and VEGF-C mRNA. We achieved better concordance between RT-PCR and immunohistochemistry detection of both markers. The Cox regression analysis showed tumor T classification, positive expression of CCR7/VEGF-C mRNA, and positive expression of CCR7/VEGF-C protein in tumor tissues to be independent risk factors for 3 year recurrence.

CONCLUSIONS

Patients with positive expression of CCR7 and/or VEGF-C have a higher recurrence rate than patients without expression of both CCR7 and VEGF-C. CCR7 and VEGF-C may become molecular indicators of disease in patients vulnerable to lymphatic metastatic recurrence.

Patterns and time of recurrence after complete resection of esophageal cancer

PURPOSE

The results and outcomes of surgical resection for esophageal carcinoma have improved remarkably in recent years; however, recurrence still frequently develops, even after complete resection. The purpose of this study is to clarify the characteristics of recurrence in this patient population.

METHODS

Among 208 patients, who underwent R0 resection for esophageal carcinoma, recurrence developed in 61. Clinical data were available for 56 of these patients, who were the subjects of this study. We evaluated the time, patterns, and treatment of recurrence in these patients.

RESULTS

Recurrence developed within 1 and 2 years after esophagectomy in 71 and 84% of the patients, respectively, and was classified as loco-regional (54%), hematogenous (36%), or mixed type (10%). The prognosis of patients with loco-regional recurrence tended to be better than that of those with distant metastasis, although the difference was not significant (P = 0.088). Patients with recurrence treated by chemotherapy alone or multimodal therapy, such as radiation or surgery combined with systemic chemotherapy, survived significantly longer than those with untreatable recurrence (P = 0.016).

CONCLUSION

These findings reinforce the importance of careful follow-up for both loco-regional and hematogenous recurrence after esophagectomy, particularly during the first 2 years.

Long-term results of radiochemotherapy for solitary lymph node metastasis after curative resection of esophageal cancer

PURPOSE

To evaluate the long-term efficacy and toxicity of definitive radiochemotherapy for solitary lymph node metastasis after curative surgery of esophageal cancer.

METHODS AND MATERIALS

We performed a retrospective review of 35 patients who underwent definitive radiochemotherapy at Tohoku University Hospital between 2000 and 2009 for solitary lymph node metastasis after curative esophagectomy with lymph node dissection for esophageal cancer. Radiotherapy doses ranged from 60 to 66 Gy (median, 60 Gy). Concurrent chemotherapy was platinum based in all patients. The endpoints of the present study were overall survival, cause-specific survival, progression-free survival, irradiated-field control, overall tumor response, and prognostic factors.

RESULTS

The median observation period for survivors was 70.0 months. The 5-year overall survival was 39.2% (median survival, 39.0 months). The 5-year cause-specific survival, progression-free survival, and irradiated-field control were 43.3%, 31.0% and 59.9%, respectively. Metastatic lesion, size of the metastatic lymph node, and performance status before radiochemotherapy were significantly correlated with prognosis. Complete response and partial response were observed in 22.9% and 57.1% of the patients, respectively. There was no Grade 3 or higher adverse effect based on the Common Terminology Criteria for Adverse Events (CTCAE v3.0) in the late phase.

CONCLUSIONS

Based on our study findings, approximately 40% of patients with solitary lymph node metastasis after curative resection for esophageal cancer have a chance of long-term survival with definitive radiochemotherapy.

High phosphorylated 4E-binding protein 1 expression after chemoradiotherapy is a predictor for locoregional recurrence and worse survival in esophageal squamous cell carcinoma patients

BACKGROUND

As a well-known pivotal factor of 4E-binding protein 1 (4E-BP1) in controlling cancer proliferation, high expression of its phosphorylated form (p-4E-BP1) has been reported to be associated with poor outcome in various human cancers without pretreated with chemoradiotherapy (CRT). However, no data is available regarding the implication of p-4E-BP1 expression after CRT. Therefore, we conducted this study.

METHODS

The expression of p-4E-BP1 was semiquantitatively examined with immunohistochemical staining in 60 ypT1T2 esophageal squamous cell carcinoma (SCC) patients and verified by western blot analysis in representative cases. The impact of p-4E-BP1 expression intensity on cancer recurrence and survival was assessed in combination with clinical and pathological descriptors.

RESULT

The 5-year disease specific survival (DSS) rate of patients with high p-4E-BP1 expression was significantly lower than that of patients with lower p-4E-BP1 expression (5 year DSS: 58% vs. 8.6%, P = 0.00064). Furthermore, in a multivariate analysis by Cox regression model, high p-4E-BP1 expression was confirmed to be an independent prognostic factor (HR: 2.269; unfavorable, P = 0.024) for DSS, while lymph node (HR: 3.016; unfavorable, P = 0.005) was also significant prognostic factor. High p-4E-BP1 expression was specifically associated with locoregional recurrence (LR; P < 0.05). The locoregional control rate reached 97.1% in low p-4E-BP1 tumors.

CONCLUSION

High p-4E-BP1 expression after CRT is a predictor for LR and worse survival in esophageal SCC patients.

The significance of lymph node status as a prognostic factor for esophageal cancer

The revision of the TNM Classification of Malignant Tumors, 7th Edition, suggests the lymph node (LN) status to be the most significant risk factor in esophageal cancer. This article reviews the current status of LNs as indicators of prognosis. The significance of the number of metastatic LNs, the number of resected LNs, and a novel index, the "LN ratio" (metastatic LNs/removed LNs) in patients with esophageal cancer, were reviewed. The number of metastatic LNs independently predicted the prognosis of both overall survival and relapse-free survival. The number of positive LNs was also the best predictive marker of survival. Furthermore, overall survival significantly depended on the number of surgically removed LNs, and the LN ratio closely correlated with survival. The LN status is considered to be the most significant information that can be used to predict the prognosis. However, there are many issues that still need to be resolved. Better knowledge of the N-status is therefore needed to effectively utilize this information. Further research should focus on the N-status of patients with esophageal cancer.

Treatment outcome and prognosis of patients with lymph node recurrence of thoracic esophageal squamous cell carcinoma after curative resection

BACKGROUND

This study aimed to assess treatment outcome and factors influencing survival after lymph node recurrence of thoracic esophageal squamous cell carcinoma (SCC) after curative resection.

METHODS

A total of 207 patients who underwent curative resection of thoracic esophageal SCC between March 1999 and March 2009 were retrospectively analyzed. Of these, lymph node recurrence was observed in 45 (21.7%) patients. Twenty-nine patients received intensive treatment (radiation therapy, chemoradiotherapy, or lymphadenectomy) directed at recurrent nodes, 9 patients received chemotherapy, and 7 patients received best supportive care (BSC). Treatment outcome and prognostic factors of these patients were investigated.

