Tumors of the esophagogastric junction. Long-term survival in relation to the pattern of lymph node metastasis and a critical analysis of the accuracy or inaccuracy of pTNM classification

Nomogram for predicting the likelihood of liver metastases at initial diagnosis in patients with Siewert type II gastroesophageal junction adenocarcinoma

The liver is one of the most ordinary metastatic sites of gastroesophageal junction adenocarcinoma and significantly affects its prognosis. Therefore, this study tried to construct a nomogram that can be applied to predict the likelihood of liver metastases from gastroesophageal junction adenocarcinoma. 3001 eligible patients diagnosed with gastroesophageal junction adenocarcinoma between 2010 and 2015 in the Surveillance, Epidemiology, and End Results (SEER) database were involved in the analysis. Patients were randomly divided into a training cohort and an internal validation cohort using R software, with an allocation ratio of 7:3. According to the consequences of univariate and multivariate logistic regression, we constructed a nomogram for predicting the risk of liver metastases. The discrimination and calibration ability of the nomogram was appraised by the C-index, ROC curve, calibration plots, and decision curve analysis (DCA). We also used Kaplan-Meier survival curves to compare differences in overall survival in patients with gastroesophageal junction adenocarcinoma with and without liver metastases. Liver metastases developed in 281 of 3001 eligible patients. The overall survival of patients with gastroesophageal junction adenocarcinoma with liver metastases before and after propensity score matching (PSM) was obviously lower than that of patients without liver metastases. Six risk factors were finally recognized by multivariate logistic regression, and a nomogram was constructed. The C-index was 0.816 in the training cohort and 0.771 in the validation cohort, demonstrating the good predictive capacity of the nomogram. The ROC curve, calibration curve, and decision curve analysis further demonstrated the good performance of the predictive model. The nomogram can accurately predict the likelihood of liver metastases in gastroesophageal junction adenocarcinoma patients.

Critical number of lymph node involvement in esophageal and gastric cancer and its impact on long-term survival-A single-center 8-year study

BACKGROUND

Nodal disease in esophageal and gastric cancer is associated with poor survival.

OBJECTIVES

To determine the critical level of lymph node involvement where survival becomes significantly compromised.

METHODS

Survival analyses using multivariable Cox regression and receiver operator characteristics (ROC) were undertaken to determine what number of positive lymph nodes were most sensitive and specific in predicting survival.

RESULTS

A total of 317 patients underwent esophagectomy (n = 190, 59.9%) and gastrectomy (n = 127, 40.1%) for adenocarcinoma. At multivariable analyses, four nodes positivity (irrespective of T-category) was associated with nearly a fivefold increased risk of mortality when compared to node-negative patients (hazard ratio [HR], 4.9; interquartile range 2.0-11.5; P < .001). A positive ratio of up to 50.0% was not associated with worse survival than having four nodes positive (HR, 4.6; 95% confidence interval, 2.6-8.1; P < .001). ROC analysis demonstrated four lymph nodes positive to have a sensitivity of 80.5%, a specificity of 60.1%, and an accuracy of 77.8 (P < .001).

CONCLUSION

The absolute number of nodes positive for cancer is more important than the proportion of positive nodes in predicting survival in esophageal/gastric cancer. Four positive lymph nodes are associated with a fivefold increase in mortality. Beyond this, increasing numbers of positive lymph nodes make no appreciable difference to survival.

Survival nomogram for patients with metastatic siewert type II adenocarcinoma of the esophagogastric junction: a population-based study

BACKGROUND

The aim of this study was to construct a nomogram to predict the survival of patients with metastatic Siewert Type II adenocarcinomas of the esophagogastric junction (AEG).

METHODS

Patients were identified using the Surveillance, Epidemiology, and End Results (SEER) database. Cox regression analysis was performed to assess the prognostic factors. A nomogram comprising independent prognostic factors was established and evaluated using C-indexes, calibration curves, and decision curve analyses.

RESULTS

In total 1616 eligible patients were enrolled. Race, age, bone metastasis, liver metastasis, lung metastasis, other metastasis sites, and distant lymph nodes metastasis were independent prognostic factors and were integrated to construct the nomogram. The nomogram had a C-index of 0.590 (95% CI: 0.569-0.611) in the training cohort and 0.569 (95% CI: 0.532-0.606) in the validation cohort. The calibration plots for the probabilities of 6-month and 1-year overall survival demonstrated there was an optimum between nomogram prediction and actual observation.

CONCLUSION

We developed and validated a nomogram to predict individual prognosis for patients with metastatic Siewert Type II AEG, and the risk stratification system based on the nomogram could effectively stratify the patients into two risk subgroups, which can help clinicians accurately predict mortality risk and recommend personalized treatment modalities.

Risk Factors and Prognostic Impact of Mediastinal Lymph Node Metastases in Patients with Esophagogastric Junction Cancer

PURPOSE

We retrospectively investigated the risk factors for mediastinal lymph node (MLN) metastasis in esophagogastric junction (EGJ) cancer with an epicenter within 2 cm above and below the anatomical cardia, including both adenocarcinoma (AC) and squamous cell carcinoma (SCC).

METHODS

Fifty patients who underwent initial surgery for EGJ cancer from January 2002 to December 2013 were included in this study. We defined metastatic lymph nodes as pathological metastases in resected specimens and recurrence within 2 years postoperatively.

RESULTS

Thirty-four patients had AC and 16 had SCC; 24 patients underwent transhiatal resection and 26 underwent transthoracic resection. MLN metastasis was observed in 13 patients (26%) regardless of the histological type, 9 of whom had metastasis in the upper and middle mediastinum. Metastasis occurred when the esophageal invasion length (EIL) exceeded 20 mm. In addition, 10/13 patients had stage pN2-3 cancer. Multivariable analysis identified EIL ≥ 20 mm and stage pN2-3 as significant risk factors for MLN metastasis. The 5-year overall survival was 38% and 65% in the MLN-positive and -negative groups, respectively (p = 0.12). Multivariable Cox regression analysis showed that only stage pN2-3, and not the presence of MLN metastasis, was a significantly poor prognostic factor.

CONCLUSION

MLN metastasis in EGJ cancer may have a close association with the EIL of the tumor, but the presence of MLN metastasis itself was not a poor prognostic factor. The significance and indications for MLN dissection should be clarified in prospective clinical trials.

Pathologic Complete Response After Preoperative Chemotherapy With a Regimen Containing Trastuzumab in Esophagogastric Junction Adenocarcinoma: A Case Report

Perioperative adjuvant treatment for esophagogastric junction adenocarcinoma has been attempted, but the efficacy of preoperative therapy is unclear. We report here a case of pathologic complete response after preoperative treatment containing trastuzumab in esophagogastric junction adenocarcinoma. A 54-year-old man presented at our institution with dysphagia. Esophagogastroduodenoscopy and computed tomography revealed an 8 × 5 cm sized tumor on the gastric cardia and lower intrathoracic esophagus with invasion to the diaphragm (T4bN0M0, Stage IIIB). Biopsy showed a well-differentiated and human epidermal growth factor receptor 2–positive adenocarcinoma. He received 2 cycles of preoperative chemotherapy consisting of trastuzumab, cisplatin, and capecitabine, without severe toxicity. Afterward, he underwent esophagectomy and total gastrectomy with mediastinal and abdominal D2 lymph node dissections. No cancer cells were detected during histopathologic examination, indicating pathologic complete response. Regimens containing trastuzumab are feasible and promising as preoperative chemotherapy for human epidermal growth factor receptor 2–positive esophagogastric junction adenocarcinoma.

A Randomized Phase II Study of Leucovorin/5-Fluorouracil with or without Oxaliplatin (LV5FU2 vs. FOLFOX) for Curatively-Resected, Node-Positive Esophageal Squamous Cell Carcinoma

Purpose

The optimal perioperative treatment for resectable esophageal squamous cell carcinoma (ESCC) remains controversial. We evaluated the efficacy and safety of leucovorin and 5-fluorouracil (LV5FU2) and LV5FU2 plus oxaliplatin (FOLFOX) combination chemotherapies administered adjuvantly for curatively-resected, node-positive ESCC.

Materials and Methods

Patients with pathologically node-positive esophageal cancer after curative R0 resection were enrolled and randomly assigned to receive LV5FU2 or FOLFOX biweekly for up to eight cycles. The primary endpoint was disease-free survival (DFS).

