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Du J, Xu G, Yang Z, Zheng B, Chen C. Pericancerous lymph node imaging with indocyanine green-guided near-infrared fluorescence in radical esophagectomy: Protocol for a single-center, prospective, randomized controlled clinical trial. Thorac Cancer 2022; 13:2283-2287. [PMID: 35770339 PMCID: PMC9346187 DOI: 10.1111/1759-7714.14548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/05/2022] [Accepted: 06/07/2022] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION The incidence and mortality rates of esophageal carcinoma are higher than those of most malignancies in humans. Radical esophagectomy is the preferred treatment for early-stage esophageal cancer. However, the extent of lymphadenectomy during radical esophagectomy remains controversial. Indocyanine green (ICG) is the most commonly used imaging agent for the diagnosis of tumors and metastatic lymph nodes in clinical settings. Thus, the main aim of this study was to evaluate pericancerous lymph nodes imaging in video-assisted thoracoscopic surgery radical esophagectomy using a near-infrared (NIR) ICG imaging system and to improve the detection rate of sentinel lymph nodes (SLNs) and overall survival of patients with esophageal cancer. METHODS This was a single-center, prospective, randomized controlled clinical trial (allocation rate = 1:1). Forty treatment-naive esophageal cancer patients were recruited and divided into two groups: the ICG and control groups. The inclusion criteria were age, absence of preoperative neoadjuvant therapy, elective surgery, and signed informed consent. Data of participants at four different time points (preoperation, intraoperation, postoperative 1 week and 3 months) were collected and recorded. The main endpoint of this study was to explore the accuracy and false-negative rate of lymphadenectomy using NIR-ICG fluorescence imaging and to identify the location of esophageal cancer SLN combined with postoperative pathological reports. DISCUSSION This trial will provide more evidence on the extent of lymph node dissection for esophageal cancer and contribute to the development of treatment guidelines for esophageal cancer. TRIAL REGISTRATION NUMBER NCT04615806.
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Affiliation(s)
- Jianting Du
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China.,Key Laboratory of Cardio-Thoracic Surgery(Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
| | - Guobing Xu
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China.,Key Laboratory of Cardio-Thoracic Surgery(Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
| | - Zhang Yang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China.,Key Laboratory of Cardio-Thoracic Surgery(Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
| | - Bin Zheng
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China.,Key Laboratory of Cardio-Thoracic Surgery(Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
| | - Chun Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China.,Key Laboratory of Cardio-Thoracic Surgery(Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
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Chen Y, Zhao XK, Xu RH, Song X, Yang MM, Zhou FY, Lei LL, Fan ZM, Han XN, Gao SG, Wang XZ, Liu ZC, Li Li A, Gao WJ, Hu JF, Zhang LG, Wei JC, Jiao FL, Zhong K, Wang WP, Li LY, Ji JJ, Li XM, Wang LD. Transthoracic, thoracoabdominal, and transabdominal surgical approaches for gastric cardia adenocarcinomas: a survival evaluation based on a cohort of 7103 patients. World J Surg Oncol 2022; 20:217. [PMID: 35764996 PMCID: PMC9238161 DOI: 10.1186/s12957-022-02680-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 06/13/2022] [Indexed: 11/22/2022] Open
Abstract
Background This study compared the survival outcomes of different surgical approaches to determine the optimal approach for gastric cardia adenocarcinoma (GCA) and aimed to standardize the surgical treatment guidelines for GCA. Methods A total of 7103 patients with GCA were enrolled from our previously established gastric cardia and esophageal carcinoma databases. In our database, when the epicenter of the tumor was at or within 2 cm distally from the esophagogastric junction, the adenocarcinoma was considered to originate from the cardia and was considered a Siewert type 2 cancer. The main criteria for the enrolled patients included treatment with radical surgery, no radio- or chemotherapy before the operation, and detailed clinicopathological information. Follow-up was mainly performed by telephone or through home interviews. According to the medical records, the surgical approaches included transthoracic, thoracoabdominal, and transabdominal approaches. Kaplan–Meier and Cox proportional hazards regression models were applied to correlate the surgical approach with survival in patients with GCA. Results There were marked differences in age and tumor stage among the patients who underwent the three surgical approaches (P < 0.001). Univariate analysis showed that survival was related to sex, age, tumor stage, and N stage (P < 0.001 for all). Cox regression model analysis revealed that thoracoabdominal approach (P < 0.001) and transabdominal approach (P < 0.001) were significant risk factors for poor survival. GCA patients treated with the transthoracic approach had the best survival (5-year survival rate of 53.7%), and survival varied among the different surgical approaches for different tumor stages. Conclusion Thoracoabdominal approach and transabdominal approach were shown to be poor prognostic factors. Patients with (locally advanced) GCA may benefit from the transthoracic approach. Further prospective randomized clinical trials are necessary. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-022-02680-5.
