Comparison Between Established and the Worldwide Esophageal Cancer Collaboration Staging Systems

Comparative study of computed tomography (CT) and pathological diagnosis toward mediastinal lymph node metastasis in esophageal carcinoma

OBJECTIVE

To investigate the diagnostic criteria of mediastinal lymph node metastasis (MLNM) in esophageal carcinoma (EC) by comparing the lymph node sizes measured by computed tomography (CT) and obtained by postoperative pathological examination.

METHOD

A total of 305 EC patients were selected. MLNM location, shortest diameter and number were investigated one week before surgery, and then compared with their pathological findings.

RESULTS

The receiver operating characteristic (ROC) curve analysis revealed that the minimum diameters of MLNM in the thoracic cavity was 8 mm (area under curve [AUC] = 0.766, Youden index = 0.424), 5 mm in supraclavicular fossa (AUC = 0.785, Youden index = 0.494), 6 mm in tracheoesophageal groove (AUC = 0.755, Youden index = 0.405); the sensitivity was increased significantly, and the Youden index was increased significantly when compared with 10 mm.

CONCLUSION

The shortest diameter of diagnostic criteria of lymph nodes in EC could be less than 10 mm on CT.

The revised American Joint Committee on Cancer staging system (7th edition) improves prognostic stratification after minimally invasive esophagectomy for esophagogastric adenocarcinoma

BACKGROUND

Staging for esophagogastric adenocarcinoma lacked sufficient prognostic accuracy and was revised. We compared survival prognostication between American Joint Committee on Cancer (AJCC) 6th and 7th editions.

METHODS

We abstracted data for 836 patients who underwent minimally invasive esophagectomy for esophagogastric adenocarcinoma (n = 256 neoadjuvant). Monotonicity and strength of survival trends, by stage, were assessed (log-rank test of trend chi-square statistic) and compared using permutation testing. Overall survival (Cox regression) and model fit (Akaike Information Criterion) were determined.

RESULTS

A greater log-rank test of trend statistic indicated stronger survival trends by stage in AJCC 7th (152.872 vs 167.623; permutation test P < .001) edition. Greater Cox likelihood chi-square value (162.957 vs 173.951) and lower Akaike Information Criterion (4,831.011 vs 4,820.016) indicated better model fit. Superior performance was also shown after neoadjuvant therapy.

CONCLUSION

AJCC 7th edition staging for esophagogastric adenocarcinoma provides superior prognostic stratification after minimally invasive esophagectomy, overall and after neoadjuvant therapy compared with AJCC 6th edition.

Is there a role for PET/CT with esophagogastric junction adenocarcinoma?

The value of 18F-FDG PET/CT in the initial diagnosis and in the locoregional staging of esophagogastric junction adenocarcinoma is not fully established. However, 18F-FDG PET/CT is widely accepted as the best modality for identification of suspected metastases in staging of the disease. Results published in the literature suggest that 18F-FDG PET/CT may provide useful information for response assessment to neoadjuvancy and to differentiate responding and nonresponding tumors. We review the potential role of 18F-FDG PET/CT imaging in staging, restaging, and prognostic value after chemoradiation therapy in esophagogastric junction adenocarcinoma.

HER2 positivity in gastric and esophageal adenocarcinoma: clinicopathological analysis and comparison

PURPOSE

Primary tumor classification of gastric or esophageal cancer has changed significantly with recent alterations of the tumor-node-metastasis (TNM) staging system. Considering these alterations, human epidermal growth factor receptor 2 (HER2) positivity rates were determined and compared in gastric and esophageal adenocarcinoma. Additionally, HER2 positivity in relation to other clinicopathological characteristics was evaluated.

METHODS

A total of 321 patients with histologically confirmed invasive gastric or esophageal adenocarcinoma were examined for HER2 by immunohistochemy (IHC) and chromogenic in situ hybridization (CISH). IHC 3+ or IHC 2+/CISH-positive tumors were considered HER2 positive. Clinicopathological characteristics were retrospectively retrieved from the patient records.

RESULTS

HER2 positivity was found in 50 of 321 patients (15.6 %). In univariate and multivariate logistic models, HER2 positivity rates were significantly higher in esophageal primary tumors (esophageal 25.0 % vs. gastric 7.4 %) and in intestinal histological tumor type (intestinal 22.6 % vs. diffuse/mixed 5.7 %). No significant differences in HER2 positivity were found between males and females, age below and above 65 years, biopsies and surgical specimens or advanced and early-stage disease. Using the 7th TNM edition, many tumors (30.5 % of all included tumors and 64.5 % of all esophageal primary tumors) previously classified as gastric cancer are now classified as esophageal cancer.