Results

Between 2011 and 2015, 62 patients were randomized into the two treatment groups (32 in the LV5FU2 arm and 30 in the FOLFOX arm). The median age was 60 years and both groups had similar pathologic characteristics in tumor, nodal status, and location. Treatment completion rates were similarly high in both groups. The DFS rate at 12 months was 67% in the LV5FU2 group and 63% in the FOLFOX group with a hazard ratio of 1.3 (95% confidence interval [CI], 0.66 to 2.62). After a median follow-up period of 27 months, the median DFS was 29.6 months (95% CI, 4.9 to 54.2) in the LV5FU2 arm and 16.8 months (95% CI, 7.5 to 26.1) in the FOLFOX arm (p=0.428), respectively, while the median overall survival was not reached in either arm. Grade 3 or 4 neutropenia was more frequent in patients in the FOLFOX arm than the LV5FU2 arm (20.0% vs. 3.1%).

Conclusion

The addition of oxaliplatin (FOLFOX) did not lead to better efficacy compared to LV5FU2 chemotherapy in an adjuvant setting in node-positive ESCC patients.

Prognostic significance of the location of metastatic lymph nodes in patients with adenocarcinoma of the oesophagogastric junction

BACKGROUND

Adenocarcinoma of the oesophagogastric junction (AEG) potentially metastasizes to lymph nodes (LNs) in the abdomen and thorax. The aim of this study was to analyse the impact of metastatic LN location on prognosis in patients with AEG.

METHODS

From May 2000 to March 2002, 645 patients with AEG underwent resection in our hospital. There were 525 males and 120 females, aged from 31 to 78 years (median = 60 years). Follow-up was carried out by correspondence every 6 months. N-classification according to the number (0, 1-2, 3-6, >6; N0-3), station (0, 1, 2, 3; S0-3) or field (0, 1 (abdominal or mediastinal), 2 (abdominal and mediastinal); F0-2) of LN metastasis and other prognostic factors were evaluated by univariate and multivariate survival analyses.

RESULTS

Of the 645 patients, 307 (47.6%) had LN metastasis. The 5-year survival rate for patients with LN metastases was 16.0% compared to 36.8% for those without LN metastases (P = 0.000). The length of tumour, and the number, station and field of the LN metastasis were independent prognostic factors by multivariate analysis. However, when patients without LN metastasis were excluded from the survival analysis by log-rank test, there were significant differences only in patients with F1 versus F2 LN metastasis, with 5-year survival rates of 14.4% and 8.0%, respectively (P = 0.022).

CONCLUSION

The presence of LN metastases concurrently in both the abdomen and mediastinum is a significant adverse prognostic factor for patients with AEG, and should be included in the future TNM staging system.

Chinese herbal medicine for oesophageal cancer

BACKGROUND

Oesophageal cancer is the seventh leading cause of cancer death worldwide. Traditional Chinese herbal medicine is sometimes used as an adjunct to radiotherapy or chemotherapy for this type of cancer. This review was first published in 2007 and updated in 2009; this 2016 update is the latest version of the review.

OBJECTIVES

To assess the efficacy and possible adverse effects of the addition of Chinese herbal medicine to treatment with radiotherapy or chemotherapy for oesophageal cancer.

SEARCH METHODS

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register, the Cochrane Library, MEDLINE, EMBASE, Allied and Complementary Medicine Database (AMED), China National Knowledge Infrastructure (CNKI), VIP database, Wanfang database and the Chinese Cochrane Centre Controlled Trials Register up to 1 October, 2015. We also searched databases of ongoing trials, the Internet and reference lists.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the use of radiotherapy or chemotherapy with and without the addition of Chinese herbal medicine.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted data and assessed trial quality.

MAIN RESULTS

We tried to contact the 142 study authors by telephone, and finally included nine studies with 490 participants. All included studies were conducted in China, and allocated advanced oesophageal cancer patients to radiotherapy or chemotherapy groups, with and without additional Chinese herbal medicine. Quality of life, short-term therapeutic effects, TCM symptoms and adverse events caused by radiotherapy or chemotherapy were reported in these studies. Overall, we considered the trials to be at unclear or high risk of bias.The quality of life measure was conducted before and after the intervention; our analysis showed a beneficial effect, both in number of participants experiencing an improvement (risk ratio (RR) 2.20, 95% confidence interval (CI) 1.42 to 3.39; 5 RCTs, 233 participants, change of performance status score ≥ 10) and number of participants experiencing a deterioration (RR 0.41, 95% CI 0.27 to 0.62; 6 RCTs, 287 participants, change of performance status score ≤ 10). We judged this to have low quality evidence, downgrading quality of evidence for risk of bias and imprecision, and upgrading quality of evidence for the large effect.For short-term therapeutic effects, the results suggest that traditional Chinese medicine (TCM) has a positive impact on improvement (complete response + partial response) (RR 1.17, 95% CI 1.02 to 1.35; 8 RCTs, 450 participants), moderate quality evidence and downgrading for risk of bias. There was no significant difference for progressive disease (RR 0.73, 95% CI 0.52 to 1.01; 8 RCTs, 450 participants), low quality evidence and downgrading for risk of bias and imprecision. Three studies assessed this outcome after four weeks or three months' follow-up, the remaining studies gave no detailed information for this outcome. TCM symptoms, which was similar to short-term therapeutic effects evaluated with TCM clinical criteria, was diagnosed in two studies of 88 people at the end of the intervention. The results suggest that TCM has a positive impact on both total effectiveness (RR 1.84, 95% CI 1.20 to 2.81) and ineffectiveness (RR 0.22, 95% CI 0.05 to 0.93); we judged the studies to have very low quality evidence, downgrading for risk of bias and imprecision.Nine studies reported a series of adverse events caused by radiotherapy or chemotherapy at the end of the intervention, including mucositis, radiation oesophagitis, arrest of bone marrow, gastrointestinal reactions, renal and hepatic impairment, white blood cell descent, neurotoxicity, cardiac toxicity and anaemia. For those containing multiple studies, we conducted a pooled analysis. As a result, TCM showed a significant effect on radiation oesophagitis (RR 0.66, 95% CI 0.47 to 0.94; 2 RCTs, 90 participants), gastrointestinal reactions (RR 0.54, 95% CI 0.36 to 0.81; 4 RCTs, 268 participants) and white blood cell descent (RR 0.60, 95% CI 0.44 to 0.83; 4 RCTs, 224 participants). The quality of evidence was low or very low, downgrading for risk of bias and imprecision.

AUTHORS' CONCLUSIONS

We currently find no evidence to determine whether TCM is an effective treatment for oesophageal cancer. The effect of TCM on short-term therapeutic effects is uncertain. TCM probably has positive effects on quality of life and on some adverse events caused by radiotherapy or chemotherapy in advanced oesophageal cancer patients undergoing radiotherapy or chemotherapy. The results of the review need to be interpreted cautiously owing to overall low quality evidence. Future trials should be large and correctly designed to detect important clinical effects and minimise risk of bias.

Surgical treatments for esophageal cancers

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high-grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long-term quality of life in patients following esophagectomy.

Location of lymph node involvement in patients with esophageal adenocarcinoma predicts survival

BACKGROUND

The location of positive lymph nodes has been abandoned in the seventh classification of the TNM staging system for esophageal adenocarcinoma. The present study evaluates whether distribution of involved nodes relative to the diaphragm in addition to TNM 7 further refines prediction.

METHODS

Pathology reports of patients who underwent esophagectomy between 2000 and 2008 for adenocarcinoma of the esophagus were reviewed and staging was performed according to the seventh UICC-AJCC staging system. In addition, lymph node involvement of nodal stations above and below the diaphragm was investigated by endoscopic ultrasonography (EUS) in a separate cohort of patients who were scheduled for esophagectomy between 2008 and 2009 at two institutions. Survival was calculated by the Kaplan-Meier method, and multivariate analysis was performed with a Cox regression model.

RESULTS

Some 327 patients who had undergone esophagectomy for cancer were included. Multivariate analysis revealed that patients with from three to six involved lymph nodes in the resection specimen on both sides of the diaphragm had a twofold higher chance of dying compared to patients with the same number of involved lymph nodes on one side of the diaphragm. EUS assessment of lymph node metastases relative to the diaphragm in 102 patients showed that nodal involvement on both sides of the diaphragm was associated with worse survival than when nodes on one side or no nodes are involved [HR (95 % CI) 2.38 (1.15-4.90)].