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Affiliation(s)
- Yao Chen
- State Key Laboratory of Esophageal Cancer Prevention & Treatment and Henan Key Laboratory for Esophageal Cancer Research of The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Xue Ke Zhao
- State Key Laboratory of Esophageal Cancer Prevention & Treatment and Henan Key Laboratory for Esophageal Cancer Research of The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Rui Hua Xu
- State Key Laboratory of Esophageal Cancer Prevention & Treatment and Henan Key Laboratory for Esophageal Cancer Research of The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Xin Song
- State Key Laboratory of Esophageal Cancer Prevention & Treatment and Henan Key Laboratory for Esophageal Cancer Research of The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Miao Miao Yang
- State Key Laboratory of Esophageal Cancer Prevention & Treatment and Henan Key Laboratory for Esophageal Cancer Research of The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Fu You Zhou
- Department of Thoracic Surgery, Anyang Tumor Hospital, Anyang, Henan Province, China
| | - Ling Ling Lei
- State Key Laboratory of Esophageal Cancer Prevention & Treatment and Henan Key Laboratory for Esophageal Cancer Research of The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Zong Min Fan
- State Key Laboratory of Esophageal Cancer Prevention & Treatment and Henan Key Laboratory for Esophageal Cancer Research of The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Xue Na Han
- State Key Laboratory of Esophageal Cancer Prevention & Treatment and Henan Key Laboratory for Esophageal Cancer Research of The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - She Gan Gao
- Department of Oncology, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan Province, China
| | - Xian Zeng Wang
- Department of Thoracic Surgery, Linzhou People's Hospital, Linzhou, Henan Province, China
| | - Zhi Cai Liu
- Department of Oncology, Tumor Hospital of Linzhou, Linzhou, Henan Province, China
| | - Ai Li Li
- Department of Oncology, Tumor Hospital of Linzhou, Linzhou, Henan Province, China
| | - Wen Jun Gao
- Department of Thoracic Surgery, Linzhou People's Hospital, Linzhou, Henan Province, China
| | - Jing Feng Hu
- State Key Laboratory of Esophageal Cancer Prevention & Treatment and Henan Key Laboratory for Esophageal Cancer Research of The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Li Guo Zhang
- Department of Thoracic Surgery, Central Hospital of Xinxiang, Xinxiang, Henan Province, China
| | - Jin Chang Wei
- Department of Pathology and Thoracic Surgery, Linzhou Esophageal Cancer Hospital, Linzhou, Henan Province, China
| | - Fu Lin Jiao
- Department of Pathology and Thoracic Surgery, Linzhou Esophageal Cancer Hospital, Linzhou, Henan Province, China
| | - Kan Zhong
- State Key Laboratory of Esophageal Cancer Prevention & Treatment and Henan Key Laboratory for Esophageal Cancer Research of The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Wei Peng Wang
- Department of Pathology and Thoracic Surgery, Centre for Health Screening and Endoscopy, Cixian People's Hospital, Cixian, Hebei Province, China
| | - Liu Yu Li
- State Key Laboratory of Esophageal Cancer Prevention & Treatment and Henan Key Laboratory for Esophageal Cancer Research of The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Jia Jia Ji
- State Key Laboratory of Esophageal Cancer Prevention & Treatment and Henan Key Laboratory for Esophageal Cancer Research of The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Xue Min Li
- Department of Pathology and Thoracic Surgery, Centre for Health Screening and Endoscopy, Cixian People's Hospital, Cixian, Hebei Province, China
| | - Li Dong Wang
- State Key Laboratory of Esophageal Cancer Prevention & Treatment and Henan Key Laboratory for Esophageal Cancer Research of The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, Henan Province, China.