RESULTS

Patients who received intensive treatment had significantly higher survival rates after recurrence than those who received chemotherapy or BSC (P = 0.0049 and 0.0004, respectively). In univariate analysis of survival after recurrence, the number of recurrent nodes (a single node or multiple nodes), the region of recurrent nodes (limited to a single region or extended to multiple regions), and the presence of simultaneous organ recurrence (present or absent) were prognostic factors (P = 0.0004, 0.0017, and <0.0001, respectively). Multivariate analysis demonstrated that the region of recurrent nodes and simultaneous organ recurrence were independent prognostic factors (P = 0.0396 and 0.0006, respectively).

CONCLUSIONS

Our findings suggest that the region of recurrent nodes (limited to a single region or extended to multiple regions) and simultaneous organ recurrence are factors influencing survival after lymph node recurrence of thoracic esophageal SCC after curative resection.

Multimodal treatment for resectable esophageal cancer

Surgical resection has been traditionally the mainstay of treatment for localized esophageal cancers. However, survival after surgery alone for advanced esophageal cancer is not satisfactory. In Japan, the development of multimodal therapy for esophageal cancers has centered mainly on systemic chemotherapy plus surgery to control distant metastasis. Based on the results of the recent Japan Clinical Oncology Group (JCOG) 9907 study, preoperative chemotherapy (consisting of 5-FU and cisplatin) followed by surgery has emerged as the standard treatment. In Western countries, where chemoradiotherapy followed by surgery has been mainly explored for patients with resectable esophageal cancers, two large controlled trials that evaluated the effectiveness of preoperative chemotherapy reported conflicting results. However, a recent meta-analysis reported significant survival benefits for preoperative chemotherapy in patients with adenocarcinoma of the esophagus. We need to find new effective preoperative chemotherapeutic regimens, including molecular target agents, with response rates higher than that of the conventional chemotherapy of 5-FU and cisplatin. However, we also must compare the survival benefits of preoperative chemotherapy with preoperative chemoradiotherapy.

Aortobronchial fistula after esophagectomy for esophageal cancer -- a very rare complication

Most aorto-respiratory fistulas are related to aortic pathology or procedures, but fistula formation after esophageal resection has never been reported in the literature. We are now reporting a case of hemoptysis that occurred after esophagectomy for locally advanced esophageal cancer. Aortobronchial fistula was detected by computed tomography scan. The patient was finally saved by emergency surgery-Dacron graft interposition of the descending thoracic aorta. There was no malignant cell in the postoperative specimen of the fistula. The erosion of the ligaclips (Johnson & Johnson) might be responsible for the aortobronchial fistula formation. For esophageal surgery, avoidance of trauma to aortic wall and careful using of ligaclips are important to circumvent this complication.

The total number of resected lymph node is not a prognostic factor for recurrence in esophageal squamous cell carcinoma patients undergone transthoracic esophagectomy

BACKGROUND

The total number of resected lymph nodes (TLN) has been shown to predict survival in esophageal cancer, but its relationship with recurrence has been rarely reported. We aim to study the prognostic factors in esophageal squamous cell carcinoma (ESCC) patients, with a particular focus on the role of TLN.

METHODS

Two hundred sixty-eight ESCC patients who underwent transthoracic esophagectomy were selected for the study. A Cox regression model was used to identify prognostic factors.

RESULTS

Recurrence occurred in 115 of 268 patients. The median time to recurrence was 10 months (range, 1-58). The recurrence-free survival at 1, 3, and 5 years was 62.3%, 32.1%, and 28.5%, respectively. Multivariate analysis identified age (P = 0.001), N stage (N1-3 vs. N0, P = 0.001), tumor length (P = 0.019), and development of recurrence (P < 0.001) as independent prognostic factors for overall survival, whereas T (T3/4 vs. T1/2, P = 0.029) and N stage (N1-3 vs. N0, P = 0.017) were independent prognostic factors for recurrence. TLN was a significant factor only when predicting overall survival in N0 patients (HR, 0.976; 95% CI, 0.953-0.999; P = 0.042).

CONCLUSION

The TLN is not a prognostic factor for recurrence in ESCC patients undergone transthoracic esophagectomy.

Survival factors in patients with recurrence after curative resection of esophageal squamous cell carcinomas

BACKGROUND

Approximately half of patients who undergo curative resection for esophageal cancers develop recurrence postoperatively. The factors affecting survival after such recurrence remain largely unknown.

METHODS

To investigate factors affecting survival after recurrence in patients who had undergone curative resection for esophageal cancer, we retrospectively reviewed data for 461 patients who underwent curative esophagectomy with or without preoperative therapy for esophageal squamous cell carcinoma from January 1996 to December 2007. The correlations between several clinicopathological factors and survival after recurrence were examined.

RESULTS

Recurrence occurred in 196 of 461 patients (42.5%), with a median survival time after recurrence of 8.2 months. Multivariate analysis identified advanced tumor stage, preoperative chemoradiotherapy (CRT), number of recurrent tumors, and the presence of recurrence at the local site and liver as associated with shortened survival after recurrence. The analysis also indicated that treatment of the recurrence prolonged survival regardless of the treatment type. Although the pattern of recurrence did not significantly differ according to type of preoperative therapy, patients who underwent preoperative CRT were less often treated with radiotherapy for recurrence. Patients with multiple recurrent tumors less often received radiotherapy or surgery than those with a solitary recurrence. Chemotherapy for recurrence was not associated with either preoperative therapy or the number of recurrences.

CONCLUSIONS

Our retrospective study showed that multiple recurrent tumors and preoperative CRT limit the available treatment for recurrence and thereby are associated with poor prognosis. Vigorous treatment for recurrence can extend survival after recurrence in patients who undergo esophagectomy.

Risk factors that influence early death due to cancer recurrence after extended radical esophagectomy with three-field lymph node dissection

BACKGROUND

Extended radical esophagectomy with three-field lymph node dissection (3-FLD) has offered significant survival benefit, but some patients still suffer from early recurrence and die within 1 year after surgery. The purpose of this study was to identify the risk factors that influence early death due to cancer recurrence after extended radical esophagectomy with 3-FLD.

METHODS

A consecutive series of 276 patients who underwent extended radical esophagectomy with 3-FLD was retrospectively reviewed. Excluding patients who underwent incomplete resection or died of other diseases within 1 year, we compared the clinicopathological characteristics between 203 patients who survived more than 1 year (1-year survival group) and 27 who died of cancer recurrence within 1 year (early-death group) by univariate and multivariate analysis.

RESULTS

Sixty-six patients (32.5%) had recurrent disease in the 1-year survival group. Hematogenous recurrences were more frequent in the early-death group than in the 1-year survival group (41% vs. 26%, respectively, p = 0.0481). There was a significant difference in nodal status, number of metastatic nodes, pathological stage, vessel invasion, and intramural metastasis, and there was borderline significance in the difference of depth of invasion and histological type between the two groups by univariate analysis. Multivariate analysis demonstrated that intramural metastasis was an independent risk factor.