CONCLUSIONS

A combined staging system that incorporates distribution of lymph nodes relative to the diaphragm refines prognostication after esophagectomy as assessed in the resected specimen and pretreatment as assessed by EUS. This improved staging has the potential to have a great impact on clinical decision making as to whether to embark upon potentially curative or palliative treatments.

Pattern of abdominal nodal spread and optimal abdominal lymphadenectomy for advanced Siewert type II adenocarcinoma of the cardia: results of a multicenter study

BACKGROUND

It remains uncertain whether radical lymphadenectomy combined with total gastrectomy actually contributes to long-term survival for Siewert type II adenocarcinoma of the cardia. We identified the pattern of abdominal nodal spread in advanced type II adenocarcinoma and defined the optimal extent of abdominal lymphadenectomy.

METHODS

Eighty-six patients undergoing R0 total gastrectomy for advanced type II adenocarcinoma were identified from the gastric cancer database of 4,884 patients. Prognostic factors were investigated by multivariate analysis. The therapeutic value of lymph node dissection for each station was estimated by multiplying the incidence of metastasis by the 5-year survival rate of patients with positive nodes in each station.

RESULTS

The overall 5-year survival rate was 37.1%. Age less than 65 years [hazard ratio, 0.455 (95% confidence interval (CI), 0.261-0.793)] and nodal involvement with pN3 as referent [hazard ratio for pN0, 0.129 (95% CI, 0.048-0.344); for pN1, 0.209 (95% CI, 0.097-0.448); and for pN2, 0.376 (95% CI, 0.189-0.746)] were identified as significant prognosticators for longer survival. Perigastric nodes of the lower half of the stomach in positions 4d-6 were considered not beneficial to dissect, whereas there were substantial therapeutic benefits to dissecting the perigastric nodes of the upper half of the stomach in positions 1-3 and the second-tier nodes in positions 7 and 11.

CONCLUSIONS

Limited lymphadenectomy attained by proximal gastrectomy might suffice as an alternative to extended lymphadenectomy with total gastrectomy for obtaining potential therapeutic benefit in abdominal lymphadenectomy for advanced Siewert type II adenocarcinoma.

Results of postoperative radiochemotherapy of the patients with resectable gastroesophageal junction adenocarcinoma in Slovenia

Background.

Although the incidence of adenocarcinomas of the gastroesophageal junction (GEJ) is sharply rising in the Western world, there are still some disagreements about the staging and the treatment of this disease. The aim of this retrospective study was to analyse the effectiveness and safety of postoperative radiochemotherapy in patients with a GEJ adenocarcinoma treated at the Institute of Oncology Ljubljana.

Patients and methods.

Seventy patients with GEJ adenocarcinoma, who were treated with postoperative radiochemotherapy between January 2005 and June 2010, were included in the study. The treatment consisted of 6 cycles of chemotherapy with 5-FU and cisplatin and concomitant radiotherapy with the total dose of 45 Gy.

Results.

Twenty-six patients (37.1%) completed the treatment according to the protocol. The median follow-up time was 17.7 months (range: 3.3–64 months). Acute toxicity grade 3 or more, such as stomatitis, dysphagia, nausea or vomiting, and infection, occurred in 2.9%, 34.3%, 38.6% and 41.5% of patients, respectively. At 3 years locoregional control (LRC), disease-free survival (DFS), disease-specific survival (DSS) and overall survival (OS) were 78.2%, 25.3%, 35.8%, and 33.9%, respectively. In the multivariate analysis of survival, splenectomy and level of Ca 19-9 >20 kU/L before the adjuvant treatment were identified as independent prognostic factors for lower DFS, DSS and OS. Age <60 years, higher number of involved lymph nodes and advanced disease stage were identified as independent prognostic factors for lower DSS and OS.

Conclusions.

In patients with GEJ adenocarcinoma who first underwent surgery, postoperative radiochemotherapy is feasible, but we must be aware of a high risk of acute toxic side effects.

Factors predicting survival in patients with proximal gastric carcinoma involving the esophagus

AIM: To investigate the clinicopathologic features which predict surgical overall survival in patients with proximal gastric carcinoma involving the esophagus (PGCE).

METHODS: Electronic pathology database established in the Department of Pathology of the Nanjing Drum Tower Hospital was searched for consecutive resection cases of proximal gastric carcinoma over the period from May 2004 through July 2009. Each retrieved pathology report was reviewed and the cases with tumors crossing the gastroesophageal junction line were selected as PGCE. Each tumor was re-staged, following the guidelines on esophageal adenocarcinoma, according to the 7th edition of the American Joint Commission on Cancer Staging Manual. All histology slides were studied along with the pathology report for a retrospective analysis of 13 clinicopathologic features, i.e., age, gender, Helicobacter pylori (H. pylori) infection, surgical modality, Siewert type, tumor Bormann’s type, size, differentiation, histology type, surgical margin, lymphovascular and perineural invasion, and pathologic stage in relation to survival after surgical resection. Prognostic factors for overall survival were assessed with uni- and multi-variate analyses.

RESULTS: Patients’ mean age was 65 years (range: 47-90 years). The male: female ratio was 3.3. The 1-, 3- and 5-year overall survival rates were 87%, 61% and 32%, respectively. By univariate analysis, age, male gender, H. pylori, tumor Bormann’s type, size, histology type, surgical modality, positive surgical margin, lymphovascular invasion, and pT stage were not predictive for overall survival; in contrast, perineural invasion (P = 0.003), poor differentiation (P = 0.0003), > 15 total lymph nodes retrieved (P = 0.008), positive lymph nodes (P = 0.001), and distant metastasis (P = 0.005) predicted poor post-operative overall survival. Celiac axis nodal metastasis was associated with significantly worse overall survival (P = 0.007). By multivariate analysis, ≥ 16 positive nodes (P = 0.018), lymph node ratio > 0.2 (P = 0.003), and overall pathologic stage (P = 0.002) were independent predictors for poor overall survival after resection.

CONCLUSION: Patients with PGCE showed worse overall survival in elderly, high nodal burden and advanced pathologic stage. This cancer may be more accurately staged as gastric, than esophageal, cancer.

Should adenocarcinoma of the esophagogastric junction be classified as esophageal cancer? A comparative analysis according to the seventh AJCC TNM classification

OBJECTIVE

The aim of this study was to evaluate the adequacy of esophageal classification for adenocarcinoma of the esophagogastric junction (AEJ) of the seventh American Joint Committee on Cancer (AJCC) TNM classification.

BACKGROUND

The seventh AJCC TNM classification proposed the new classification for AEJ as a part of esophageal cancer depending on the esophagogastric junction (EGJ) involvement. However, there are still many controversies over the classification system for AEJ.

METHODS

A review of pathologic reports and photographic findings at Seoul National University Hospital from 2003 to 2009 identified 4524 patients with single, primary adenocarcinoma of the EGJ (n = 497) and other regions of the stomach (GC, n = 4027) who underwent an operation with curative intent. We analyzed the clinicopathologic features and postoperative prognosis of AEJ using the Siewert classification and the seventh AJCC TNM classification.

RESULTS

There was no Siewert type I (AEJ I) in this study. The prognosis of AEJ was similar to that of GC. There was no difference in clinicopathologic features between AEJ II and AEJ III. Even though AEJ extending into the EGJ (AEJe) showed more advanced pathologic features than AEJ not extending into the EGJ (AEJg), the prognosis of AEJe and AEJg was not significantly different when stratified by T stage. Compared with the classification of gastric cancer applied for AEJ, esophageal classification for AEJ from the seventh AJCC TNM classification showed a loss of distinctiveness at each TNM stage.

CONCLUSIONS

To evaluate the postoperative prognosis of AEJ within the stomach, AEJ II and AEJ III should be considered a part of gastric cancer irrespective of EGJ involvement.

Lower Mediastinal Lymph Node Metastasis is an Independent Survival Factor of Siewert Type II and III Adenocarcinomas in the Gastroesophageal Junction

We examined clinicopathological features and surgical outcomes in patients with adenocarcinoma in the gastroesophageal junction (GEJ), while also analyzing the survival factors that have a prognostic impact. Between 1991 and 2009, 61 patients with tumors in the GEJ (Siewert type II and III) underwent primary surgical resection. Thirty of 61 patients had type II tumors (49.2%) and 31 had type III tumors (50.8%). The tumor size was larger in type III tumors than type II tumors ( P = 0.0026). The overall 5-year survival rates in patients with type II tumors and type III tumors were 44.2 per cent and 41.4 per cent, respectively, with no significant differences ( P = 0.1888). The independent survival factors were lower mediastinal lymph node metastasis ( P = 0.0323) and a noncurative resection ( P = 0.0442). The independent survival factors for patients who underwent curative resections were the tumor size ( P = 0.0422), M category ( P = 0.0489), and lower mediastinal lymph node metastasis ( P = 0.0482). This study showed lower mediastinal lymph node metastasis to be an independent survival factor, and also suggested that lower mediastinal lymph node metastasis was associated with distant metastasis in patients with adenocarcinoma in the GEJ (Siewert type II and III). Therefore, the preoperative early detection of such metastasis is important to improve patient survival.