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Sun Z, Xu X, Zhao X, Ma X, Ye Q. Impact of postoperative lymph node status on the prognosis of esophageal squamous cell carcinoma after esophagectomy following neoadjuvant chemoradiotherapy: a retrospective study. J Gastrointest Oncol 2021; 12:2685-2695. [PMID: 35070398 PMCID: PMC8748053 DOI: 10.21037/jgo-21-807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 12/20/2021] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (nCRT) and surgery are widely used treatments for locally advanced esophageal squamous cell carcinoma (ESCC). Thus, it is critically important to investigate risk factors that affect patient prognosis after preoperative chemoradiotherapy and surgery. METHODS We conducted a retrospective analysis of 77 patients with ESCC who received nCRT and underwent surgery at our center from January 2015 to December 2019. We analyzed the primary clinical data, postoperative pathological results, recurrence, and death results. RESULTS Among the 77 ESCC patients who received nCRT and surgery, 19 achieved a postoperative pathologic complete response (pCR), and the overall pCR rate was 24.68%. The univariate analysis indicated that postoperative post-neoadjuvant treatment N stage (ypN) metastasis [hazards ratio (HR): 2.908; 95% confidence interval (CI): 0.874-9.676; P=0.082], a high lymph-node ratio [(LNR) >0.1] (HR: 7.149, 95% CI: 1.740-29.369; P=0.006), post-neoadjuvant treatment T3-4 (ypT3-4) (HR: 3.626, 95% CI: 0.824-15.956; P=0.088) affected disease-specific survival (DSS). The multivariate analysis indicated that a high LNR (>0.1) (HR: 6.170; 95% CI: 1.472-25.856; P=0.013) was a significant independent predictor of DSS. The univariate analysis indicated that postoperative ypN metastasis (HR: 2.283; 95% CI: 1.047-4.979; P=0.038) and a high LNR (>0.1) (HR: 4.210; 95% CI: 1.547-11.458; P=0.005) were associated with recurrence-free survival (RFS). The multivariate survival analysis showed that a high LNR (>0.1) (HR: 4.289; 95% CI: 1.538-11.965; P=0.005) was also a significant independent predictor of RFS. In this study, 57 positive lymph nodes were found in 30 of the 77 patients, including 16 left gastric lymph nodes, 9 pericardial lymph nodes, and 7 left supraclavicular lymph nodes. CONCLUSIONS A high LNR (>0.1) in ESCC patients after nCRT is a risk factor of DSS and RFS. ypN metastasis is also an independent predictor of RFS. Left gastric-arterial lymph nodes, para-cardiac lymph nodes, and left supraclavicular lymph nodes are the most common sites of metastasis in ESCC after nCRT.
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Affiliation(s)
- Zhiyong Sun
- Department of Thoracic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xin Xu
- Department of Radiation Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaojing Zhao
- Department of Thoracic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiumei Ma
- Department of Radiation Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qing Ye
- Department of Thoracic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Liu X, Wu L, Zhang D, Lin P, Long H, Zhang L, Ma G. Prognostic impact of lymph node metastasis along the left gastric artery in esophageal squamous cell carcinoma. J Cardiothorac Surg 2021; 16:124. [PMID: 33941213 PMCID: PMC8091502 DOI: 10.1186/s13019-021-01466-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 04/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although the incidence of lymph node (LN) metastasis (LNM) along the left gastric artery is high, its relationship with the prognosis in postoperative patients with esophageal squamous cell carcinoma (ESCC) is rarely reported. This study clarified the prognostic impact of LNM along the left gastric artery in postoperative patients with ESCC. METHODS This study assessed data of 1521 patients with ESCC who underwent esophagectomy at the Sun Yat-sen University Cancer Center between March 1992 and March 2012. A chi-squared test and Mann-Whitney U test were used to explore the preliminary correlation between clinical factors and LNM along the left gastric artery. Univariate and multivariate Cox regression analyses were used to assess whether LNM along the left gastric artery was an independent predictor of overall survival. Kaplan-Meier analysis and the log-rank test were used to present a classifying effect based on LN status. RESULTS LNM was observed in 598 patients (39.3%) and was found along the branches of the left gastric artery in 256 patients (16.8%). The patients were classified into two groups based on the presence of LNM along the left gastric artery. Patients without LNM along the left gastric artery had better cancer-specific survival than those with positive LNs (P < 0.001). CONCLUSIONS This study indicated that LNM along the left gastric artery was an important independent prognostic factor for long-term survival among ESCC patients (P = 0.011).
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Affiliation(s)
- Xuan Liu
- Department of thoracic surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangdong Esophageal Cancer Institute, 651 Dongfengdong Road, Guangzhou, 510060, China
| | - Leilei Wu
- Department of thoracic surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangdong Esophageal Cancer Institute, 651 Dongfengdong Road, Guangzhou, 510060, China
| | - Dongkun Zhang
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Peng Lin
- Department of thoracic surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangdong Esophageal Cancer Institute, 651 Dongfengdong Road, Guangzhou, 510060, China
| | - Hao Long
- Department of thoracic surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangdong Esophageal Cancer Institute, 651 Dongfengdong Road, Guangzhou, 510060, China
| | - Lanjun Zhang
- Department of thoracic surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangdong Esophageal Cancer Institute, 651 Dongfengdong Road, Guangzhou, 510060, China
| | - Guowei Ma
- Department of thoracic surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangdong Esophageal Cancer Institute, 651 Dongfengdong Road, Guangzhou, 510060, China.
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Louie BE. Commentary: Defining low-risk lesions for esophageal preservation informed by resecting the organ. J Thorac Cardiovasc Surg 2020; 162:1282-1283. [PMID: 33419551 DOI: 10.1016/j.jtcvs.2020.11.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Brian E Louie
- Division of Thoracic Surgery, Swedish Medical Center, Thoracic Research Program, and Minimally Invasive Thoracic Surgery Program, Swedish Digestive Health Institute, Seattle, Wash.