CONCLUSIONS

Patients with intramural metastasis have a significant risk of early death even after extended radical esophagectomy with 3-FLD; however, it remains unknown whether surgical intervention can play a significant role for these patients.

Prognostic factors for post-recurrence survival in esophageal squamous cell carcinoma patients with recurrence after resection

OBJECTIVE

The survival of recurrent esophageal cancer is poor. But reports regarding prognostic factors for post-recurrence survival are limited. We analyzed the recurrence pattern and the prognostic factors for post-recurrence survival in esophageal squamous cell carcinoma with recurrence after resection.

METHODS

Two hundred sixty-eight patients were included. Tumor recurrence occurred in 115 (42.9%) patients. Recurrence pattern was classified as locoregional, distant, and combined recurrence. The post-recurrence survival was defined as the interval between initial recurrence and either death or the last follow-up.

RESULTS

Mediastinum lymphadenopathy was the most common site for locoregional recurrence, whereas lung, liver, and bone were the most common sites for distant recurrence. The overall 1- and 2-year post-recurrence survival rates were 32.6% and 12.6% with a median survival after recurrence of 6.0 months. The independent prognostic factors included liver recurrence (HR = 2.255, 95%CI = 1.073-4.741, p = 0.032), time to recurrence ≤10 months (HR = 2.657, 95%CI = 1.438-4.911, p = 0.002), and no treatment for recurrences (HR = 2.745, 95%CI = 1.635-4.608, p < 0.001).

CONCLUSIONS

We identify liver recurrence, early recurrence, and no treatment for recurrence as risk factors for dismal post-recurrence survival.

Early recurrence and death after esophagectomy in patients with esophageal squamous cell carcinoma

BACKGROUND

The aim of this retrospective study is to analyze recurrence and death within 1 year after esophagectomy in patients with esophageal carcinoma.

METHODS

The records of 533 consecutive patients with esophageal squamous cell carcinoma who underwent surgery from January 2002 to January 2005 were reviewed. Patients who died of recurrence within 1 year after operation (group A) were compared with patients who survived more than 5 years without any recurrence (group B). Their clinicopathologic characteristics were evaluated by univariate and multivariate analyses.

RESULTS

The overall 1-year and 5-year survival rates for the entire cohort were 76.1% and 32.3%, respectively, with the follow-up rate of 93.4%. Of the 119 patients who died within 1 year after the esophagectomy, local recurrence or distant metastasis or both were documented in 62 patients (52.1%). The radicality of resection, size of tumor, radicality of resection, grade of differentiation, depth of invasion, status of lymph node metastasis, number of lymph node metastases, and marginal status were shown by univariate analysis to be the significant prognostic factors. By multivariate analysis, they were also the independent prognostic factors, except for the size of tumor and the radicality of resection.

CONCLUSIONS

More than half of early death in esophageal squamous cell carcinoma patients after esophagectomy were still tumor recurrence related, especially hematogeneous spreading. The grade of differentiation, depth of invasion, lymph node metastasis, number of lymph node metastases, and marginal status are valuable prognostic factors in predicting early death.

The prognostic value of clinical and pathologic factors in esophageal adenocarcinoma: a mayo cohort of 796 patients with extended follow-up after surgical resection

OBJECTIVE

To identify and describe clinicopathologic prognostic factors in patients with esophageal adenocarcinoma who underwent surgical resection with curative intent.

PATIENTS AND METHODS

The study cohort consisted of 796 patients with adenocarcinoma of the esophagus, gastroesophageal junction, or gastric cardia who underwent complete tumor resection at Mayo Clinic from January 1, 1980, to December 31, 1997. We reviewed individual patient medical records and abstracted demographic, pathologic, perioperative, and cancer outcome data. Median follow-up for vital status and disease recurrence was 12.8 and 5.8 years, respectively.

RESULTS

Univariate analysis revealed the following factors to be statistically associated with worse 5-year disease-specific survival: higher N and T status, higher tumor grade, age older than 76 years, and the presence of extracapsular lymph node extension and signet ring cells. The following factors remained significantly linked with worse 5-year disease-specific survival on multivariate analysis: higher N and T status, grade, and age and the absence of preoperative chemotherapy or radiotherapy. Anatomic location of tumor was not associated with differential prognosis. Lymph node metastases were found in 25 (27%) of 93 T1b tumors, 397 (85%) of 468 T3 tumors, and 22 (67%) of 33 T4a tumors. Disease-specific survival was better in T3-4N0 than in T1bN1-3 carcinomas (hazard ratio, 0.50; 95% confidence interval, 0.28-0.89, adjusted for grade and age; P=.02).

CONCLUSION

Our results confirm the importance of T and N status and tumor grade and suggest that age may affect prognosis. In addition, we show that a significant proportion of superficial esophageal adenocarcinomas exhibit regional metastases and have worse prognosis than more invasive nonmetastatic tumors.

Number and location of positive nodes, postoperative radiotherapy, and survival after esophagectomy with three-field lymph node dissection for thoracic esophageal squamous cell carcinoma

PURPOSE

To analyze influences of the number and location of positive lymph nodes and postoperative radiotherapy on survival for patients with thoracic esophageal squamous cell carcinoma (TE-SCC) treated with radical esophagectomy with three-field lymphadenectomy.

METHODS AND MATERIALS

A total of 945 patients underwent radical esophagectomy plus three-field lymph node dissection for node-positive TE-SCC at Fujian Provincial Tumor Hospital between January 1993 and March 2007. Five hundred ninety patients received surgery only (S group), and 355 patients received surgery, followed 3 to 4 weeks later by postoperative radiotherapy (S+R group) to a median total dose of 50 Gy in 25 fractions. We assessed potential associations among patient-, tumor-, and treatment-related factors and overall survival.

RESULTS

Five-year overall survival rates were 32.8% for the entire group, 29.6% for the S group, and 38.0% for the S+R group (p = 0.001 for S vs. S+R). Treatment with postoperative radiotherapy was particularly beneficial for patients with ≥3 positive nodes and for those with metastasis in the upper (supraclavicular and upper mediastinal) region or both the upper and lower (mediastinal and abdominal) regions (p < 0.05). Postoperative radiotherapy was also associated with lower recurrence rates in the supraclavicular and upper and middle mediastinal regions (p < 0.05). Sex, primary tumor length, number of positive nodes, pathological T category, and postoperative radiotherapy were all independent predictors of survival.

CONCLUSIONS

Postoperative radiotherapy was associated with better survival for patients with node-positive TE-SCC, particularly those with three or more positive nodes and positive nodes in the supraclavicular and superior mediastinal regions.

Thoracoscopic-assisted esophagectomy for esophageal cancer: analysis of patterns and prognostic factors for recurrence

OBJECTIVE

The authors report the recurrence pattern of esophageal cancer after thoracoscopic-assisted esophagectomy (TAE), comparing it to the recurrence pattern after open surgery and identify prognostic factors for recurrence.