Transthoracic versus transhiatal esophagectomy for the treatment of esophagogastric cancer: a meta-analysis

OBJECTIVE

To study the differences in short and long-term outcomes of transthoracic and transhiatal esophagectomy for cancer.

BACKGROUND

Studies have compared transthoracic with transhiatal esophagectomy with varying results. Previous systematic reviews (1999, 2001) do not include the latest randomized controlled trials.

METHODS

Systematic review of English-language studies comparing transthoracic with transhiatal esophagectomy up to January 31, 2010. Meta-analysis was used to summate the study outcomes. Methodological and surgical quality of included studies was assessed.

RESULTS

Fifty-two studies, comprising 5905 patients (3389 transthoracic and 2516 transhiatal) were included in the analysis. No study met all minimum surgical quality standards. Transthoracic operations took longer and were associated with a significantly longer length of stay. There was no difference in blood loss. The transthoracic group had significantly more respiratory complications, wound infections, and early postoperative mortality, whereas anastomotic leak, anastomotic stricture, and recurrent laryngeal nerve palsy rate was significantly higher in the transhiatal group. Lymph node retrieval was reported in 4 studies and was significantly greater in the transthoracic group by on average 8 lymph nodes. Analysis of 5-year survival showed no significant difference between the groups and was subject to significant heterogeneity.

CONCLUSIONS

This meta-analysis of studies comparing transthoracic with transhiatal esophagectomy for cancer demonstrates no difference in 5-year survival, however lymphadenectomy and reported surgical quality was suboptimal in both groups and the transthoracic group had significantly more advanced cancer. The finding of equivalent survival should therefore be viewed with caution.

Lymph node metastases and prognosis in oesophageal carcinoma--a systematic review

Oesophageal cancer is the 7th most common cause of cancer-related death in the developed world and the incidence of oesophageal adenocarcinoma is now the fastest growing of any gastrointestinal cancer. Lymph node involvement is the single most important prognostic factor in oesophageal cancer. Imaging to determine the extent of lymph node involvement and plan treatment often requires a combination of modalities to avoid under-staging. The 7th edition of the staging system released by the International Union Against Cancer (IUCC) has stratified lymph node involvement according to the number of lymph nodes involved and redefined its groupings for location of metastatic lymph node involvement. This review discusses the prognostic and treatment implications of these modifications and explores micrometastatic lymph node involvement, capsular infiltration and lymph node ratio as possible additions to the staging system.

Cervical nodal metastases of unresectable thoracic esophageal squamous cell carcinoma: characteristics of long-term survivors after concurrent chemoradiotherapy

PURPOSE

To analyze the clinical implications of metastatic cervical lymph nodes in unresectable thoracic esophageal squamous cell carcinoma (SCC) after concurrent chemoradiotherapy (CRT).

METHODS AND MATERIALS

208 thoracic esophageal SCC patients treated with concurrent CRT were analyzed retrospectively. Patients were divided into 3 groups according to different status of metastatic cervical lymph nodes: 1. CLN(-), no evidence of metastatic cervical lymph nodes; 2. CPLN(+), evidence of enlarged cervical paraesophageal lymph node without any other metastatic cervical lymph nodes; 3. OCLN(+), any other situations of enlarged cervical lymph nodes. The prognostic factors were examined univariately, then selected for inclusion in a multivariate Cox regression model.

RESULTS

Three-year OS of CLN(-),CPLN(+), and OCLN(+) groups were 39%, 33%, and 15% (logrank p=0.001). On univariate analysis, variables significantly associated with OS included sex, primary esophageal tumor location, length and cervical nodal disease. On multivariate analysis, primary tumor location (HR1.5, 95%CI 1.1-1.9, p=0.005), tumor length (HR1.5, 95%CI 1.1-2.0, p=0.010) and cervical nodal disease (HR1.2, 95%CI 1.0-1.5, p=0.014) were prognostic factors on OS.

CONCLUSIONS

(1) Primary tumor location, tumor length, and cervical nodal disease were significant prognostic factors on OS in esophageal SCC patients. (2) Patients with CPLN(+) disease tended to have a potential better long-term survival than those with OCLN(+) disease, and metastatic CPLN could be considered as local disease. The survival benefit in CPLN(+) subgroup might be contributed by the patients who presented with upper third thoracic tumors and shorter tumor length. Further investigation is needed.

Histological regression of squamous esophageal carcinoma assessed by percentage of residual viable cells after neoadjuvant chemoradiation is an important prognostic factor

BACKGROUND

Whether the TNM staging system is applicable after neoadjuvant chemoradiation in esophageal cancer is controversial. The aim of this study was to evaluate the prognostic value of histopathological regression of the primary tumor in postchemoradiated patients.

MATERIALS AND METHODS

The pretherapeutic and pathological ypTNM stages of patients who have had neoadjuvant chemoradiation followed by esophagectomy were analyzed. The percentage of residual viable cells of the primary tumor (ypV) and other clinicopathological factors were tested for their prognostic value.

RESULTS

Of 175 recruited patients, 55 (31.4%) achieved pathological complete response. The median survival of these 55 patients was significantly longer than those with other disease stages (124.8 vs 21.1 months) (P < .001). Gender, ypT, ypN, ypTNM, and ypV stage were significant prognostic factors in univariate analysis. In patients without nodal metastases, the median survival in patients with residual viable cells in the primary tumor (ypV+) was 24.6 months, compared with that of 124.8 months in those with no viable cells (ypV0) (P = .043). In those who had nodal metastases, the median survival of patients with ypV0 and ypV+ were 21.2 months and 17.4 months respectively (P = .37). Cox regression analysis showed that male gender, high percentage of residual viable cells (ypV), and positive nodal status (ypN1) were independent predictors of poor prognosis.

CONCLUSIONS

In patients who underwent neoadjuvant chemoradiation therapy, histopathological regression of the primary tumor indicated by percentage of residual viable cells is an important prognostic factor in addition to nodal status and gender.

Dysphagia as a cause of chest pain: an otolaryngologist's view

Dysphagia is an important alarm symptom, commonly associated with chest pain; it is often associated with reflux disease, xerostomia, or tumors of the head and neck. However, simple diagnoses such as aspiration of a foreign body can be overseen and may result in major complications, such as perforation and mediastinitis. It is thus of crucial importance that a thorough gastrointestinal, cardiac, and radiologic examination precede a rigid esophagoscopy by an otolaryngologist. In this article the differential diagnoses of dysphagia are discussed, and the otolaryngologist's approach to diagnosis and therapy are explained.

Lymph node staging in esophageal adenocarcinoma with PET-CT based on a visual analysis and based on metabolic parameters

BACKGROUND

In order to investigate the value of FDG positron emission tomography-computed tomography (PET-CT), FDG PET (reviewed side-by-side with CT), and metabolic parameters in the assessment of lymph node status and prognosis.

METHODS

Fifty-five subjects with lymph node positive (N1) and 26 subjects with lymph node negative (N0) disease were included. In the slice with the maximum FDG uptake of the tumor, the axial area of the primary tumor, the maximum diameter of the tumor, and the mean and maximum standardized uptake values were measured.

RESULTS

Fused PET-CT correctly characterized 289 of 325 lymph node groups (accuracy 89%) compared to 273 of 325 with PET (accuracy 84%). In lymph node staging (N0 vs. N1), PET-CT (accuracy 83%) was more accurate than PET (accuracy 78%). Among the metabolic parameters, the tumor diameter measured on PET-CT was the best predictor of lymph node stage (N0 vs. N1: accuracy 86%; threshold 25.5 mm) and overall survival. However, the highest accuracy of lymph node staging (N0 vs. N1) was achieved with the synergistic combination of visual analysis and primary tumor diameter measurements (accuracy 95%).

CONCLUSIONS

PET-CT increases accuracy of lymph node staging in esophageal adenocarcinoma compared to PET. The primary tumor diameter further improves accuracy in lymph node staging and was shown to be an independent predictor of overall survival.

