Outcomes of cervical lymph node recurrence in patients with esophageal squamous cell carcinoma after esophagectomy with 2-field lymph node dissection

Oligometastatic Adenocarcinoma of the Esophagus: Current Understanding, Diagnosis, and Therapeutic Strategies

Esophageal adenocarcinoma is an aggressive cancer of increasing incidence and is associated with poor prognosis. The early recognition of synchronous and metachronous oligometastasis in esophageal adenocarcinoma may allow for prompt intervention and potentially improved survival. However, curative approaches to oligometastatic esophageal disease remain unproven and may represent an area of emerging divergence of opinion for surgical and medical oncologists. We sought to identify the current understanding and evidence for management of oligometastatic esophageal adenocarcinoma by performing a thorough review of the available literature.

Clinicopathologic Characteristics of Oligometastases from Esophageal Cancer and Long-Term Outcomes of Resection

BACKGROUND

Recurrent esophageal cancer after radical therapy usually is thought to be incurable and treated with palliative-intent systemic therapy. However, it is empirically known that surgical resection may be effective for selected patients, although no consensus exists on the efficacy of surgery for recurrent esophageal cancer. This study sought to identify a group of patients for whom surgical resection is considered effective.

METHODS

The study enrolled 206 patients at a single center who had recurrence after radical therapy for esophageal cancer. Prognostic factors after recurrence were identified, and efficacy of surgery was analyzed according to whether the recurrent lesions were oligometastases (i.e., ≤ 5 lesions in a single domain) or not.

RESULTS

In the multivariate analysis, oligometastatic presentation was the only factor associated with survival after recurrence (hazard ratio 6.29; 95% confidence interval, 4.10-9.71). The actuarial survival rates for the patients with oligometastases were 59.5% at 3 years and 51.7% at 5 years. The survival rates at 3 and 5 years were significantly higher for the patients who underwent resection (64.3% and 55.6%, respectively) than for those who did not (both 100%) and for the patients with multiple metastases (9.8% and 0%, respectively). The survival rates for the patients who had oligometastases without resection were comparably lower than for the patients with multiple metastases.

CONCLUSION

Oligometastatic presentation at recurrence was associated with better survival outcomes for the patients who experienced recurrence after radical treatment for esophageal cancer, and surgical resection could be a choice of treatment for this group of patients.

Detection and management of oligometastatic disease in oesophageal cancer and identification of prognostic factors: A systematic review

BACKGROUND

Oesophageal cancer is the eighth most common cancer worldwide. The prognosis of oesophageal cancer patients still remains poor. The 5-year survival rate rarely exceeds 5% in case of metastatic disease. Some patients may however present with oligometastasis which can be treated with loco-regional therapy.

AIM

To assess the current practice regarding the management of patients with oligometastatic oesophageal cancer and identify prognostic factors affecting survival following treatment for oligometastasis.

METHODS

A systematic search of the literature was performed in Cochrance Library, MEDLINE and EMBASE databases from September 1950 to January 2019. Relevant electronic databases were searched for studies assessing the clinical outcome of oligometastasis.

RESULTS

A total of 14 publications were included, of which 12 studies assessing metachronous oligometastasis and 2 on synchronous oligometastasis. All included articles evaluated the specific outcomes of metastasis, management modality and survival outcomes. The majority of the patients presented with oesophageal squamous cell carcinoma. The median disease free interval (time to recurrence) in patients was 19.6 mo and the overall survival reached 30.8 months. Unfavourable prognostic factors were assessed in eight studies and included time to recurrence < 12 mo, large diameter pulmonary lesions (> 20 mm), disease free interval (DFI) < 12 mo, extra-pulmonary metastasis, primary tumour pathological stage III/IV.

CONCLUSION

Oligometastatic oesophageal cancer in selected patients is amenable to loco-regional treatment, and the overall survival of this patient cohort may be improved with patient and tumour-specific treatments.