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Jang JY, Yu J, Song KJ, Jo YY, Yoo YJ, Kim SB, Park SR, Kim YH, Kim HR, Kim JH. Prognostic significance of lymph node ratio after neoadjuvant chemoradiation therapy for esophageal squamous cell carcinoma. Radiat Oncol J 2020; 38:244-252. [PMID: 33233030 PMCID: PMC7785840 DOI: 10.3857/roj.2020.00850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 11/18/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose We retrospectively evaluated the prognostic significance of lymph node ratio (LNR) in patients with esophageal squamous cell carcinoma who underwent neoadjuvant concurrent chemoradiation therapy (NCRT) followed by surgery. Materials and Methods In total, 270 patients who underwent NCRT followed by surgery between August 2005 and December 2015 were included. They were divided into three groups: LNR 0 (n = 196), LNR low (0 < LNR ≤ 0.1; n = 63), and LNR high (>0.1; n = 11). The primary endpoint was overall survival (OS), and the secondary endpoints were freedom from local recurrence (FFLR), distant metastasis-free survival (DMFS), and disease-free survival (DFS). Results The median number of retrieved lymph nodes per patient was 33. Pathologically, 74 patients had positive lymph nodes. The median follow-up duration was 36.1 months, and the median survival period was 68.4 months. There was a significant correlation between LNR and the number of positive lymph nodes (correlation coefficient = 0.763, p < 0.001). There was a substantial difference in the OS among the LNR groups, with 2-year survival rates of 79.0%, 54.0%, and 9.1% in the LNR 0, LNR low, and LNR high groups, respectively (p < 0.001). A marked decrease in FFLP, DMFS, and DFS was observed with the increasing LNR. In subgroup analysis, the survival results of patients with clinically positive lymph node were similar from those of entire cohort. Conclusion LNR is a significant prognostic factor in patients with esophageal squamous cell carcinoma who underwent NCRT followed by surgery. Additional treatment and closer follow-up would be necessary for patients with a high LNR.
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Affiliation(s)
- Jeong Yun Jang
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jesang Yu
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kye Jin Song
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yoon Young Jo
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ye Jin Yoo
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Bae Kim
- Department of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sook Ryun Park
- Department of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Hee Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Hoon Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Askari A, Munster AB, Jambulingam P, Riaz A. Critical number of lymph node involvement in esophageal and gastric cancer and its impact on long-term survival-A single-center 8-year study. J Surg Oncol 2020; 122:1364-1372. [PMID: 32803769 DOI: 10.1002/jso.26145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/22/2020] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Alan Askari
- Department of Surgery, West Hertfordshire Hospitals NHS Trust, Watford, UK
| | - Alex B Munster
- Department of Surgery, West Hertfordshire Hospitals NHS Trust, Watford, UK
| | | | - Amjid Riaz
- Department of Surgery, West Hertfordshire Hospitals NHS Trust, Watford, UK
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Kumble LD, Silver E, Oh A, Abrams JA, Sonett JR, Hur C. Treatment of early stage (T1) esophageal adenocarcinoma: Personalizing the best therapy choice. World J Meta-Anal 2019; 7:406-417. [DOI: 10.13105/wjma.v7.i9.406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/03/2019] [Accepted: 10/19/2019] [Indexed: 02/06/2023] Open
Abstract
Esophagectomy is considered the primary form of management for esophageal adenocarcinoma (EAC); however, the surgery is associated with high rates of morbidity and mortality. For patients with early-stage EAC, endoscopic resection (ER) presents a potential curative treatment option that is less invasive and carries fewer risks procedure related risks, but it is associated with higher rates of cancer recurrence following the procedure. For some patients, age and comorbidities may prevent them from having esophagectomy as a treatment option, while other patients may be operative candidates but do not wish to undergo esophagectomy for a variety of reasons related to their values and preferences. Furthermore, while anxiety of cancer recurrence following ER may significantly diminish a patient’s quality of life (QOL), so might the morbidity surrounding esophagectomy. In addition to considering health status, patient preferences, and impacts on QOL, physicians and patients must also consider what treatments would be both beneficial and available to the patient, considering esophagectomy methods-minimally invasive vs open-or the use of chemoradiotherapy in addition to ER. Our article reviews and summarizes available treatment options for patients with early EAC and their potential effects on the health and wellbeing of patients based on the current data. We conclude with a request for more research of available options for early EAC patients, the conditions that determine when each option should be employed, and their effects not only on patient health but also QOL.