Chinese herbal medicines for esophageal cancer

BACKGROUND

Esophageal cancer is the seventh leading cause of cancer death worldwide. Traditional Chinese herbal medicines are sometimes used as an adjunct to radiotherapy or chemotherapy for this type of cancer.

OBJECTIVES

To assess the efficacy and possible adverse effects of the addition of Chinese herbal medicines to treatment with radiotherapy or chemotherapy for esophageal cancer.

SEARCH STRATEGY

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register, The Cochrane Library, MEDLINE, EMBASE, AMED (Allied and Complementary Medicine Database), CBM (Chinese Biomedical Database), China National Knowledge Infrastructure, the Chinese Cochrane Centre Controlled Trials Register and CISCOM (The Research Council for Complementary Medicine) (up to 10 July, 2008). Databases of ongoing trials, the Internet and reference lists were also searched.

SELECTION CRITERIA

Randomised controlled trials comparing the use of radiotherapy or chemotherapy with and without the addition of Chinese herbal medicines.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data and assessed trial quality.

MAIN RESULTS

We identified 43 trials which claimed to use random allocation. The first authors of all the RCTs we initially identified were contacted by telephone and we discovered that the authors had misunderstood the randomisation procedure. Using this new information, we reassigned all the identified RCTs as non-randomised trials. Because we identified no authentic randomised controlled trials, we were unable to perform a meta-analysis.

AUTHORS' CONCLUSIONS

We were unable to find any evidence from RCTs on the effectiveness of TCM in the treatment of esophageal cancer. New trials should be carried out and we recommend that they are large scaled, correctly randomised and that the assessors of the results are blinded to the conditions of allocation.

Predictors of long-term survival after resection of esophageal carcinoma with nonregional nodal metastases

BACKGROUND

Patients with esophageal carcinoma and celiac, cervical, or other nonregional nodal metastases generally have a poor prognosis after surgical resection. Factors predicting long-term survival are unclear. The goal of this study was to analyze factors predicting long-term survival in this subset of patients.

METHODS

We conducted a retrospective review of a prospective database over a 20-year period to identify patients with resected esophageal carcinoma with nonregional lymph node metastases. Medical records were reviewed and risk factors were analyzed.

RESULTS

Sixty-seven patients underwent esophagectomy for M1a or M1b disease from 1987 to 2007. Esophagectomy was transthoracic in 62 patients and transhiatal in 5. The median number of lymph nodes harvested was 36. Sites of nodal metastases were the following: recurrent nodal chain in 42 patients, celiac in 20, both recurrent and celiac in 4, and paratracheal in 1. Median length of follow-up was 66 months. The 5-year overall survival for the entire cohort was 25%. The 5-year overall survival was significantly higher with earlier T-status, (pathologic tumor [pT]1/T2 vs pT3/T4; 62% vs 15%, p = 0.006). Thirteen patients who had nonregional nodal metastases without involvement of regional nodes (pN0) had a significant improvement in 5-year survival (67% vs 15%; p < 0.001). Patients with squamous cell carcinomas had higher 5-year survival compared with those with adenocarcinomas (42% vs 14%; p = 0.009). Patients treated with induction chemotherapy had prolonged 5-year survival (41%, p = 0.06) compared with those treated with adjuvant chemotherapy (11%) or no therapy (20%). Multivariate analysis demonstrated that chemotherapy treatment, squamous cell type, and early T stage (pT1/T2) are significant positive predictors of survival.

CONCLUSIONS

Surgical resection for patients with esophageal cancer associated with nonregional nodal metastases results in 25% survival at five years. Squamous histology, earlier T status, and perioperative chemotherapy are independent positive predictors of long-term survival.

Traditional Chinese medicinal herbs in the treatment of patients with esophageal cancer: a systematic review

Traditional Chinese medicines are sometimes used as an adjunct to radiotherapy or chemotherapy for esophageal cancer. These medicines may have a benefit on the survival and quality of life of patients who have advanced esophageal cancer. Evidence from current studies appears weak due to methodological limitations. Due to conflicting reports, it is difficult to argue for or against the use of traditional Chinese medicines as a treatment for esophageal cancer.

Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus: five-year survival of a randomized clinical trial

OBJECTIVE

To determine whether extended transthoracic esophagectomy for adenocarcinoma of the mid/distal esophagus improves long-term survival.

BACKGROUND

A randomized trial was performed to compare surgical techniques. Complete 5-year survival data are now available.

METHODS

A total of 220 patients with adenocarcinoma of the distal esophagus (type I) or gastric cardia involving the distal esophagus (type II) were randomly assigned to limited transhiatal esophagectomy or to extended transthoracic esophagectomy with en bloc lymphadenectomy. Patients with peroperatively irresectable/incurable cancer were excluded from this analysis (n = 15). A total of 95 patients underwent transhiatal esophagectomy and 110 patients underwent transthoracic esophagectomy.

RESULTS

After transhiatal and transthoracic resection, 5-year survival was 34% and 36%, respectively (P = 0.71, per protocol analysis). In a subgroup analysis, based on the location of the primary tumor according to the resection specimen, no overall survival benefit for either surgical approach was seen in 115 patients with a type II tumor (P = 0.81). In 90 patients with a type I tumor, a survival benefit of 14% was seen with the transthoracic approach (51% vs. 37%, P = 0.33). There was evidence that the treatment effect differed depending on the number of positive lymph nodes in the resection specimen (test for interaction P = 0.06). In patients (n = 55) without positive nodes locoregional disease-free survival after transhiatal esophagectomy was comparable to that after transthoracic esophagectomy (86% and 89%, respectively). The same was true for patients (n = 46) with more than 8 positive nodes (0% in both groups). Patients (n = 104) with 1 to 8 positive lymph nodes in the resection specimen showed a 5-year locoregional disease-free survival advantage if operated via the transthoracic route (23% vs. 64%, P = 0.02).

CONCLUSION

There is no significant overall survival benefit for either approach. However, compared with limited transhiatal resection extended transthoracic esophagectomy for type I esophageal adenocarcinoma shows an ongoing trend towards better 5-year survival. Moreover, patients with a limited number of positive lymph nodes in the resection specimen seem to benefit from an extended transthoracic esophagectomy.

PET/CT of esophageal cancer: its role in clinical management

Positron emission tomography (PET)/computed tomography (CT) has important utility and limitations in the initial staging of esophageal cancer, evaluation of response to neoadjuvant therapy, and detection of recurrent malignancy. Esophageal cancer is often treated by using a combined modality approach (chemotherapy, radiation therapy, and esophagectomy); correct integration of PET/CT into the conventional work-up of esophageal cancer requires a multidisciplinary approach that combines the information from PET/CT with results of clinical assessment, diagnostic CT, endoscopic gastroduodenoscopy, and endoscopic ultrasonography. PET/CT has limited utility in T staging of esophageal cancer and relatively limited utility in detection of dissemination to locoregional lymph nodes. However, PET/CT allows detection of metastatic disease that may not be identifiable with other methods. PET/CT is not sufficiently reliable in the individual patient for determination of treatment response in the primary tumor. Interpretation of PET/CT results is optimized by understanding the diagnostic limitations and pitfalls that may be encountered, together with knowledge of the natural history of esophageal cancer and the staging and treatment options available.

WITHDRAWN: Medicinal herbs for esophageal cancer

BACKGROUND

Esophageal cancer is the seventh leading cause of cancer death worldwide. Traditional Chinese medicinal herbs are sometimes used as an adjunct to radiotherapy or chemotherapy for this type of cancer.

OBJECTIVES

To assess the efficacy and possible adverse effects of the addition of Chinese medicinal herbs to treatment with radiotherapy or chemotherapy for esophageal cancer.

SEARCH STRATEGY

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register, The Cochrane Library, MEDLINE, EMBASE, AMED (Allied and Complementary Medicine Database), CBM (Chinese Biomedical Database), China National Knowledge Infrastructure, the Chinese Cochrane Centre Controlled Trials Register and CISCOM (The Research Council for Complementary Medicine) (up to June 2004). Databases of ongoing trials, the internet and reference lists were also searched.

SELECTION CRITERIA

Randomised controlled trials comparing the use of radiotherapy or chemotherapy with and without the addition of Chinese medicinal herbs.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data and assessed trial quality.