CONCLUSIONS

HER2 positivity occurs in 15.6 % of invasive gastroesophageal adenocarcinoma in Western patients, of which the majority is esophageal primary tumors and of the intestinal tumor type. With the introduction of the 7th TNM edition, a large number of tumors previously classified as gastric are now classified as esophageal tumors instead, with relatively high HER2 positivity rates in these esophageal primary tumors.

Undifferentiated carcinoma of the esophagus: a clinicopathological study of 16 cases

Undifferentiated carcinoma of the esophagus is a rare histologic variant of esophageal carcinoma. Using criteria based on studies of undifferentiated carcinomas arising at other sites, we have collected 16 cases of resected esophageal undifferentiated carcinomas. Patients ranged in age from 39 to 84 years (mean, 65.5 years) and were predominantly male (94%). The tumors were characterized by an expansile growth pattern of neoplastic cells organized in solid sheets and without significant glandular, squamous, or neuroendocrine differentiation. The neoplastic cells had a syncytial-like appearance, little intervening stroma, and patchy tumor necrosis. In a subset of cases, the tumor cells adopted a sarcomatoid (n = 2), rhabdoid (n = 1), or minor component (<5%) of glandular morphology (n = 3). In 1 case, reactive osteoclast-like giant cells were found interspersed among the neoplastic cells. Lymphovascular invasion, perineural invasion, and lymph node metastases were identified in 88%, 56%, and 81% of cases, respectively. In 12 (75%) specimens, the background esophageal mucosa was notable for Barrett esophagus. Consistent with the epithelial nature of these neoplasms, cytokeratin positivity was identified in all cases. In addition, SALL4 expression was present in 8 (67%) of 12 cases. Follow-up information was available for 15 (94%) of 16 patients, all of whom were deceased. Survival after surgery ranged from 1 to 50 months (mean, 11.9 months). Before death, 67% patients had documented locoregional recurrence and/or distant organ metastases. In summary, esophageal undifferentiated carcinomas are aggressive neoplasms and associated with a high incidence of recurrence and/or metastases and a dismal prognosis.

Downregulated expression of PTK6 is correlated with poor survival in esophageal squamous cell carcinoma

To investigate the clinical prognostic value of protein tyrosine kinase 6 (PTK6) in patients with esophageal squamous cell carcinoma (ESCC), quantitative RT-PCR and Western blotting were utilized to measure the mRNA and protein expression levels of PTK6 in 29 and eight pairs of ESCC and peritumoral normal esophageal tissues, respectively. Furthermore, the expression of PTK6 protein in 210 ESCCs was examined with immunohistochemistry (IHC), and its clinical value was analyzed using Kaplan-Meier plots and the Cox proportional hazards regression model. The results found that the expression levels of both PTK6 mRNA and protein in ESCC tissues were significantly lower than those in peritumoral normal esophageal tissues. Regarding the IHC analysis of ESCC, the cytoplasmic expression of PTK6 was significantly correlated with tumor grade (P < 0.001). Compared with patients with low PTK6 expression, ESCC patients with overexpression of PTK6 displayed preferable disease-free survival (DFS) and overall survival (OS) (P < 0.001 and P = 0.001, respectively), especially in stage II disease (P = 0.002 and P = 0.021, respectively). PTK6 was evaluated as an independent prognostic factor for ESCC using multivariate Cox regression analysis. All data demonstrated that the expression level of PTK6 is an independent prognostic factor in ESCCs. Low expression of PTK6 is correlated with poor DFS and OS in ESCCs.

Overexpression of cystatin SN positively affects survival of patients with surgically resected esophageal squamous cell carcinoma

Background

Cystatin SN is a secreted protein and a cysteine proteinase inhibitor. It has been considered to be a tumor marker for gastrointestinal tract cancer in several functional researches. However, the clinicopathological and prognostic significance of Cystatin SN expression in esophageal squamous cell carcinoma (ESCC) has not been elucidated.