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Affiliation(s)
| | - Elisabeth Silver
- General Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Aaron Oh
- General Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Julian A Abrams
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Joshua R Sonett
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Chin Hur
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
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Haque W, Verma V, Bernicker E, Butler EB, Teh BS. Management of pathologic node-positive disease following initial surgery for clinical T1-2 N0 esophageal cancer: patterns of care and outcomes from the national cancer data base. Acta Oncol 2018; 57:782-789. [PMID: 29188742 DOI: 10.1080/0284186x.2017.1409435] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Although clinical T1-2N0 esophageal cancer (EC) is often initially surgically resected (without neoadjuvant therapy), several studies have illustrated substantial rates of discovering pathologically node-positive disease. This study evaluated national practice patterns of adjuvant therapy for this population. METHODS The National Cancer Database (NCDB) was queried (2004-2013) for patients with cT1-2N0M0 EC that received up-front surgery (esophagectomy/local techniques) with subsequent discovery of nodal metastasis. Patients receiving any neoadjuvant therapy were excluded. Multivariable logistic regression determined factors predictive of receiving adjuvant therapy. Kaplan-Meier analysis evaluated overall survival (OS), and Cox proportional hazards modeling determined variables associated with OS. Propensity score matching assessed groups in a balanced manner while reducing indication biases. RESULTS Altogether, 715 patients met inclusion criteria; 114 (16%) underwent adjuvant chemotherapy, 183 (26%) chemoradiation, 16 (2%) radiotherapy alone, and 402 (56%) observation. Observation was more likely performed with advanced age (p = .002) and at nonacademic centers (p = .001). Median OS in the respective cohorts were 42.6, 35.1, 22.2, and 27.0 months. Both chemotherapy and chemoradiation were statistically similar (p = .462) but superior to observation (p < .05 for both). There was a survival benefit to any adjuvant treatment (median OS 38.5 vs. 27.0 months, p < .001), which persisted after propensity matching (median OS 35.1 vs. 24.3 months, p < .001). On multivariable analysis, any adjuvant treatment was independently associated with improved OS, along with treatment at an academic center (p < .05 for all). CONCLUSIONS In the largest study to date evaluating patterns of care for pN + disease following resection of cT1-2N0 EC, a strikingly high proportion of patients were observed. Adjuvant treatment, ideally chemotherapy or chemoradiation, independently correlated with higher survival, and should be considered in able patients. Treatment at academic facilities also associated with higher survival, which has implications for patient counseling.
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Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Eric Bernicker
- Department of Medical Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - E. Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Bin S. Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
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Shimamura Y, Ikeya T, Marcon N, Mosko JD. Endoscopic diagnosis and treatment of early esophageal squamous neoplasia. World J Gastrointest Endosc 2017; 9:438-447. [PMID: 28979708 PMCID: PMC5605343 DOI: 10.4253/wjge.v9.i9.438] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/14/2017] [Accepted: 08/17/2017] [Indexed: 02/06/2023] Open
Abstract
Esophageal cancer is one of the leading causes of cancer-related death and is associated with high morbidity and mortality. It carries a poor prognosis as more than half of patients present with advanced and unresectable disease. One contributing factor is the increased risk of lymph node metastases at early stages of disease. As such, it is essential to detect squamous cell neoplasia (SCN) at an early stage. In order to risk stratify lesions, endoscopists must be able to perform image enhanced endoscopy including magnification and Lugol’s chromoendoscopy. The assessment of both the horizontal extent and depth of any lesion is also of utmost importance prior to treatment. Endoscopic mucosal resection and submucosal dissection remain the standard of care with literature supportive their respective use. Radiofrequency ablation and other endoscopic treatments are currently available although should not be considered first line at this time. Our objective is to review the current options for the endoscopic diagnosis and treatment of esophageal SCN.