MAIN RESULTS

We identified 43 trials which claimed to use random allocation. Sixteen study authors were contacted by telephone and we discovered that they misunderstood the randomisation procedure and the trials were identified as non-RCTs. The situation of lack of authentic randomised controlled trial leads us cannot draw a conclusion to recommend or against the use of TCM as a treatment for esophageal cancer.

AUTHORS' CONCLUSIONS

There was no evidence of effect of TCM in the treatment of esophageal cancer due to no any authentic RCT in this field yet. New trials should be large scaled, correctly randomised and results assessor blinded in the future.

Lymph node involvement in advanced gastroesophageal junction adenocarcinoma

OBJECTIVE

The prognosis of gastroesophageal junction adenocarcinoma is unquestionably related to the extent of nodal involvement; nonetheless, few studies deal with the pattern of lymph node spread and specifically analyze the prognostic value of the site of metastasis. The present study was aimed at evaluating these key aspects in advanced gastroesophageal junction adenocarcinoma.

METHODS

Of 219 patients consecutively operated on for gastroesophageal junction adenocarcinoma at the Department of General Surgery and Surgical Oncology, University of Siena, and at the Department of General Surgery, University of Verona, 143 pT2-4 tumors not submitted to prior chemoradiation were analyzed according to the Japanese Gastric Cancer Association pN staging system.

RESULTS

The majority of patients were given diagnoses of nodal metastases (77.6%). The mean number (P = .076) and the percentage of patients with pN+ disease (P = .022) progressively increased from Siewert type I to type III tumors. Abdominal nodes were involved in all but 1 of the patients with pN+ disease; conversely, nodal metastases into the chest were 46.2% for type I, 29.5% for type II, and 9.3% for type III tumors. Survival analysis showed virtually no chance of recovery for patients with more than 6 metastatic nodes or lymph nodes located beyond the first tier.

CONCLUSIONS

In advanced gastroesophageal junction adenocarcinoma, the high frequency of nodal metastases and the related unfavorable long-term outcome achieved by means of surgical intervention alone are indicative of the need for aggressive multimodal treatment along with surgical intervention to improve long-term results.

Proposed modification of nodal status in AJCC esophageal cancer staging system

BACKGROUND

The current American Joint Committee on Cancer (AJCC) esophageal cancer staging for nodal status is difficult to interpret and is based solely on lymph node location relative to the primary tumor's esophageal location. Recent reports suggest that the number of lymph nodes involved is also an important factor. We reviewed our esophageal experience to propose an improved nodal staging system.

METHODS

In all, 1,027 patients with resected esophageal cancer from 1970 to 2005 were reviewed. Lymph nodes stations were assigned according to AJCC criteria. Overall survival was assessed by Kaplan-Meier analysis. The impact of location, number of involved lymph nodes, and use of preoperative chemotherapy or radiation therapy, or both, was assessed.

RESULTS

Nonregional nodal involvement (n = 17) was associated with decreased survival compared with regional (n = 441) or celiac nodal (n = 73) involvement (3-year: 0% versus 24% and 23%; p < 0.001). The number of involved lymph nodes was strongly associated with survival (3-year: 0 nodes = 63%, 1 to 3 nodes = 31%, more than 3 nodes = 13%; p < 0.001), and multivariable Cox proportional-hazards analysis suggested that the location and number of involved lymph nodes were independent predictors of survival (p < 0.001). We propose a modified nodal staging system that designates celiac nodes as regional and includes number of involved nodes: pN0, no nodes (3 years = 63%, n = 496); pN1-regional, 1 to 3 nodes (3 years = 32%, n = 292); pN2-regional, more than 3 nodes (3 years = 14%, n = 222); pN3-nonregional node (3 years = 0%, n = 17 [p < 0.0001]). This modified nodal staging system better predicts survival than the current AJCC nodal staging system in which survival for pN1 (3 years = 24%) and pM1a (3 years = 23%) do not differ (p = 0.67). The use of induction before surgical resection did not alter the predictive effect of the new nodal staging system.

CONCLUSIONS

Modification of the AJCC nodal classification system to incorporate the number of involved lymph nodes with regional and nonregional node location simplifies and better predicts long-term survival than does the current AJCC nodal system.

Proposal for a new definition of true cardia carcinoma

BACKGROUND AND OBJECTIVES

It remains controversial whether cardia carcinoma should be categorized and treated as esophageal cancer or gastric cancer. The purpose of this study was to develop a reasonable definition of cardia carcinoma.

METHODS

Patients with Siewert type II carcinomas were divided into two subgroups: 25 patients with a tumor center within 1 cm of the esophagogastric junction (EGJ) (type IIA) and 22 patients with tumor center 1-2 cm aboral of the EGJ (type IIB). Patients with subcardia carcinomas, 40 with invasion to the EGJ (type III) and 110 without (type IIIe-), were used as controls.

RESULTS

The patients with type IIB carcinomas showed no different characteristics from those with type III or type IIIe- carcinomas, except for the stage of the disease. On the other hand, those with type IIA carcinomas were associated with a higher male/female ratio, higher incidences of elevated appearance, differentiated histology, and mediastinal node metastasis, and a significantly lower survival rate as compared with patients with subcardia carcinomas. Multivariate survival analysis revealed that type IIA is a significant prognostic determinant, but that type IIB is not.

CONCLUSION

Type IIA carcinomas should be treated as true cardia carcinoma; type IIB as subcardia carcinoma. Our results should be confirmed by a prospective study.

MODIFIED CLASSIFICATION FOR ADENOCARCINOMA OF THE GASTRO-OESOPHAGEAL JUNCTION

BACKGROUND

Incidence of the gastro-oesophageal junction adenocarcinoma is increasing. Siewert's classification subdivides junctional adenocarcinomas anatomically. Cytokeratin (CK) 7 and 20 immunophenotypes differentiate Barrett's intestinal metaplasia (IM) from gastric IM. Comparing CK immunostaining with Siewert's classification may establish tumour origin and influence surgical choice.

METHODS

In this experimental study, 57 patients with gastro-oesophageal junction adenocarcinoma were subdivided endoscopically into 15 type 1, 26 type 2 and 16 type 3 adenocarcinomas. Representative biopsies were immunostained for CK7 and CK20.

RESULTS

Intestinal metaplasia was associated with type 1 adenocarcinoma in 12 of 15 patients, 80%; with type 2 in 13 of 26 patients, 50% and type 3 in 6 of 16 patients, 37.5%. All type 1 patients showed Barrett's CK7/CK20 phenotype within IM; type 2 a mixture: 69% (n=9) Barrett's CK7/CK20 and 31% (n=4) gastric CK7/CK20 whereas type 3 patients had a gastric CK7/CK20 pattern in 83% (n=5). Immunostaining within the adenocarcinoma was variable.

CONCLUSION

Siewert's type 1 adenocarcinomas express Barrett's CK7/CK20 pattern, type 3 a gastric CK7/CK20 pattern and type 2 tumours a mixture of Barrett's and gastric CK7/CK20 patterns within associated IM. CK immunostaining may refine Siewert's classification into oesophageal type 1 or gastric type 2 adenocarcinoma with IM.

Prognostic nomogram for patients undergoing oesophagectomy for adenocarcinoma of the oesophagus or gastro-oesophageal junction

Background

Tumour node metastasis (TNM) staging predicts survival on the basis of the pathological extent of a tumour. The aim of this study was to develop a prognostic model with improved survival prediction after oesophagectomy.

Methods

Consecutive patients who had potentially curative oesophagectomy for adenocarcinoma of the oesophagus or gastro-oesophageal junction were included. Cox regression analyses were performed to examine the association between risk factors and time to death from oesophageal cancer. The concordance index, calculated after bootstrapping, was used to measure accuracy. A nomogram was designed for use in clinical practice.

Results

Oesophageal cancer-specific survival rates for the 364 included patients who underwent oesophagectomy between 1993 and 2003 were 75·8, 54·9 and 39·2 per cent at 1, 2 and 5 years respectively. A prognostic model using all prognostic variables outperformed TNM staging (concordance index 0·79 versus 0·68 respectively; P &lt; 0·001). A reduced model derived after backward elimination, containing only T stage, lymph node ratio and extracapsular lymph node involvement, also outperformed TNM staging (concordance index 0·77; P &lt; 0·001).

Conclusion

A prognostic model developed to predict disease-specific survival after oesophagectomy was superior to TNM staging. More reliable prognostic information might lead to different approaches to patient follow-up.