SUMMARY OF BACKGROUND DATA

To improve long-term survival for esophageal cancer radical surgery has been proposed increasingly, however, recurrent disease remains a problem. Opinion is divided as to the adequacy of resection possible using minimally invasive techniques with concerns that there may be an increased incidence in locoregional recurrence.

METHODS

A total of 221 patients who underwent esophagectomy at the Princess Alexandra Hospital without any neoadjuvant or adjuvant therapy were identified from a prospective database. Patients were followed up for the detection of symptomatic recurrence for a median of 59 months.

RESULTS

Within this group 165 patients underwent TAE and 56 an open transthoracic esophagectomy (TTE). The 5-year overall recurrence rate was 133/221 (60%). The 5-year rates of symptomatic first recurrence following TAE was 4%, 9%, and 47% for local, regional, and distant recurrence, respectively. The 5-year rates of symptomatic first recurrence following TTE was 5%, 18%, and 55% for local, regional, and distant recurrence, respectively. Operative approach was not a prognostic factor for any type of recurrence. Independent prognostic factors associated with locoregional recurrence were positive margins and number of positive nodes. Distant recurrence was associated with T stage, differentiation, tumor length >6 cm, and number of positive nodes.

CONCLUSION

Distant recurrence remains a significant problem in esophageal cancer. TAE achieved adequate locoregional control and compared favorably with open TTE.

Postoperative radiotherapy improved survival of poor prognostic squamous cell carcinoma esophagus

BACKGROUND

The purpose of this study was identify prognostic factors and to investigate the association between postoperative radiotherapy and overall survival of thoracic esophageal squamous cell carcinoma patients.

METHODS

From January 1993 to March 2007, 1,715 patients underwent extended esophagectomy with three-field lymph node dissection with or without postoperative radiotherapy and were eligible for analysis. Patients were grouped to surgery only (n = 1,277) and surgery plus postoperative radiotherapy (n = 438). Radiation dose was 50 Gy in 25 fractions.

RESULTS

The overall survival rates at 1, 3, 5, and 10 years were 86.6%, 61.3%, 49.4%, and 36.1%, respectively. Univariate and multivariate analyses showed that age 60 years or more, male sex, tumor more than 5 cm long, poorly differentiated histology, T4 tumor, presence of a vascular cancer thrombus in the surgical specimen, lymph node positivity, 3 or more positive lymph nodes, and disease stage II or higher were negative prognostic factors for overall survival. Postoperative radiation therapy improved overall survival for patients with poor disease-related prognostic factors: positive nodal disease, 3 or more positive lymph nodes, stage III/IV, and large or deeply invading tumor. Postoperative radiation had no survival benefit for patients who did not have the poor disease-related prognostic factors.

CONCLUSIONS

Postoperative radiotherapy is indicated for patients with poor disease-related prognostic factors.

Esophageal stents for the palliation of malignant dysphagia and fistula recurrence after esophagectomy

BACKGROUND

Despite advances in staging methods, surgical techniques, and adjuvant treatment, recurrent cancer after esophagectomy is a major cause of morbidity and mortality.

OBJECTIVE

Our purpose was to investigate the safety and efficacy of a self-expandable metal stent (SEMS) in patients with dysphagia or fistula caused by recurrent cancer after esophagectomy.

DESIGN

Prospective, observational study with standardized treatment and follow-up.

SETTING

Single university center.

PATIENTS

In 81 patients with recurrent cancer after previous surgical esophagectomy, 100 esophageal SEMSs were inserted for dysphagia (n = 66) or fistula formation (n = 15).

INTERVENTIONS

Stent placement.

MAIN OUTCOME MEASUREMENTS

Technical and functional outcome, complications, and survival.

RESULTS

The SEMSs restored luminal patency in 65 (98%) of 66 patients and sealed malignant fistulae in 14 (93%) of 15 patients. Stent dysfunction occurred in 24 (30%) of 81 patients. They all were successfully managed by subsequent endoscopic intervention. After stent placement, a total of 16 complications were observed. Major complications occurred in 9 (11%) of 81 patients, mild complications occurred in 7 (9%) of 81 patients. The overall 30-day mortality rate after stent insertion was 25%. Progression of the disease resulted in death after a median interval of 70 days (range 1 day to 91 months).

LIMITATIONS

Nonrandomized design.

CONCLUSIONS

SEMS placement in recurrent esophageal cancer after surgical resection offers adequate palliation by relieving dysphagia and sealing off esophageal respiratory fistulae. Therefore, in these patients who have a relatively short life expectancy, SEMS placement should be considered the treatment of choice.

Pattern of relapse in surgical treated patients with thoracic esophageal squamous cell carcinoma and its possible impact on target delineation for postoperative radiotherapy

OBJECTIVE

To provide a reference for determination of the postoperative radiotherapy target volume for thoracic esophageal squamous cell carcinoma.

BACKGROUND DATA

The irradiation target volume is important for effective postoperative treatment of thoracic esophageal squamous cell carcinoma.

METHODS

One hundred forty patients with recurrent or metastatic thoracic esophageal squamous cell carcinoma who had been treated with radical surgery but not with postoperative radiotherapy were enrolled in this study. The information of locoregional recurrence and distant metastasis for these patients was analyzed.

RESULTS

The median time to progression in the 140 patients with recurrence or metastasis was 18.3 months (range 15.4-21.1 months). Anastomotic recurrence accounted for 13.6% of treatment failures. The supraclavicular and station 1-5 and 7 lymph nodes had high metastasis rates for esophageal squamous cell carcinomas in all locations. The order from highest to lowest metastasis rate for the station 3 and 4 lymph nodes was middle, upper and lower thoracic esophageal regions and the order for upper abdominal lymph nodes was lower, middle, and upper thoracic esophageal regions. Locoregional recurrence was the most common type of recurrence.

CONCLUSIONS

For upper and middle thoracic esophageal squamous cell carcinomas, the anastomosis, supraclavicular, and station 1-5 and 7 lymph nodes should be delineated as the postoperative prophylactic irradiation target volume with upper abdominal lymph nodes excluded; for lower thoracic esophageal squamous cell carcinomas, anastomosis, supraclavicular, station 1-5 and 7 lymph nodes and upper abdominal lymph nodes should be delineated as the postoperative prophylactic irradiation target volume.

Therapeutic efficacy comparison of two surgical procedures to treat middle thoracic esophageal carcinoma

BACKGROUND

The aim of this study was to evaluate the therapeutic efficacy of two surgical procedures used to treat middle thoracic esophageal squamous cell carcinoma and compare the results.

METHODS

A total of 167 patients with middle thoracic esophageal squamous cell carcinoma were included in the study, including 102 patients who underwent Ivor-Lewis esophagectomy and another 65 who underwent dual-incision esophagectomy through the left chest and neck (Dual-incision). The Kaplan-Meier method was used to calculate the survival rate, and Cox regression analysis was performed to identify prognostic risk factors.