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Affiliation(s)
- Yuto Shimamura
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON M5B1W8, Canada
| | - Takashi Ikeya
- Department of Gastroenterology, St. Luke’s International Hospital, Tokyo 104-8560, Japan
| | - Norman Marcon
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON M5B1W8, Canada
| | - Jeffrey D Mosko
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON M5B1W8, Canada
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Schölvinck D, Künzli H, Meijer S, Seldenrijk K, van Berge Henegouwen M, Bergman J, Weusten B. Management of patients with T1b esophageal adenocarcinoma: a retrospective cohort study on patient management and risk of metastatic disease. Surg Endosc 2016; 30:4102-13. [PMID: 27357927 DOI: 10.1007/s00464-016-5071-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 06/21/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Esophagectomy for submucosal (T1b) esophageal adenocarcinoma (EAC) is performed in order to optimize patient outcomes given the risk of concurrent lymph node metastases (LNM). However, not seldom, comorbidity precludes these patients from surgery. Therefore, the aim of our study was to assess the course of follow-up after treatment in submucosal EAC patients undergoing surgery versus conservative therapy and to evaluate the incidence of metastatic disease. METHODS Between 2001 and 2012, all patients undergoing diagnostic endoscopic resection for EAC in two centers were reviewed. Only patients with histopathologically proven submucosal tumor invasion were included. Submucosal EACs were divided into tumors that were removed radically (R0) and irradically (R1). Subsequently, in the R0 group, EACs were classified as either low risk (LR; submucosal invasion <500 nm, G1-G2, no LVI) or high risk (HR; deep submucosal invasion >500 nm, G3-G4 and/or LVI). Metastatic disease was defined as LNM in surgical resection specimen and/or evidence of malignant disease during follow-up (FU). RESULTS Sixty-nine patients with a submucosal EAC were included [23 R1-resections and 46 R0-resection (14 R0-LR and 32 R0-HR)]. Twenty-six patients underwent surgical treatment (1 R0-LR, 12 R0-HR and 13 R1). None of the 14 R0-LR patients developed metastatic disease after a median FU of 60 months. In the R0-HR group and R1 group, metastatic disease was diagnosed in 16 and 30 % of patients, respectively. Surgical patients tended to have a better overall survival than non-surgical patients (p = 0.09). Tumor-related deaths, however, were 12 % in both groups. CONCLUSIONS In LR submucosal EAC, the risk of metastatic disease appears to be very low. In deep submucosal EAC (either R0- or R1-resection), the rate of metastatic disease is lower than reported in earlier surgical series. Given the reasonable disease-free survival and high background mortality, conservative management of these patients seems to be a valid alternative for surgery in selected cases.
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Affiliation(s)
- Dirk Schölvinck
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Hannah Künzli
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Sybren Meijer
- Department of Pathology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Kees Seldenrijk
- Department of Pathology, St. Antonius Hospital, Nieuwegein, Nieuwegein, The Netherlands
| | | | - Jacques Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Bas Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Nieuwegein, The Netherlands. .,Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Shao Y, Ning Z, Chen J, Geng Y, Gu W, Huang J, Pei H, Shen Y, Jiang J. Prognostic nomogram integrated systemic inflammation score for patients with esophageal squamous cell carcinoma undergoing radical esophagectomy. Sci Rep 2015; 5:18811. [PMID: 26689680 PMCID: PMC4686940 DOI: 10.1038/srep18811] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 11/26/2015] [Indexed: 12/26/2022] Open
Abstract
Growing evidence indicates that nomogram combined with the biomarkers of systemic inflammation response could provide more accurate prediction than conventional staging systems in tumors. This study aimed to establish an effective prognostic nomogram for resectable thoracic esophageal squamouscell carcinoma (ESCC) based on the clinicopathological parameters and inflammation-based prognostic scores. We retrospectively investigated 916 ESCC patients who underwent radical esophagectomy. The predictive accuracy and discriminative ability of the nomogram were determined by concordance index (C-index) and calibration curve, and compared with the 6th and 7th AJCC TNM classifications. The neutrophil lymphocyte ratio (NLR), C-reactive protein albumin (CRP/Alb) ratio, histological grade, T stage and modified N stage were integrated in the nomogram. The C-index of the nomogram for predicting the survival was 0.72, which showed better predictive ability of OS than the 6th or 7th TNM stages in the primary cohort (P < 0.001). The calibration curve showed high consistency between the nomogram and actual observation. The decision curve analysis showed more potential of clinical application of the prediction models compared with TNM staging system. Moreover, our findings were supported by the validation cohort. The proposed nomogram showed more accurate prognostic prediction for patients with ESCC after radical esophagectomy.
