Extranodal Spreading of Esophageal Squamous Cell Carcinoma: Clinicopathological Characteristics and Prognostic Impact

Partial omentectomy maybe practicable for T3 or shallower gastric cancer patients

BACKGROUND

Total omentectomy is often performed with gastrectomy as radical surgery for gastric cancer (GC) patients. However, it remains controversial whether GC patients can benefit from omentectomy. The aim of this study was to analyze the incidence and clinical significance of tumor deposits (TDs) in different anatomical subregions of perigastric omentum in GC patients undergoing gastrectomy with total omentectomy.

METHODS

From October 2011 to December 2013, 1253 patients who underwent gastrectomy with total omentectomy for GC were retrospective reviewed. The TDs in different anatomical subregions of perigastric omentum were examined.

RESULTS

Of 1253 patients, TDs positivity was 11.2%. Tumor deposits in the omentum of greater curvature and in the omentum of lesser curvature were associated with lymphovascular invasion, perineural invasion, advanced tumor node metastasis stages, and unfavorable survival. Besides, TDs in the proximal omentum of greater curvature and in the omentum of lesser curvature correlated with older patients and larger tumors. Kaplan-Meier curves showed that patients with TDs had worser overall survival (OS) than those without, regardless of TD positions. Patients with TDs in the omentum of greater curvature had the worst prognosis, followed by patients with TDs in the omentum of lesser curvature and patients with no TDs. Tumor deposits in the proximal omentum of greater curvature was an independent prognostic factor for OS. Moreover, only patients classified as pT4 had TDs in the distal omentum of greater curvature.

CONCLUSIONS

Patients with TDs in the omentum of greater curvature had the worst prognosis, followed by patients with TDs in the omentum of lesser curvature and patients with no TDs. In addition, partial omentectomy might be practicable for gastric cancer patients classified as T3 or shallower tumors.

Outcomes of esophagectomy for patients with esophageal squamous cell carcinoma accompanied by recurrent laryngeal nerve palsy at diagnosis

BACKGROUND

Hoarseness is one of the classical symptoms in patients with locally advanced thoracic esophageal squamous cell carcinoma (ESCC), and it results from recurrent laryngeal nerve palsy, which is caused by nodal metastasis along the recurrent laryngeal nerve or by main tumors. We reviewed the short-term and long-term results of esophagectomy for patients with locally advanced ESCC and hoarseness at diagnosis.

PATIENTS

Patients who initially presented with hoarseness from recurrent laryngeal nerve palsy between 2009 and 2018 and underwent esophagectomy for thoracic ESCC were eligible for this study. Pharyngolaryngectomy or cervical ESCC were exclusionary.

RESULTS

A total of 15 patients were eligible, and 14 underwent resection of the recurrent laryngeal nerves. The remaining patient had nerve-sparing surgery. Nine patients (60%) had post-operative complications ≥ Clavien-Dindo class II and, pulmonary complications were most common. Two patients (13%) died in the hospital. The 5-year overall survival rate for all patients was 16%. Age (≤ 65 years), cT1/T2 tumor, and remarkably good response to neoadjuvant treatment were likely related to longer survival; however, these relationships were not statistically significant.

CONCLUSIONS

Esophagectomy for ESCC patients who are diagnosed with recurrent laryngeal nerve paralysis at initial presentation could be a treatment option if the patient is relatively young, has a cT1/T2 tumor, or shows a remarkably good response to neoadjuvant treatment. However, clinicians should be aware of the possibility of postoperative pulmonary complications, which were frequently observed with the procedure.

Assessing the Prognostic Value of Extranodal Extension in Esophageal Cancer from the Pathological Staging Perspective

BACKGROUND

Extranodal extension (ENE) is a prognostic factor for several types of malignant tumors, including esophageal cancer. Although the prognostic value of ENE has been investigated in esophageal cancer, its clinical utility warrants further investigation.

MATERIALS AND METHODS

This retrospective single-center study evaluated 105 patients who underwent esophagectomy and had histologically node-positive metastasis between January 2007 and June 2017. The abilities of ENE to predict overall survival (OS) and disease-free survival (DFS) were evaluated using the Kaplan-Meier method and log-rank test, as well as Cox proportional hazard models. Subgroup analyses of ENE's prognostic value were performed according to each pathological tumor-node-metastasis category.

RESULTS

Significant differences according to ENE status were observed in the Kaplan-Meier analyses of OS (p = 0.001) and DFS (p = 0.001), as well as in the Cox proportional hazards models for OS (p = 0.009) and DFS (p = 0.012). Relative to patients without ENE, patients with ENE had significantly poorer OS if they also had pT3 status, pN1 status, or pathological stage III disease. However, no significant differences were observed in the subgroup analyses of pN3 status and pathological stage IV disease.

CONCLUSIONS

Among patients with esophageal cancer, ENE status can predict a poor prognosis and may be useful for patient stratification. However, the prognostic value of ENE status may be limited to patients with specific pathological factors.