RESULTS

Perioperative complications occurred in 35 patients (21%). The incidence rate of recurrent laryngeal nerve injury and anastomotic leakage was higher in the Dual-incision group (p < 0.05), and the incidence rate of gastric retention was higher in the Ivor-Lewis group. However, there were no statistically significant differences. The 3-year local recurrence rate was 37.3% in the Ivor-Lewis group and 40% in the Dual-incision group (p > 0.05). The overall 5-year survival rate was 34.6%; the rates of the Ivor-Lewis group and the Dual-incision group were 36.0 and 32.3%, respectively (p > 0.05). The Cox analysis indicated that the pTNM staging was an independent prognostic risk factor (p = 0.00, hazard ratio = 2.69).

CONCLUSIONS

Both Ivor-Lewis esophagectomy and Dual-incision esophagectomy through the left chest and neck are options for treating middle thoracic esophageal squamous cell carcinoma. It is suggested that a patient's individual condition be taken into account when choosing the operative approach.

Prognostic factors and patterns of recurrence in esophageal cancer assert arguments for extended two-field transthoracic esophagectomy

BACKGROUND

High recurrence rates determine the dismal outcome in esophageal cancer. We reviewed our experiences and defined prognostic factors and patterns of recurrences after curatively intended transthoracic esophagectomy.

METHODS

Between January 1991 and December 2005, 212 consecutive patients underwent a radical transthoracic esophagectomy with extended 2-field lymphadenectomy. Recurrence rates, survival, and prognostic factors were analyzed (minimal follow-up period, 2 y).

RESULTS

Radicality was obtained in 85.6%. The median follow-up period was 26.6 months. The overall recurrence rate at 1, 3, and 5 years was 28%, 44%, and 64%, respectively, and locoregional recurrence rate was 17%, 27%, and 43%, respectively. Overall survival rates, including postoperative deaths, were 45% and 34% at 3 and 5 years, respectively. pT stage and lymph node (LN) ratio greater than .20 were independent prognostic factors for survival and recurrences. Radicality was most prognostic for survival, and for N+ greater than 4 positive LN for recurrences.

CONCLUSIONS

Radicality and LN ratio are strong prognostic factors. High radicality and adequate nodal assessment are guaranteed by an extended transthoracic approach.

Pattern of lymph node metastases and its implication in radiotherapeutic clinical target volume in patients with thoracic esophageal squamous cell carcinoma: A report of 1077 cases

PURPOSE

To study the pattern of lymph node metastases after esophagectomy and clarify the clinical target volume (CTV) delineation of thoracic esophageal squamous cell carcinoma (ESCC).

METHODS AND MATERIALS

Total 1077 thoracic ESCC patients who had undergone esophagectomy and lymphadenectomy were retrospectively examined. The clinicopathologic factors related to lymph node metastasis were analyzed using logistic regression analysis.

RESULTS

The rates of lymph node metastases in patients with upper thoracic tumors were 16.7% (9/54) cervical, 38.9% (18/54) upper mediastinal, 11.1% (6/54) middle mediastinal, 5.6% (3/54) lower mediastinal, and 5.6% (3/54) abdominal, respectively. The rates of lymph node metastases in patients with middle thoracic tumors were 4.0% (27/680), 3.8% (26/680), 32.9% (224/680), 7.1% (48/680), and 17.1% (116/680), respectively. The rates of lymph node metastases in patients with lower thoracic tumors were 1.0% (5/343), 3.0% (10/343), 22.7% (78/343), 37.0% (127/343), and 33.2% (114/343), respectively. T stage, the length of tumor and the histological differentiation emerged as statistically significant risk factors of lymph node metastases of thoracic ESCC (P < 0.001).

CONCLUSIONS

T stage, the length of tumor and the histologic differentiation influence the pattern of lymph node metastases in thoracic ESCC. These factors should be considered comprehensively to design the CTV for radiotherapy (RT) of thoracic ESCC. Selective regional irradiation including the correlated lymphatic drainage regions should be performed as well.

Radiotherapy with or without concurrent chemotherapy for lymph node recurrence after radical surgery of thoracic esophageal squamous cell carcinoma

PURPOSE

To retrospectively compare the outcomes of patients with lymph node recurrence after radical surgery of esophageal cancer, when given radiotherapy with or without concurrent chemotherapy.

METHODS AND MATERIALS

Between January 1996 and December 2005, the data from 73 patients with lymph node recurrence after radical surgery of thoracic esophageal squamous cell carcinoma were retrospectively reviewed. The patients were separated into two groups: radiochemotherapy (RC, 31 patients) and radiotherapy alone (RA, 42 patients). Patients in the RC group received at least two cycles of 5-fluorouracil/cisplatin chemotherapy concurrently with radiotherapy.

RESULTS

The median duration of follow-up was 11 months (range, 2-48). The overall survival rate for all patients was 46.7% and 4.7% at 1 and 3 years, respectively. The median overall survival time was 9 months (95% confidence interval, 6.96-11.04) and 17 months (95% confidence interval, 13.61-20.39) for RA and RC groups, respectively. The survival rate at 1 and 3 years was 62.5% and 10.5% in the RC group and 33.8% and 0% in the RA group (p = .0049, log-rank test; hazard ratio for death, 0.52; 95% confidence interval, 0.30-0.92). Acute toxicities were more frequent in the RC group than in the RA group. No significant differences were found in the late toxicity profiles between the two groups.

CONCLUSION

The results of the present retrospective analysis suggest that RC should be considered an effective and well-tolerated treatment of patients with thoracic esophageal squamous cell carcinoma and postoperative lymph node recurrence.

Prognostic value of lymph node metastases and lymph node ratio in esophageal squamous cell carcinoma

AIMS

Although the positive lymph node (LN) metastasis in patients with thoracic esophageal squamous cell carcinoma carcinoma (SCC) has been reported to be a risk factor to reduce long-term survival, only a few studies have so far evaluated the lymph node metastasis among this group of patients. The purpose of this study was to evaluate the impact of lymph node positivity and ratio on survival of esophageal SCC.

METHODS

All patients undergoing esophagectomy at the Forth Hospital of Hebei Medical University between January 1986 and December 2002 were reviewed. Survival curves were estimated using the Kaplan-Meier method.

RESULTS

Of 1,325 patients with invasive cancer, had squamous cell cancer of the esophagus. Median overall survival (OS) of the entire group was 36.7 months and 5-year OS was 39.3%. The most significant prognostic factor for overall survival was the presence of positive LN (P<0.01). Additionally, patients with zero involved LN had a 5-year survival of 49.1%, while patients with 1-3 positive LN and >3 positive LN had 5-year survival of 19.5% and 11.0%, respectively (P<0.01). Finally, an increasing ratio of positive to examined LN was linearly associated with a worsening 5-year survival, patients with <25%, 25%-50% and >50% positive LN had 5-year survival of 47.53%, 14.6% and 8.9%, respectively (P<0.01).