Methods

In our study, the expression of Cystatin SN was detected in 209 surgically resected ESCC tissues and 170 peritumoral normal esophageal mucosae by immunohistochemistry. The prognostic significance of Cystatin SN expression was analysed with Kaplan-Meier plots and the Cox proportional hazards regression models.

Results

The results showed that the immunostaining of Cystatin SN in ESCC tissues was less intense than that in the normal control tissue (P < 0.001). Compared with patients with low tumoral Cystatin SN expression, ESCC patients with tumors high-expression Cystatin SN exhibited increased disease-free survival (DFS) and overall survival (OS) (P < 0.001 and P < 0.001, respectively). Furthermore, the expression level of Cystatin SN could further stratify the ESCC patients by survival (DFS and OS) in the stage II subgroup (P < 0.001 and P < 0.001, respectively). Multivariate analyses showed that Cystatin SN expression, N status and differentiation were independent and significant predictors of survival.

Conclusions

We concluded that ESCC patients whose tumors express high levels of Cystatin SN have favourable survival compared with those patients with low Cystatin SN expression. Tumoral Cystatin SN expression may be an independent predictor of survival for patients with resectable ESCCs.

Comparison of the 6th and 7th Editions of the UICC-AJCC TNM Classification for Esophageal Cancer

BACKGROUND

The new 7th edition of the Union for International Cancer Control-American Joint Committee on Cancer (UICC-AJCC) tumor, node, metastasis (TNM) staging system is the ratification of data-driven recommendations from the Worldwide Esophageal Cancer Collaboration database. Generalizability remains questionable for single institutions. The present study serves as a validation of the 7th edition of the TNM system in a prospective cohort of patients with predominantly adenocarcinomas from a single institution.

METHODS

Included were patients who underwent transhiatal esophagectomy with curative intent between 1991 and 2008 for invasive carcinoma of the esophagus or gastroesophageal junction. Excluded were patients who had received neoadjuvant chemo(radio)therapy, patients after a noncurative resection and patients who died in the hospital. Tumors were staged according to both the 6th and the 7th editions of the UICC-AJCC staging systems. Survival was calculated by the Kaplan-Meier method, and multivariate analysis was performed with a Cox regression model. The likelihood ratio chi-square test related to the Cox regression model and the Akaike information criterion were used for measuring goodness of fit.

RESULTS

A study population of 358 patients was identified. All patients underwent transhiatal esophagectomy for adenocarcinoma. Overall 5-year survival rate was 38%. Univariate analysis revealed that pT stage, pN stage, and pM stage significantly predicted overall survival. Prediction was best for the 7th edition, stratifying for all substages.

CONCLUSIONS

The application of the 7th UICC-AJCC staging system results in a better prognostic stratification of overall survival compared to the 6th edition. The fact that the 7th edition performs better predominantly in patients with adenocarcinomas who underwent a transhiatal surgical approach, in addition to findings from earlier research in other cohorts, supports its generalizability for different esophageal cancer practices.

Prediction of major postoperative complications and survival for locally advanced esophageal carcinoma patients

BACKGROUND

Predicting the major complications after esophagectomy is important and may help in preselecting patients who are most likely to benefit from surgery, especially in locally advanced esophageal cancer patients who have poor prognosis.

OBJECTIVE

To identify the factors associated with the development of pneumonia and anastomotic leakage complications, and the survival characteristics in locally advanced esophageal cancer patients.

METHODS

A consecutive series of 232 locally advanced esophageal cancer patients (183 men and 49 women, median age 63 years) who underwent esophagectomy at Prince of Songkla University Hospital between 1998 and 2007 was analyzed.

RESULTS

There were nine (3.8%) 30-day mortalities. Pneumonia occurred in 53 patients (22.8%) and anastomotic leakage in 37 patients (15.9%). Multivariate analyses showed that low body mass index was related to leakage (p = 0.015), while soft-diet dysphagia (p = 0.009), forced expiratory volume in 1 second <75% (p = 0.0005), type of surgery (McKeown technique) (p = 0.019), and long operative time (p = 0.006) were related to pneumonia. The median survival rate was 13.0 months. Stage 2b patients had longer survival than stages 3 and 4a patients (p = 0.0001).

CONCLUSION

Patient body mass index, dysphagia, spirometry, type of surgical technique, and operative time can help predict the likelihood of pulmonary or leak complications after esophagectomy. TNM (Tumor, Node, Metastasis) staging can help predict the overall survival after resection in locally advanced cases.