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Affiliation(s)
- Yingjie Shao
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, 185 Juqian Street, Changzhou 213003, P.R. China
| | - Zhonghua Ning
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, 185 Juqian Street, Changzhou 213003, P.R. China
| | - Jun Chen
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, 185 Juqian Street, Changzhou 213003, P.R. China
| | - Yiting Geng
- Department of Oncology, The Third Affiliated Hospital of Soochow University, 185 Juqian Street, Changzhou 213003, P.R. China
| | - Wendong Gu
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, 185 Juqian Street, Changzhou 213003, P.R. China
| | - Jin Huang
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, 185 Juqian Street, Changzhou 213003, P.R. China
| | - Honglei Pei
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, 185 Juqian Street, Changzhou 213003, P.R. China
| | - Yueping Shen
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Soochow University, Suzhou 215123, China
| | - Jingting Jiang
- Department of Tumor Biological Treatment, The Third Affiliated Hospital of Soochow University, 185 Juqian Street, Changzhou 213003, P.R. China
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Yuan F, Qingfeng Z, Jia W, Chao L, Shi Y, Yuzhao W, Chao A, Yue Y. Influence of Metastatic Status and Number of Removed Lymph Nodes on Survival of Patients With Squamous Esophageal Carcinoma. Medicine (Baltimore) 2015; 94:e1973. [PMID: 26632887 PMCID: PMC4674190 DOI: 10.1097/md.0000000000001973] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The aim of this study was to determine the impact of lymph node (LN) metastasis conditions on the prognosis of patients with esophageal squamous carcinoma and the minimum number of LNs that should be removed to maximize overall postoperative survival among patients with this specific pathologic subtype. In this study, 312 patients with thoracic squamous esophageal carcinoma who received in-patient thoracic surgery by the same surgeon in our hospital from August 1, 2003 to December 31, 2009 were recruited. Subsequently, Kaplan-Meier methods were used to determine associations between LN metastasis conditions and mortality and between the numbers of LNs removed during esophagectomy and mortality. Cox regression models were used to adjust for potential confounding covariates. According to Kaplan-Meier analyses, the number of metastatic LNs was a good predictor for the prognosis of patients with esophageal squamous carcinoma and the dissection of ≥ 29 LNs during thoracic surgery significantly improved patient survival (P = 0.011).Lymph node metastasis rates may be a significant predictor for the prognosis of patients with esophageal squamous carcinoma. The number of LNs removed during esophagectomy is an independent predictor for the survival of patients with esophageal squamous carcinoma with maximal postoperative survival after the removal of ≥ 29 LNs.
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Affiliation(s)
- Feng Yuan
- From the Department of Thoracic Surgery II, Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University School of Oncology, Beijing Cancer Hospital and Institute, Beijing, China
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Chen SB, Weng HR, Wang G, Zou XF, Liu DT, Chen YP, Zhang H. Lymph node ratio-based staging system for esophageal squamous cell carcinoma. World J Gastroenterol 2015; 21:7514-7521. [PMID: 26139998 PMCID: PMC4481447 DOI: 10.3748/wjg.v21.i24.7514] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 01/06/2015] [Accepted: 03/19/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze a modified staging system utilizing lymph node ratio (LNR) in patients with esophageal squamous cell carcinoma (ESCC).
METHODS: Clinical data of 2011 patients with ESCC who underwent surgical resection alone between January 1995 and June 2010 at the Cancer Hospital of Shantou University Medical College were reviewed. The LNR, or node ratio (Nr) was defined as the ratio of metastatic LNs ompared to the total number of resected LNs. Overall survival between groups was compared with the log-rank test. The cutoff point of LNR was established by grouping patients with 10% increment in Nr, and then combining the neighborhood survival curves using the log-rank test. A new TNrM staging system, was constructed by replacing the American Joint Committee on Cancer (AJCC) N categories with the Nr categories in the new TNM staging system. The time-dependent receiver operating characteristic curves were used to evaluate the predictive performance of the seventh edition AJCC staging system and the TNrM staging system.
RESULTS: The median number of resected LNs was 12 (range: 4-44), and 25% and 75% interquartile rangeswere8 and 16. Patients were classified into four Nr categories with distinctive survival differences (Nr0: LNR = 0; Nr1: 0% < LNR ≤ 10%; Nr2: 10% < LNR ≤ 20%; and Nr3: LNR > 20%). From N categories to Nr categories, 557 patients changed their LN stage. The median survival time (MST) for the four Nr categories (Nr0-Nr3) was 155.0 mo, 39.0 mo, 28.0 mo, and 19.0 mo, respectively, and the 5-year overall survival was 61.1%, 41.1%, 33.0%, and 22.9%, respectively (P < 0.001). Overall survival was significantly different for the AJCC N categories when patients were subgrouped into 15 or more vs fewer than 15 examined nodes, except for the N3 category (P = 0.292). However, overall survival was similar when the patients in all four Nr categories were subgrouped into 15 or more vs fewer than 15 nodes. Using the time-dependent receiver operating characteristic, we found that the Nr category and TNrM stage had higher accuracy in predicting survival than the AJCC N category and TNM stage.
CONCLUSION: A staging system based on LNR may have better prognostic stratification of patients with ESCC than the current TNM system, especially for those undergoing limited lymphadenectomy.