CONCLUSION

Increasing number of positive LN in patients with esophageal cancer and increasing ratio of metastatic to examine LN portend a poor prognosis. These factors should play an important role in predicting prognosis of patients.

Current trends in extended lymph node dissection for esophageal carcinoma

Extended lymph node dissection helps increase the curativeness of resection, the accuracy of surgical-pathological staging, and the prognosis of thoracic esophageal carcinoma. However, it is also associated with significantly increased surgical morbidity and has noticeable negative effects on the quality of life after surgery. Current trends for selective lymph node dissection based on clinical evidence may be helpful in reducing surgical risks while assuring the completeness of resection.

Robot-assisted thoracoscopic oesophagectomy for cancer

BACKGROUND

Thoracoscopic oesophagectomy was introduced to reduce the morbidity of transthoracic oesophagectomy. The aim was to assess the short- and mid-term results of robot-assisted thoracoscopic oesophagectomy for oesophageal cancer.

METHODS

Between October 2003 and May 2007, 47 patients with resectable oesophageal cancer underwent robot-assisted thoracoscopic oesophagectomy. Clinical data were collected prospectively.

RESULTS

Conversion to thoracotomy was necessary in seven patients. Median operating time was 450 min and median blood loss 625 ml. Median postoperative ventilation time was 1 day, intensive care stay 3 days and hospital stay 18 days. Twenty-one of 47 patients had pulmonary complications. Three patients died in hospital. A median of 29 (range 8-68) lymph nodes was dissected and R0 resection was achieved in 36 patients. Twenty-three patients had stage IVa disease. After a median follow-up of 35 months, median disease-free survival was 15 (95 per cent confidence interval 12 to 18) months.

CONCLUSION

Robot-assisted thoracoscopic oesophagectomy was oncologically acceptable. Operating time, blood loss and pulmonary complications might decrease with further experience.

Triterpenes augment the inhibitory effects of anticancer drugs on growth of human esophageal carcinoma cells in vitro and suppress experimental metastasis in vivo

The antineoplastic effects of combinations of anticancer drugs (5-fluorouracil, irinotecan and cisplatin) and triterpenes (ursolic acid, betulinic acid, oleanolic acid and a Japanese apricot extract (JAE) containing triterpenes) on esophageal squamous carcinoma cells were examined by the WST-8 (2-(2-methoxy- 4-nitrophenyl)-3-(4-nitrophenyl)-5-(2,4-disulfophenyl)-2H-tetrazolium, monosodium salt) assay in vitro and by an animal model in vivo. Triterpenes and JAE showed additive and synergistic cytotoxic effects, respectively, on esophageal squamous carcinoma cells (YES-2 cells) by combinational use of 5-fluorouracil. JAE and 5-fluorouracil induced cell cycle arrest at G2/M phase and at S phase, respectively, and caused apoptosis in YES-2 cells. A new animal model of esophageal cancer causing tumor colonization of the peritoneal cavity and producing bloody ascites was made by injecting YES-2 cells into the peritoneal cavity of a severe combined immunodeficiency mouse. In this model, 5-fluorouracil inhibited colonization of tumor cells in the peritoneum. The addition of JAE to 5-fluorouracil augmented the suppression of experimental metastasis of the peritoneum. The numbers of peritoneal nodules of more than 2 mm in diameter in mice treated with 5-fluorouracil and JAE were less than those in mice treated with 5-fluorouracil alone or JAE alone. These results suggest that triterpenes, especially JAE, are effective supplements for enhancing the chemotherapeutic effect of 5-fluorouracil on esophageal cancer.

Impact of the number of resected and involved lymph nodes on esophageal cancer survival

BACKGROUND

Using a large data set, we investigated the impact of the number of resected and involved lymph nodes on overall survival for patients with esophageal cancer.

METHODS

From the National Oncology Database, esophageal cancer cases with data available on the total number of resected and involved nodes as well as other variables were evaluated as it relates to overall survival by multivariate analysis using Cox proportional hazards method. Patients with 0, exactly 1 or 1-3 positive nodes were separately studied to determine the association between the number of lymph nodes resected and overall survival.

RESULTS

From 1969 to 2002, 3,144 (17%) of 18,390 esophageal cancer cases with complete data were identified. Increasing number of involved nodes predicted poorer outcome (P < 10(-6)). Results from studying patients with 0, exactly 1 or 1-3 positive nodes showed that survival improved with increasing number of nodes analyzed up to 12. Three-tier nodal grouping with increasing risk of death were identified, 0, 1-3, and >or=4 positive nodes (P < 10(-5)).

CONCLUSIONS

The pathological assessment of minimal 12 lymph nodes provides sufficient prognostic information. Three-tier nodal grouping is suggested for the next version of AJCC staging system for esophageal cancer.

Adjuvant radiotherapy after modified Ivor-Lewis esophagectomy: can it prevent lymph node recurrence of the mid-thoracic esophageal carcinoma?

BACKGROUND

Even if complete resection was performed, some patients with esophageal carcinoma still develop tumor recurrence. This study was undertaken to evaluate the effectiveness of adjuvant radiotherapy after modified Ivor-Lewis esophagectomy on preventing lymph node recurrence of the mid-thoracic esophageal carcinoma.

METHODS

Three hundred sixty-six patients with mid-thoracic esophageal squamous cell carcinoma who underwent modified Ivor-Lewis esophagectomy between June 1999 and June 2004 were retrospectively reviewed. All patients were followed up within 3 years after surgery to detect lymph node recurrence. The Kaplan-Meier method was used to calculate the recurrence rate, and Cox regression analysis was performed to identify risk factors of lymph node recurrence.

RESULTS

The overall 3-year and 5-year survival rates in all patients were 57.9% and 43.7%, respectively. Lymph node recurrence occurred in 105 patients (28.7%) within 3 years after surgery. The lymph node recurrence rate of patients with postoperative adjuvant radiotherapy was significantly lower than that of those with adjuvant chemotherapy (p = 0.03) and those without adjuvant therapy (p < 0.01). Cox regression analysis showed that T stage, N status, and postoperative adjuvant radiotherapy were independent relevant factors for lymph node recurrence.

CONCLUSIONS

Postoperative adjuvant radiotherapy after modified Ivor-Lewis esophagectomy might prevent lymph node recurrence of mid-thoracic esophageal carcinoma.

Clinical usefulness of 18F-FDG PET/CT in the restaging of esophageal cancer after surgical resection and radiotherapy

AIM: To evaluate the clinical usefulness of ¹⁸F-fluorodeoxyglucose positron emission and computed tomography (¹⁸F-FDG PET/CT) in restaging of esophageal cancer after surgical resection and radiotherapy.