Adenocarcinoma of the esophago-gastric junction

BACKGROUND

The border between the esophagus and stomach gives rise to many discrepancies in the current literature regarding the etiology, classification and surgical treatment of adenocarcinoma arising at the esophago-gastric junction. We have consequently used the AEG-criteria (adenocarcinoma of the esophago-gastric junction) for classification and have based the selection of the surgical approach on the anatomic topographic subclassification.

METHODS

In the following we report an analysis of a large and homogeneously classified population of 1602 consecutive patients with adenocarcinoma of the esophago-gastric junction, with an emphasis on the surgical approach, the pattern of lymphatic spread, the outcome after surgical treatment and the prognostic factors. Demographic data, morphologic and histopathologic tumor characteristics, and long-term survival rates were compared among the three tumor subclassifiations.

RESULTS

The study confirms the marked differences in sex distribution, associated specialized intestinal metaplasia in the esophagus, tumor grading, tumor growth pattern, lymphatic spread, and stage between the three tumor entities. The degree of resection and lymph node status were the dominating independent prognostic factors by multivariate analysis. The data show no significant differences of long-term survival after abdomino-thoracic esophagectomy and extended total gastrectomy in these patients.

CONCLUSION

The classification of adenocarcinomas of the esophago-gastric junction in three types, AEG type I, type II and type III shows marked differences between the tumor entities and is recommended for selection of a proper surgical approach. Complete tumor resection and adequate lymphadenectomy are associated with good long-term prognosis. Better surgical management and standardized procedures will improve the outcome also of patients who need to undergo more radical surgery, i.e. abdomino-thoracic esophagectomy.

Pathological analysis of clinical target volume margin for radiotherapy in patients with esophageal and gastroesophageal junction carcinoma

PURPOSE

To clarify the radiotherapy clinical target volume (CTV) margin needed for esophageal squamous-cell carcinoma (SCC) and gastroesophageal junction (GEJ) adenocarcinoma.

METHODS AND MATERIALS

Surgical specimens of esophageal SCC (n = 34) and GEJ adenocarcinoma (n = 32) were prospectively collected and analyzed for microscopic spread along the esophagus and GEJ both proximally and distally from gross tumor and for lymph node (LN) metastasis.

RESULTS

For SCC, the mean microscopic spread beyond the gross tumor was 10.5 +/- 13.5 mm proximally (<30 mm in 32 of 34 cases) and 10.6 +/- 8.1 mm distally (<30 mm in 33 of 34 cases). For GEJ adenocarcinoma, the spread was 10.3 +/- 7.2 mm proximally (<30 mm in 29 of 29 cases) and 18.3 +/- 16.3 mm distally (<30 mm in 27 of 32 cases). The extent of microscopic spread of cancer was significantly associated with pathologic T stage (p = 0.012). LN metastases were observed in 12 (35%) of 34 patients with middle and lower esophageal SCC and 15 (47%) of 32 patients with GEJ adenocarcinoma.

CONCLUSIONS

The extent of microscopic spread within esophagus (recommended CTV margin) was <30 mm in about 94% of cases of esophageal cancer, except for distal microscopic spread in GEJ adenocarcinoma, in which 50 mm was needed to cover about 94% of cases.

Treatment of the Adenocarcinoma of the Esophagogastric Junction at a Single Institution in Mexico

BACKGROUND

Adenocarcinoma of the esophagogastric junction (EGJ) is rapidly increasing in the west. Our aim is to define the prognostic factors and treatment of EGJ carcinoma in Mexico, particularly the location after the Siewert's classification.

METHODS

A retrospective cohort of patients suffering from EGJ adenocarcinoma treated from 1987 to 2000. The Kaplan-Meier and the Cox's models were used to define prognostic factors.

RESULTS

Two hundred and thirty-four patients were included, 90 females and 144 males. Surgical resection was possible in 68 cases only (29%). Significant prognostic factors were tumor node metastasis (TNM) stage [stages I-II: risk ratio (RR) is 1; stage III RR is 1.3, 95% confidence interval (CI) 0.75-2.4; stage IV RR, 2.04, 95% CI 1.1-3.7], gender (male RR = 1.47, 95% CI 1.05-2.05), metastatic lymph node ratio (no resection: RR = 1; ratio 0.2-1 RR=0.67, 95% CI 0.39-1.14; ratio 0-0.19 RR = 0.42, 95% CI 0.23-0.76) and seralbumin (3 mg/dL or less RR = 2.05 95% CI 1.3-3.2; 3.1-3.4 mg/dL RR = 1.9 95% CI 1.2-3.03; 3.5-3.8 mg/dL RR = 1.3 95% CI 0.8-1.9; 3.9 mg/dL or more: RR = 1) (model P = 0.0001).

CONCLUSIONS

EGJ adenocarcinoma is a highly lethal neoplasia and the location after the Siewert' classification is not a prognostic factor. In Mexico, TNM clinical stage, serum albumin, gender, surgical resection and metastatic lymph node ratio are significant prognostic factors. Curative treatment is infrequent but radical resection is associated to longer survival. Consequently, the management must consider quality of life and surgical morbidity.

Adenocarcinoma of the esophagogastric junction: surgical therapy based on 1602 consecutive resected patients

Because of the borderline location between the esophagus and stomach, many discrepancies exist in the current literature regarding the etiology, classification, and surgical treatment of adenocarcinoma arising at the esophagogastric junction. The classification of adenocarcinomas into three types, AGE type I, type II, and type III, shows marked differences between the tumor entities and is recommended for selection of a proper surgical approach. Complete tumor resection and adequate lymphadenectomy are recommended for a good, long-term prognosis. With better surgical management and standardized procedures, even the results in patients with more radical surgical approaches, the abdomino-thoracic esophagectomy improved.

Prognostic factors in adenocarcinoma of the esophagus or gastroesophageal junction

The incidence of adenocarcinoma of the esophagus is rising rapidly in Western Europe and North America. It is an aggressive disease with early lymphatic and hematogenous dissemination. TNM cancer staging systems predict survival on the basis of the anatomic extent of the tumor. However, the adequacy of the current TNM staging system for adenocarcinoma of the esophagus or gastroesophageal junction (GEJ) is questioned repeatedly. Numerous prognostic factors have been described, but are not included in the TNM system. This review describes clinical parameters, aspects of operative technique, response to preoperative chemoradiotherapy therapy, complications and established pathologic determinants found in the resection specimen that have a prognostic impact. Furthermore, their potential application in the clinical setting in patients with adenocarcinoma of the esophagus or GEJ is discussed. Future directions to improve staging systems are given.

Adjuvant chemotherapy with 5-fluorouracil and cisplatin in lymph node-positive thoracic esophageal squamous cell carcinoma

BACKGROUND

In this study we explored the effectiveness of adjuvant chemotherapy in node-positive, resected thoracic esophageal squamous cell carcinoma patients.

METHODS

A prospective study of postoperative chemotherapy in N1 esophageal cancer patients who received curative resection was conducted and compared with the historical control group in regard to recurrence rate, patterns of failure, disease-free survival rate, and overall survival rate. The postoperative chemotherapy consisted of cisplatin (60 mg/m2 intravenously) and 5-fluorouracil (1,000 mg/m2 per day) in a continuous infusion for 4 days. Three cycles were administered at 3-week intervals.

RESULTS

Forty patients were accrued from January 1998 to January 2003 at Samsung Medical Center for adjuvant chemotherapy. The historical control group consisted of 52 patients who received curative resection but not adjuvant chemotherapy during the same period of time. The 3-year disease-free survival rate was 47.6% in the adjuvant group and 35.6% in the control group (p = 0.049). The estimated 5-year overall survival rates were 50.7% in the adjuvant group and 43.7% in the control group (p = 0.228). The significant predictive factors for tumor recurrence were the number of positive lymph nodes (p = 0.008) and the adjuvant chemotherapy (p = 0.030).

CONCLUSIONS

This study suggests that the postoperative chemotherapy may prolong disease-free survival in lymph node-positive, curatively resected esophageal cancer patients. The postoperative treatment modality for esophageal cancer patients should be determined according to the lymph node status and a randomized phase III clinical trial is warranted using adjuvant chemotherapy if the esophageal cancer is lymph node-positive.

Influence of the number of malignant regional lymph nodes detected by endoscopic ultrasonography on survival stratification in esophageal adenocarcinoma

BACKGROUND & AIMS

The nodal staging of esophageal cancer accounts for the absence or presence of metastatic lymph nodes (N0 or N1, respectively). Surgical data suggest that patients have worse survival when esophagectomy specimens contain higher numbers of regional malignant lymph nodes. It has been proposed that the staging system for esophageal cancer be modified to include the number of malignant lymph nodes. The aim of this study was to determine the influence of the number of malignant-appearing regional lymph nodes detected on endoscopic ultrasonography (EUS) on survival in patients with esophageal adenocarcinoma.