Salvage lymphadenectomy for isolated cervical lymph node recurrence after curative resection of thoracic esophageal squamous cell carcinoma

Background

Patients with thoracic esophageal squamous cell carcinoma (ESCC) often display recurrence in the cervical lymph nodes after surgery. The optimal treatment strategy for these patients has not been established. We retrospectively reviewed patients who underwent salvage lymphadenectomy plus adjuvant radiotherapy/chemotherapy for recurrence limited to the cervical lymph nodes to explore whether salvage treatment could provide an opportunity for curing these patients and to observe the prognostic factors for the patients after salvage treatment.

Methods

All patients with ESCC who underwent esophagectomy with lymphadenectomy and who were diagnosed with a relapse in the cervical nodes between 2007 to 2014. All cases received salvage lymphadenectomy plus adjuvant radiotherapy/chemotherapy. Their clinical characteristics and outcomes were analysed.

Results

A total of 66 patients were diagnosed with recurrence in the cervical nodes after esophagectomy. Among these patients, 21 (31.8%) relapsed 6 months after esophagectomy and 45 (68.2%) recurrences were found 6 months later. Solitary cervical node recurrence was found in 31 (47.0%) patients while 35 (53.0%) cases showed multiple node relapse. Fifty-four (81.8%) patients underwent radical resection while 12 (18.2%) received reduction surgery. The univariate survival analysis showed that patients with solitary cervical node relapse had a better prognosis than patients with multiple node relapse (P=0.001). Patients who were diagnosed with a recurrence in 6 months after esophagectomy had worse outcomes than patients who relapsed 6 months later (P=0.007). Patients who underwent radical salvage lymphadenectomy had better survival than patients who underwent reduction dissection (P=0.004). The number of positive nodes at esophagectomy (3 or more/2 or less) and surgical treatment for recurrence (reduction/radical surgery) were found to have independent prognostic values by multivariate analysis, whereas the other two factors were not statistically significant.

Conclusions

Salvage cervical lymphadenectomy plus adjuvant radiotherapy/chemotherapy is an effective and safe treatment for ESCC patients who develop cervical lymph node recurrence after curative esophagectomy. A lower primary N stage and radical resection of recurrent nodes were found to have independent prognostic values for these patients.

Predictors of Survival After Treatment of Oligometastases After Esophagectomy

BACKGROUND

Recurrent esophageal carcinoma (EC) has a dismal prognosis. However, prior studies showed that selected patients with isolated recurrence may benefit from definitive therapy. The aim of this study was to identify the predictors of postrecurrence survival (PRS) in patients with isolated EC recurrence who were treated with curative intent.

METHODS

A retrospective review of a prospective database (1988 to 2015) was performed to identify all recurrent EC patients after curative esophagectomy. Demographic and clinicopathologic data were reviewed. The probability of PRS was estimated with the Kaplan-Meier method. Predictors of PRS after definitive therapy for isolated EC recurrence were determined by the multivariable Cox proportional hazards model.

RESULTS

Of the 640 curative esophagectomies, 241 patients (37.7%) experienced recurrences (median follow-up 50 months). Fifty-six patients (9%) received definitive treatment of isolated EC recurrence (31 were treated surgically with or without chemotherapy-radiotherapy [CTRT] and 25 received definitive CTRT alone). Median time to recurrence (TTR) was 19 months. The 1- and 3-year PRSs were 78% and 38% (median survival 26 months). On multivariable analysis; TTR was the only significant independent predictor for survival after recurrence (hazards ratio 0.98, 95% confidence interval: 0.96 to 0.99, p = 0.034). No pronounced difference was found in disease-free survival or in PRS between recurrent patients treated with operation with or without CTRT and patients who received definitive CTRT.

CONCLUSIONS

A select subgroup of patients with isolated EC recurrence can be treated with curative intent. TTR was the best predictor for PRS.