METHODS: Between January 2007 and Aug 2008, twenty histopathologically diagnosed esophageal cancer patients underwent 25 PET/CT scans (three patients had two scans and one patient had three scans) for restaging after surgical resection and radiotherapy. The standard reference for tumor recurrence was histopathologic confirmation or clinical follow-up for at least ten months after ¹⁸F-FDG PET/CT examinations.

RESULTS: Tumor recurrence was confirmed histopathologically in seven of the 20 patients (35%) and by clinical and radiological follow-up in 13 (65%). ¹⁸F-FDG PET/CT was positive in 14 patients (68.4%) and negative in six (31.6%). ¹⁸F-FDG PET/CT was true positive in 11 patients, false positive in three and true negative in six. Overall, the accuracy of ¹⁸F-FDG PET/CT was 85%, negative predictive value (NPV) was 100%, and positive predictive value (PPV) was 78.6%. The three false positive PET/CT findings comprised chronic inflammation of mediastinal lymph nodes (n = 2) and anastomosis inflammation (n = 1). PET/CT demonstrated distant metastasis in 10 patients. ¹⁸F-FDG PET/CT imaging-guided salvage treatment in nine patients was performed. Treatment regimens were changed in 12 (60%) patients after introducing ¹⁸F-FDG PET/CT into their conventional post-treatment follow-up program.

CONCLUSION: Whole body ¹⁸F-FDG PET/CT is effective in detecting relapse of esophageal cancer after surgical resection and radiotherapy. It could also have important clinical impact on the management of esophageal cancer, influencing both clinical restaging and salvage treatment of patients.

Use of positron emission tomography in surgery follow-up of esophageal cancer

INTRODUCTION

Although the prognosis of patients with esophageal cancer has been improved by extended dissection, the incidence of recurrence still remains high. In esophageal cancer, positron emission tomography (PET) using (18)F-fluorodeoxyglucose (FDG) already demonstrated to be useful for initial staging and monitoring response to therapy. This prospective study compared the ability of FDG-PET and conventional imaging to detect early recurrence of esophageal cancer after initial surgery in asymptomatic patients.

MATERIALS AND METHODS

Between October 2003 and September 2006, 41 patients with esophageal cancer were included in a prospective study after initial radical esophagectomy. FDG-PET, thoracoabdominal computed tomography (CT), abdominal ultrasonography, and endoscopy were performed every 6 months after initial treatment.

RESULTS AND DISCUSSION

Twenty-three patients had recurrent disease (56%), mostly within the first 6 months after surgery (70%). Despite two false-positive scans due to postoperative changes, FDG-PET was more accurate than CT (91% vs. 81%, p = 0.02) for the detection of recurrence with a sensitivity of 100% (vs. 65%), a specificity of 85% (vs. 91%), and a negative predictive value of 100% on a patient-by-patient-based analysis. For the detection of locoregional recurrence, FDG-PET was more accurate than CT (96.2% vs. 88.9%). FDG-PET was also more accurate than CT for the detection of distant metastases (92.5% vs. 84.9%), especially when involving either bones (100%) or liver (98.1%). A lower sensitivity of FDG-PET (57%) for the early detection of small lung metastases did not affect patient management (accuracy = 92.5%).

CONCLUSION

FDG-PET appears to be very useful for the systematic follow-up of asymptomatic patients after esophagectomy with an initial scan performed 6 months after surgery.

The changing use of palliative chemotherapy for recurrent esophagogastric cancer: a single center retrospective 15-year review

BACKGROUND

Palliative chemotherapy is often recommended in the treatment of recurrent esophagogastric (EG) cancer with limited evidence of its benefit. This study aims to define the current practice and benefit of this treatment.

METHODS

Retrospective analysis of patients who developed EG cancer recurrence between 1991 and 2006 following surgery with curative intent.

RESULTS

There were 336 recurrences. Median time to disease recurrence was 13.4 months (range 1.3-118). Survival after recurrence ranged from 0-93.2 months (six patients are currently alive). A significant increase in the use of chemotherapy was observed rising from 10% prior to 1999 (n = 100) to 23% (n = 236) after 1999. The median survival for patients receiving chemotherapy (n = 64) was 10.6 months (range 1.5-75.7), patients undergoing nonchemotherapy palliative intervention (n = 142) median survival was 2.85 months (range 0-93.2), and for patients having no active intervention (n = 130), median survival was 1.3 months (range 0-16.2). Median duration of chemotherapy was 3.1 months (range 0.5-9.2). Median survival for these patients after chemotherapy treatment was 6.6 months (range 0.4-73.5). Twenty-eight patients (44%) experienced side effects of chemotherapy. Ten cases required treatment to be modified or stopped and two patients died during chemotherapy.

CONCLUSION

There has been a significant increase in the use of palliative chemotherapy for recurrent EG cancer. While survival appears improved, a substantial proportion of this time was spent receiving chemotherapy with many patients experiencing significant comorbidity. Further studies assessing both quality and quantity of life are required to fully evaluate the use of palliative chemotherapy and to identify patients most likely to benefit.

Evaluation of gene amplification and protein expression of HER-2/neu in esophageal squamous cell carcinoma using Fluorescence in situ Hybridization (FISH) and immunohistochemistry

Background

Esophageal squamous cell carcinoma (ESCC) is the sixth most frequent neoplasia in Brazil. It is usually associated with a poor prognosis because it is often at an advanced stage when diagnosed and there is a high frequency of lymph node metastases. It is important to know what prognostic factors can facilitate diagnosis, optimize therapeutic decisions, and improve the survival of these patients. A member of the epidermal growth factor receptor (EGFR) family, c-erbB-2, has received much attention because of its therapeutic implications; however, few studies involving fluorescence in situ hybridization (FISH) analysis of HER-2/neu gene amplification and protein expression in ESCC have been conducted. The aim of this study was to verify the presence of HER-2/neu gene amplification using FISH, and to correlate the results with immunohistochemical expression and clinical-pathological findings.

Methods

One hundred and ninety-nine ESCC cases were evaluated using the Tissue Microarray (TMA) technique. A polyclonal antibody against c-erbB-2 was used for immunohistochemistry. Analyses were based on the membrane staining pattern. The results were classified according to the Herceptest criteria (DAKO): negative (0/1+), potential positive (2+) and positive (3+). The FISH reactions were performed according to the FISH HER2 PharmDx (DAKO) protocol. In each case, 100 tumor nuclei were evaluated. Cases showing a gene/CEN17 fluorescence ratio ≥ 2 were considered positive for gene amplification.

Results

The c-erbB-2 expression was negative in 117/185 cases (63.2%) and positive in 68 (36.8%), of which 56 (30.3%) were 2+ and 12 (6.5%) were 3+. No significant associations were found among protein expression, clinicopathological data and overall survival. Among the 47 cases analyzed, 38 (80.9%) showed no gene amplification while 9 (19.1%) showed amplification, as demonstrated by FISH. Cases that were negative (0/1+) and potential positive (2+) for c-erbB-2 expression by immunohistochemistry showed no gene amplification. However, all cases with gene amplification were positive (3+) by immunohistochemistry. According to univariate analysis, there was a significant difference (p = 0.003) in survival rates when cases with and without HER-2/neu amplification were compared.