Extracapsular lymph node involvement is a robust survival predictor in esophageal cancer patients: A pooled analysis

BACKGROUND

Although extracapsular lymph node involvement (EC-LNI) has been proposed to be incorporated into the staging system of esophageal cancer, the prognostic value of EC-LNI remains controversial with conflicting data available, especially in the era of neoadjuvant therapy.

METHODS

An electronic literature search was undertaken using four public databases. Studies investigating the effects of EC-LNI on survival were included. In addition to analysis of the entire cohort, subset analyses were also performed to assess the impact of EC-LNI on patients receiving different treatment modalities.

RESULTS

A total of 20 studies were included in this meta-analysis. Pooling 13 studies on overall survival (OS), we observed that presence of EC-LNI was associated with significantly worse OS (HR = 2.09, 95%CI: 1.63-2.68; p < 0.01). Nine studies describing disease-free survival (DFS) included, the pooled data revealed that presence of EC-LNI was associated with significantly worse DFS (HR = 1.89, 95%CI: 1.63-2.20; p < 0.001). Subset analyses of patients receiving neoadjuvant therapy demonstrated a survival disadvantage of EC-LNI on OS (HR = 1.928, 95%CI: 1.196-3.107; p = 0.007) and DFS (HR = 1.985, 95%CI: 1.585-2.487; p < 0.001). Similar result was also seen in patients receiving primary surgery (OS: HR = 2.219, 95%CI: 1.720-2.864; p < 0.001; DFS: HR = 1.659, 95%CI: 1.285-2.141; p < 0.001).

CONCLUSION

EC-LNI is a strong prognostic predictor of inferior survival in patients with esophageal cancer irrespective of treatment modality. The currently pooled evidence indicates that EC-LNI has great potential to be incorporated into the future staging system.

Lymphovascular invasion as a poor prognostic indicator in thoracic esophageal carcinoma: a systematic review and meta-analysis

The ability to further stratify patients with esophageal carcinoma (EC) in the same stage into high-risk patients by the presence of lymphovascular invasion (LVI) may permit refinement of multi-modality therapy. However, the role of LVI in the prognosis of EC is not definite. A meta-analysis was conducted to investigate the relationship between LVI and EC prognosis. We searched PubMed, Embase, Web of Science, and Cochrane Library databases for studies on the association between LVI and prognosis of EC. Only studies with patient survival data related to LVI were included. The effect size for this analysis was the hazard ratio (HR) with 95% confidence intervals (CI) for overall survival (OS) and recurrence-free survival (RFS). Thirty-five studies with 9876 patients were included according to the defined inclusion and exclusion criteria. LVI was a poor indicator for the OS (HR = 1.64, 95% CI: 1.44-1.87, P < 0.001) and RFS (HR = 1.79, 95% CI: 1.38-2.34, P < 0.001). However, the heterogeneity was medium in OS (I2 = 61.2%, P < 0.001) and extreme in RFS (I2 = 77.5%, P < 0.001). In subgroup analysis, heterogeneity was originated from the staining method and proportion of early disease (stage (I + II)). We concluded that LVI was a poor prognostic indicator in patients with EC, especially in those studies with the IHC staining method and a high proportion of early disease (stage (I + II)).

Clinical Significance of the Pre-therapeutic Nodal Size in Patients Undergoing Neo-Adjuvant Treatment Followed by Esophagectomy for Esophageal Squamous Cell Carcinoma

BACKGROUND

The clinical significance of pre-therapeutic nodal size in patients with esophageal squamous cell carcinoma (ESCC) is not clear. We investigated whether nodal size was correlated with survival in patients undergoing neo-adjuvant treatment followed by esophagectomy for ESCC.

METHODS

In 2009-2013, 222 patients who underwent neo-adjuvant treatment followed by esophagectomy for ESCC were enrolled in this retrospective study. Nodal size was measured along the short axis of the largest node using pre-therapeutic CT images. Patients were then stratified based on this short axis, and nodal size was correlated with clinicopathological factors and survival.

RESULTS

Patients with larger nodes were likely to have deeper cT, higher cN status, and poorer survival. Among the clinical factors cT, cN, cM, and nodal size, only cT and nodal size were independent prognostic factors in multivariate analysis [hazard ratio (HR) 2.0, 95 % confidence interval (CI) 1.1-3.5, p = 0.025 and HR 1.5, 95 % CI 1-2.3, p = 0.036, respectively]. In addition, nodal size was significantly associated with hematological recurrence (p = 0.007), but not lymphatic relapse (p = 0.272).

CONCLUSIONS

The short axis of the largest node before neo-adjuvant treatment in patients with ESCC is a prognostic factor.

Node-extranodal soft tissue stage based on extranodal metastasis is associated with poor prognosis of patients with gastric cancer

BACKGROUND

The purpose of this study was to evaluate the effect of Node-Extranodal soft tissue (pNE) stage based on Extranodal Metastasis (EM) on recurrence and survival in patients with gastric cancer (GC).