Three-field lymph node dissection in treating the esophageal cancer

There are many controversies in lymphadenectomy for thoracic esophageal cancer, and whether 3-field lymphadenectomy or 2-field lymphadenectomy is better have still been in doubt. The aim of this article is to review the role of the lymph node dissection by introducing the merits and demerits in 3-field lymphadenectomy, and the development in lymphadenectomy's selection, treatment and diagnosis. All the literatures related to esophageal lymphadenectomy and minimally invasive surgery (MIE) were searched in PubMed database and the cross references were added and reviewed to complete the reference list. Several researches elucidated that better overall survival (OS) in patients with esophageal cancer after 3-field lymphadenectomy had been reported worldwide, and 3-field lymphadenectomy is more suitable for treating esophageal cancer with cervical and/or upper mediastinal lymph nodes metastasis than 2-field lymphadenectomy regardless of the tumor's histology and location. Many approaches based on the characteristics of esophageal cancer lymph node metastasis are taken to improve the accuracy of 3-field lymphadenectomy and decrease the postoperative morbidity and mortality, while every approach needs further studies to demonstrate its feasibility. The benefits of the recently rapid-developed techniques performed in treating esophageal cancer: the MIE and the robotic-assisted thoracoscopic esophagectomy are illuminated as well, and both of them are technically safe and feasible for esophageal cancer, whereas further evaluations are still necessary.

Therapeutic efficacy evaluation of postoperative adjuvant radiotherapy in mid-thoracic esophageal carcinoma patients underwent Ivor Lewis esophagectomy with two-field lymphadenectomy

The objective of this paper is to study the treatment outcome of postoperative adjuvant radiation therapy in Ivor Lewis esophagectomy with two-field lymphadenectomy (2FL) and evaluate whether the method can replace three-field lymphadenectomy (3FL). We collected a consecutive series of 503 patients who had undergone Ivor Lewis esophagectomy with 2FL over a seven-year period in our department and evaluated the therapeutic efficacy of postoperative adjuvant radiation therapy. Recurrence and survival rates were calculated with the Kaplan-Meier method, and the differences were compared by the log-rank test. Logistic regression analysis was used to test risk factors for postoperative lymph node metastasis. Cox regression analysis was used to identify prognostic risk factors. The overall 3- and 5-year survival rates were 62.8 and 34.4 %, respectively. There was a significant difference in 5-year survival rate between patients received adjuvant radiation therapy and did not receive radiation therapy. Postoperative adjuvant radiation therapy for patients who underwent Ivor Lewis esophagectomy with 2FL may offer the patients significant survival benefits and reduces the incidence of recurrence in cervical and superior mediastinal lymph nodes.

Clinical significance of serum miR-223, miR-25 and miR-375 in patients with esophageal squamous cell carcinoma

Changes in the expression profiles of microRNAs (miRNAs) have been found in many cancers. The study was aimed to investigate the expression of miR-25, miR-223, and miR-375 in the serum of patients with esophageal squamous cell carcinoma (ESCC) and its effect on survival outcome. We examined the expression levels of miR-25, miR-223, and miR-375 in 20 pairs of ESCC cancer and matched paracancerous tissues, serum samples from 94 healthy volunteers and 194 patients with ESCC using quantitative reverse transcription polymerase chain reaction, and analyzed the relationship between expressions of serum miR-25, miR-223, and miR-375 and ESCC clinicopathological parameters as well as survival. Expressions of miR-25 and miR-223 were significantly increased in ESCC tissues compared with paracancerous tissues (P = 0.008 and 0.009, respectively), whereas the expression of miR-375 was significantly decreased in ESCC tissues compared with paracancerous tissues (P = 0.006). Expressions of serum miR-25 and miR-223 were significantly higher in ESCC patients than those in healthy controls, and, inversely, expression of serum miR-375 was significantly lower in ESCC patients than those in healthy controls (P = 0.007). High expression of serum miR-25 was significantly associated with lymph node metastasis (P = 0.01). Survival analysis showed that high expression of serum miR-223 and low expression of serum miR-375 were associated with poor survival in ESCC patients [hazard ratio (HR) = 1.717, 95% confidence intervals (CI) 1.139-2.588, P = 0.01; HR = 1.750, 95% CI 1.111-2.756, P = 0.016, respectively). Furthermore, Patients with high miR-223 and low miR-375 expression had higher risk of death than those with low miR-223 and high miR-375 expression (HR = 3.599, 95% CI 1.800-7.195, P = 2.92 × 10(-4)). In conclusion, miR-25, miR-223, and miR-375 were abnormally expressed in ESCC tissues and sera. Serum miR-223 and miR-375 are potential prognostic biomarkers for ESCC.