METHODS

Historical case series involved patients with esophageal adenocarcinoma who underwent EUS staging at a single center between 1994 and 2004. Endoscopy reports were reviewed to determine the number of malignant-appearing periesophageal lymph nodes seen on EUS examination. Subjects were categorized as having 0, 1-2, or >2 periesophageal lymph nodes. A regional cancer registry prospectively obtained survival data.

RESULTS

Among 85 patients with esophageal adenocarcinoma, the Kaplan-Meier curves showed distinct survival advantages in those with fewer malignant-appearing regional lymph nodes (P=.0008). The median survivals were 66 months, 14.5 months, and 6.5 months for 0, 1-2, and >2 malignant-appearing lymph nodes, respectively. Survival was also influenced by celiac lymph nodes and tumor length, both of which were associated with increased number of malignant nodes.

CONCLUSIONS

The number of malignant-appearing periesophageal lymph nodes detected by EUS is associated with improved survival stratification in patients with esophageal adenocarcinoma and should be considered in the presurgical staging of esophageal cancer.

Present state of the Mini-Invasive Surgery (MIS) in esophageal and gastric cancer

The purpose of this review is to stress the role of the Mini-Invasive Surgery (MIS) in the treatment of the esophagogastric malignant illnesses, supporting ourselves on the most relevant publications of the literature as well as on our own experience in this subject. In short, although no randomised prospective study has proven the MIS advantages in relation to the traditional surgery in the esophagectomy due to cancer, some authors preferently indicate this approach to selected and informed enough patients, who present the following: - High grade dysplasia, preferently choosing from laparoscopic transhiatal esophagectomy (LTE). - Carcinoma in situ, preferently choosing the LTE vs thoracoscopy. - Esophageal tumour locally advanced, in resectable patients with contraindication for a thoracotomy or, in initially non-resectable patients with tumoral reduction after neo-adjuvant chemo-radiotherapy. The arguments given by the authors are the postoperative spectacular improvement in relation to the comfort and quality of life and, the absence of oncological negative effects in the long-term followup. Concerning gastric cancer, the MIS, as exeresis surgical tool in the so-called <<advanced>> gastric forms, is such a definite and oncological approach as the traditional approach, and superior to this as far as quality of life is concerned. When the MIS is used for treating locally advanced forms of gastric cancer, it is as safe as the laparotomic way and it seems to obtain the same oncological outcomes in the long-term.

Comparison between site N-category and number N-category for nodal staging in carcinoma of the gastroesophageal junction: our experience and literature review

Gastroesophageal junction (GEJ) neoplasms have become more common over the past decade. Like mediastinal and abdominal lymph nodes and other gastric tumors, GEJ tumors spread to the retroperitoneal nodes. The TNM staging system does not consider this pattern and does not clinically distinguish GEJ tumors from gastric and esophageal cancers. The aim of the study is to compare the old and new TNM staging systems to assess whether the new TNM classifies lymph node involvement in these tumors as a prognostic factor. From January 1983 to December 1995, 438 patients underwent curative gastric resections for cancer at the Department of Surgery "P. Valdoni" of the University of Rome "La Sapienza". Sixty-two had GEJ type II and III tumors according to the Siewert classification system. The old pN1 and new pN1 survival rates (P < 0.05) were statistically different; the old pN2 and new pN2 survival rates (P = 0.483) were not. The multivariate analysis of significant statistical prognostic factors showed that the pTNM staging in type II and type III GEJ tumors is the most important prognostic factor (P < 0.001), followed by the old pN and new pN (P < 0.001) and the pT (P < 0.005). Gender, age, Lauren type, and tumor location according to Siewert (II vs III) were not independently significant prognostic factors. This study concludes that the numbers and locations of metastatic lymph nodes are important prognostic factors that should be included in the next TNM edition.

Pathologic Nodal Status Predicts Disease-Free Survival After Neoadjuvant Chemoradiation for Gastroesophageal Junction Carcinoma

BACKGROUND

The incidence of carcinoma of the gastroesophageal junction (GEJ) is rapidly increasing, and the prognosis remains poor. We examined outcomes in patients who received neoadjuvant chemoradiation for GEJ tumors to identify factors that predict disease-free (DFS) and overall (OS) survival.

METHODS

A retrospective analysis was performed of 101 consecutive patients who received chemoradiation and surgery for GEJ carcinoma between 1992 and 2001.

RESULTS

The median DFS and OS of all patients were 16 and 25 months, respectively. Twenty-eight patients with a complete histological response (T0N0) experienced greater DFS compared with all others (P = .02). Node-negative patients, regardless of T stage, experienced improved median DFS (24 months) compared with N1 patients (9 months; P = .01). Preoperative stage, age, tumor location, or Barrett's esophagus did not independently predict OS by univariate analysis. Multivariate analysis demonstrated that only posttreatment nodal status (P = .03)-not the degree of primary tumor response-predicted DFS.

CONCLUSIONS

The nodal status of patients with GEJ tumors after neoadjuvant therapy is predictive of DFS after resection. The poor outcome in node-positive patients supports postneoadjuvant therapy nodal staging, because surgical aggressiveness should be tempered by the realization that cure is unlikely and median survival is short.

Endoscopic ultrasonography-identified celiac adenopathy remains a poor prognostic factor despite preoperative chemoradiotherapy in esophageal adenocarcinoma

OBJECTIVE

We reviewed our experience with preoperative chemoradiotherapy in patients with adenocarcinoma of the distal esophagus and pretreatment endoscopic ultrasonography-identified celiac adenopathy.

METHODS

One hundred eighty-six patients with adenocarcinoma of the distal esophagus were staged with endoscopic ultrasonography before treatment from 1997 through 2004. All patients were treated with concurrent chemoradiotherapy (CRT group) and surgical intervention or induction chemotherapy followed by concurrent chemoradiotherapy (C-->CRT group) and surgical intervention. Survival analysis (excluding operative mortality) evaluated various pretreatment factors.

RESULTS

Multivariable Cox regression analysis showed that pretreatment endoscopic ultrasonography-identified celiac adenopathy was a significant predictor of decreased long-term survival (P = .03). Median and 3-year survivals were 49 months and 54% in the endoscopic ultrasonography-identified cN0 M0 group (n = 65), 45 months and 56% in the endoscopic ultrasonography-identified cN1 M0 group (n = 96), and 19 months and 12% in the endoscopic ultrasonography-identified celiac adenopathy (cM1a) group (n = 18; P = .03). Increased systemic relapse was noted in the endoscopic ultrasonography-identified cM1a group (44% vs 22%, P = .07). The only factor associated with increased survival in the endoscopic ultrasonography-identified cM1a group (27 vs 15 months, P = .02) was the addition of induction chemotherapy before concurrent chemoradiotherapy and surgical intervention.

CONCLUSIONS

Endoscopic ultrasonography-identified celiac adenopathy in patients with adenocarcinoma of the distal esophagus conveys a poor prognosis despite preoperative chemoradiotherapy. These patients should be stratified in future multimodality trials. The investigation of induction chemotherapy before concurrent chemoradiotherapy might be warranted in this high-risk group of patients.

Prospective analysis of patients with adenocarcinoma of the gastric cardia and lymph node metastasis in the proximal field of the chest

BACKGROUND

The extent to which adenocarcinoma of the cardia with lymph node metastasis in the upper mediastinum is amenable to cure by radical surgery is open to debate. It remains unclear whether these relatively distant metastases have an effect on long-term survival. The aim of this study was to identify the incidence of such positive nodes and evaluate their prognostic significance.

METHODS

Some 50 patients with adenocarcinoma of the gastric cardia and substantial invasion of the oesophagus (junctional type II), who underwent an extended transthoracic oesophagectomy as part of a prospective randomized trial between 1994 and 2000, were studied.

RESULTS

Eleven patients (22 per cent) had lymph node metastasis in the proximal field of the chest. These patients had more positive nodes overall (P = 0.020) and a shorter median survival (P = 0.009) than those without such metastasis. Multivariate analysis identified positive nodes in the proximal field as an independent predictor of poor survival.

CONCLUSION

Lymph node metastasis in the proximal field of the chest is common and is an indicator of poor prognosis in patients with adenocarcinoma of the cardia.