MATERIALS AND METHODS

A total of 642 patients were divided into two groups according to statue of EM. Clinicopathologic features were compared among the two groups, the log-rank test was used to assess statistical differences between the groups. Independent prognostic factors were identified by the Cox proportional hazards regression model. According to the number of EMs, EM was incorporated into the pN stage of gastric carcinoma. The 5-y overall survival (OS) and disease free survival (DFS) rates were 48.1% and 17.4%, 44.5% and 14.3% between the two groups. Patients with EM had a deeper tumor invasion and more number of lymph node metastases. Peritoneal dissemination and distant metastasis were more frequent with EM. EM is an independent risk factor for distance recurrence (odds ratio = 1.605), and it is the highest risk factor for peritoneal recurrence (odds ratio = 2.448). Multivariate analysis showed that depth of tumor invasion (P = 0.025), lymph node metastasis (P <0.001), and EM (P = 0.006) were independent factors associated with OS. Furthermore, EM (P = 0.0039) was also an independent prognostic factor for DFS. The differences in prognostic prediction between the seventh edition of the pN classification and the pNE classification were directly compared. We found the pNE classification (hazard ratio = 1.730, P <0.001) was more appropriate for predicting the OS of GC patients after curative surgery, and the -2 loglikehood of the pNE staging (4533.991) is smaller than the value of pN.

CONCLUSIONS

EM was closely associated with cancer aggressiveness and the presence of EM was a significant independent predictor of reduced DFS and OS in GC patients. EM is an independent risk factor for distance recurrence, especially for peritoneal recurrence, the selection of postoperative adjuvant therapy in systemic (intravenous or intra-arterial) and regional (intraperitoneal) based on EM may be a reasonable approach. The lymph node imaging techniques such as injecting nanocarbon during surgery should be applied. As an important prognostic factor, EM should be incorporated into N stage according to its number retrieved in postoperative samples.

Outcomes of preoperative chemotherapy with docetaxel, cisplatin, and 5-fluorouracil followed by esophagectomy in patients with resectable node-positive esophageal cancer

BACKGROUND

There is a consensus that neoadjuvant therapy is an essential component of treatment for resectable advanced esophageal cancer. The aim of this study was to evaluate the efficacy of preoperative docetaxel/cisplatin/5-fluorouracil (DCF) followed by esophagectomy for patients with node-positive esophageal cancer using a prospective database.

METHODS

Fifty-five consecutive patients with resectable node-positive esophageal cancer were treated with preoperative DCF between August 2008 and December 2010. Of these patients, 54 completed 2 courses of DCF, and 50 underwent esophagectomy after the planned chemotherapy. Clinical and pathologic responses to DCF were investigated, as was patient prognosis. Cox proportional hazard regression was used to determine factors that independently affected recurrence.

RESULTS

Complete response, partial response, stable disease, and progressive disease were observed in 5, 24, 24, and 2 patients, respectively. Overall, the clinical response rate was 53 %. Pathologic complete response was achieved in 6 cases (12 %), and the overall pathologic response rate was 36 %. Downstaging was observed in 23 cases (46 %). Two-year overall and disease-free survival rates were 78 and 56 %, respectively. Multivariate analysis revealed that residual tumor [R1/2; hazard ratio (HR) 5.21, 95 % confidence interval (CI) 1.64-17.2], pathologic poor response (grade 1a; HR 3.08, 95 % CI 1.08-11.1), and ypN (M1Lym; HR 13.3, 95 % CI 2.06-116) were independent predictors of recurrence.

CONCLUSIONS

DCF has strong antitumor activity for esophageal cancer and may confer survival benefits when used as preoperative chemotherapy.

Extranodal metastasis is a powerful prognostic factor in patients with adenocarcinoma of the esophagogastric junction

BACKGROUND AND OBJECTIVES

The purpose of this study is to estimate the effect of extranodal metastasis (EM) on recurrence and survival in patients with adenocarcinoma of the esophagogastric junction (AEG) after curative resection.

METHODS

Clinical data from 284 node-positive AEG patients who underwent curative resection were reviewed. Univariate and multivariate analyses were conducted to elucidate the effect of EM on recurrence-free survival (RFS) and overall survival (OS).

RESULTS

EM was detected in 70 (24.6%) of the 284 cases. It had a significant correlation with tumor size, Lauren type, histopathological grading, depth of tumor invasion, number of metastatic nodes, lymph node ratio, and TNM stage. The 5-year RFS and OS rates were 22.2% and 24.3%, respectively. Patients with EM had a significantly decreased RFS (16 vs. 36 months, P < 0.001) and OS (23 vs. 41 months, P < 0.001) compared with those without EM. Multivariate analyses identified EM as an independent prognostic factor (P = 0.003 and 0.001, respectively).

CONCLUSION

The presence of EM increases recurrence probability and reduces OS probability of AEG patients with lymph node metastasis. EM is a powerful prognostic factor reflecting a particularly aggressive biological behavior. Better understanding of EM status can help clinicians with regard to treatment decision and prognosis evaluation.