Conclusion

Our data demonstrate the correspondence between gene amplification and protein expression of HER-2/neu. Gene amplification is an indicator of poor prognosis in ESCC.

Esophageal cancer: current and emerging therapy modalities

During the last few years, there has been a gradual increase in treatment options for patients with esophageal malignancies. Several clinical studies have been performed, covering not only radiation and chemotherapy, but also the introduction of novel biological agents into the treatment arsenal. Patients with esophageal carcinoma are now offered second-line and sometimes even third-line treatments, and the number of research protocols is increasing. Despite the newly awakened interest in this malignancy, the overall 5-year survival rate has remained at approximately 10% since the 1980s. This review contains a compilation of available studies of esophageal malignancies and discusses current treatment options as well as newly developed therapies targeted at growth factor receptors.

Evaluation of combined docetaxel and nedaplatin chemotherapy for recurrent esophageal cancer compared with conventional chemotherapy using cisplatin and 5-fluorouracil: a retrospective study

This retrospective study evaluated the safety and efficacy of combination chemotherapy using docetaxel and nedaplatin in an outpatient setting compared with those of chemotherapy using cisplatin (CDDP) and 5-Fu under hospitalization. Subjects comprised 21 patients who had been diagnosed with recurrent esophageal squamous cell carcinoma (ESCC), with 10 patients receiving combination chemotherapy comprising CDDP and 5-fluorouracil (5-Fu) under hospitalization (FP group; n = 10), and 11 patients receiving combination chemotherapy comprising docetaxel and nedaplatin in an outpatient setting (Doc/Ned group; n = 11). In the Doc/Ned group, patients received 30 mg/m(2) of docetaxel over a 1-h infusion on day 1, followed by 40 mg/m(2) of nedaplatin over a 2-h infusion on day 1 in an outpatient setting. In the Doc/Ned group, complete response was observed in two patients (18.1%), one with liver metastasis and one with abdominal lymph node metastasis, and two (18.1%) achieved partial response. In contrast, no complete responses were obtained in the FP group, and partial response was observed in only one patient (10.0%) with local recurrence. Response rates were thus 36.3% for the Doc/Ned group and 10.0% for the FP group. With a median follow-up of 234 days in the Doc/Ned group and 279 days in the FP group, median survival time (MST) was 234 days in the Doc/Ned group and 378 days in the FP group. No significant differences in MST were identified between groups. Thus regimen based on docetaxel and nedaplatin allows administration on an outpatient basis and appears feasible for recurrent ESCC as a second-line chemotherapy.

Multimodal treatment for lymph node recurrence of esophageal carcinoma after curative resection

BACKGROUND

Although esophagectomy with extended lymph node dissection can improve survival of patients with esophageal carcinoma, lymph node metastasis has remained one of the main recurrence patterns. The aim of this study was to evaluate the outcome of intensive treatment for recurrent lymph node metastasis.

METHODS

Recurrent lymph node metastasis was detected in 68 patients with thoracic esophageal carcinoma after curative esophagectomy (R0, International Union Against Cancer criteria). Multimodal treatment was performed in 41 patients: 19 patients underwent lymphadenectomy with adjuvant therapy, and 22 received definitive chemoradiotherapy and repeated chemotherapy. The remaining 27 patients (40%) received chemotherapy or best supportive care.

RESULTS

Survival of the lymphadenectomy and the chemoradiotherapy groups was significantly better than that of the patients who received chemotherapy or best supportive care (P < .0001). Fifteen patients (79%) underwent curative lymph node dissection (R0) in the lymphadenectomy group. Complete response, partial response, and stable disease were obtained in 8 (37%), 10 (45%), and 4 (18%) patients who received chemoradiotherapy, respectively. There was no statistically significant difference in survival between the lymphadenectomy and the chemoradiotherapy groups. Although the location of lymph node metastasis did not influence survival significantly, seven patients with nodes around the abdominal aorta did not survive longer than 3 years. The most common repeat recurrence pattern was organ metastasis after the treatment. Multivariate analysis showed that the number of metastatic nodes and tumor marker were independent prognostic factors.

CONCLUSION

Multimodal treatment including lymphadenectomy and chemoradiotherapy could improve survival of the patients with lymph node recurrence of esophageal carcinoma after curative resection.

Surgical outcomes in esophageal cancer patients with tumor recurrence after curative esophagectomy

This study aimed to identify predictive factors and to evaluate appropriate treatments for recurrence of esophageal cancer after curative esophagectomy. About 166 consecutive patients, who underwent curative esophagectomy, were enrolled between April 1994 and March 2003. Recurrence was classified as loco-regional or distant. Logistic regression analysis was used to identify predictive factors for recurrence. Prognostic factors were evaluated by Log-rank test and Cox proportional hazard regression analysis. The disease-specific 5-year survival was 56.8%. Recurrence was observed in 72 patients (43.4%), with 64 of these occurring within 3 years. The number of metastatic lymph nodes and lymphatic invasion independently predicted recurrence. There were significant differences in time to recurrence and survival time between loco-regional, distant recurrence, and combined recurrence. The 5-year survival time in patients with recurrence was 11.9%, and median survival time was 24 months. There was also a significant difference in survival after recurrence between treatment methods (no treatment vs chemo-radiotherapy, p=0.0063; chemotherapy, p=0.0247; and radiotherapy, p<0.0001). Meticulous, long-term follow-up is particularly necessary in patients with four or more metastatic lymph nodes to achieve early detection of recurrence. Randomized controlled trials should be used to develop effective modalities for each recurrence pattern to improve therapeutic outcomes.

Improved surgical results in thoracic esophageal squamous cell carcinoma: a 40-year analysis of 792 patients

Extensive lymphadenectomy, including upper mediastinum, for thoracic esophageal carcinoma was introduced at the beginning of 1980s. However, the efficacy has not been analyzed in large series at a single institute. We evaluated factors potentially related to improved surgical results in patients with thoracic esophageal squamous cell carcinoma (SCC). From 1959 to 1998, a total of 792 patients with thoracic esophageal SCC underwent R0 surgery. A variety of clinicopathological factors were compared among patients treated from 1990 to 1998 (recent group, n=164) and 1959 to 1989 (former group, n=628). The recent group showed significantly better survival than the former group (5-year survival rates: 51 versus 17%, P<0.01), partly because earlier stage disease was included in the recent group than in the former group. Multivariable analysis, using the Cox regression analysis, indicated the time period of surgery, age, tumor location, the number of positive nodes (>5), venous invasion, and tumor-node-metastasis stage. Upper mediastinum lymphadenectomy was also an independent factor to improve survival of patients with thoracic esophageal SCC.