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Ravishankaran P, Krishnamurthy A. Prognostic value of metastatic lymph nodal ratio in squamous cell carcinoma of esophagus: A three-step extrapolative study. South Asian J Cancer 2014; 3:213-6. [PMID: 25422807 PMCID: PMC4236699 DOI: 10.4103/2278-330x.142976] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background: Transthoracic esophagectomy (TTE) and transhiatal esophagectomy (THE) are the two most common surgical approaches for carcinoma esophagus. Several studies have shown lymph nodal involvement to be one of the most important prognostic factors in carcinoma esophagus. Aims: The primary objective of this study was to explore the effectiveness of the ratio of positive lymph nodes to excised lymph nodes, namely the metastatic lymph nodal ratio (MLNR) as a prognostic factor in the survival of patients with carcinoma esophagus. Settings and Design: Retrospective analysis of a prospective database. Materials and Methods: A review of the operated esophageal cancer patients treated at a tertiary cancer center in South India between January 2002 and December 2006. Statistical analysis was done with the help of SPSS version 17 software (SPSS Inc., Chicago, IL). Proportions were compared using the Chi-square test. Survival data was generated using life table methods. Differences in survival estimates were compared using log-rank test. Results and Conclusions: Our study emphatically showed that the survival outcomes of patients with squamous cell carcinoma of the esophagus can be discriminated based on the MLNR groups, and it can be a reliable prognostic indicator. The overall survival for patients undergoing TTE, or THE for the entire cohort of patients was however not statistically significant. Whether a more aggressive TTE is a better esophageal cancer operation or whether MLNR is the factor that can significantly impact survival regardless of the technique is an issue that would require further investigation.
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Affiliation(s)
- Praveen Ravishankaran
- Departments of Surgical Oncology, Cancer Institute, Adyar, Chennai, Tamil Nadu, India
| | - Arvind Krishnamurthy
- Departments of Surgical Oncology, Cancer Institute, Adyar, Chennai, Tamil Nadu, India
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16
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Significance of the absolute number and ratio of metastatic lymph nodes in predicting postoperative survival for the International Federation of Gynecology and Obstetrics stage IA2 to IIA cervical cancer. Int J Gynecol Cancer 2013; 23:157-63. [PMID: 23221732 DOI: 10.1097/igc.0b013e3182778bcf] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
PURPOSE This study aimed to evaluate the ratio of metastatic and removed lymph nodes (RPL) and the number of metastatic lymph nodes (MLNs) in predicting postoperative survival for International Federation of Gynecology and Obstetrics stage IA2 to IIA cervical cancer after radical hysterectomy and pelvic lymphadenectomy (RHPL). METHODS A retrospective study was conducted in which 120 patients with lymph node metastasis who underwent RHPL for cervical cancer from 2000 to 2006 was analyzed to identify the prognostic indicators by using Kaplan-Meier and Cox proportional hazard methods. RESULTS Of 588 patients with cervical cancer who underwent RHPL, the 5-year survival rate (YSR) of 120 with lymph node metastasis was much lower than that of 468 without lymph node metastasis (22.4% vs 84.4%, P < 0.001). By cut-point survival analysis, RPL cutoff was designed as 10%, with the 5-YSR of 42.9% and 11.8%, and MLN count cutoffs were designed as 1 and 5, with the 5-YSR of 62.5%, 20.8%, and 7.8%, respectively. With univariate analysis, increasing RPL and MLN counts were associated with a poorer survival in women with node metastasis cervical cancers. Stage, histologic grade, RPL, and MLN count were significant independent prognostic factors for survival in a multivariate Cox proportional hazard model. In addition, RPL was verified superior to MLN count in prognostic evaluation for patients with IA2 to IIA cervical cancer after RHPL because the hazard ratio of RPL (3.195) was higher than that of MLN count (1.578). CONCLUSIONS The RPL and MLN count may be used as the independent prognostic parameters in patients with cervical cancer with lymph node metastasis after RHPL. Comparison of the superiority of RPL and MLN count for better predicting the survival of patients with cervical cancer deserves to be investigated further.
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Vignesh S, Hoffe SE, Meredith KL, Shridhar R, Almhanna K, Gupta AK. Endoscopic Therapy of Neoplasia Related to Barrett's Esophagus and Endoscopic Palliation of Esophageal Cancer. Cancer Control 2013; 20:117-29. [DOI: 10.1177/107327481302000205] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Barrett's esophagus (BE) is the most important identifiable risk factor for the progression to esophageal adenocarcinoma. Methods This article reviews the current endoscopic therapies for BE with high-grade dysplasia and intramucosal cancer and briefly discusses the endoscopic palliation of advanced esophageal cancer. Results The diagnosis of low-grade or high-grade dysplasia (HGD) is based on several cytologic criteria that suggest neoplastic transformation of the columnar epithelium. HGD and carcinoma in situ are regarded as equivalent. The presence of dysplasia, particularly HGD, is also a risk factor for synchronous and metachronous adenocarcinoma. Dysplasia is a marker of adenocarcinoma and also has been shown to be the preinvasive lesion. Esophagectomy has been the conventional treatment for T1 esophageal cancer and, although debated, is an appropriate option in some patients with HGD due to the presence of occult cancer in over one-third of patients. Conclusions Endoscopic ablative modalities (eg, photodynamic therapy and cryoablation) and endoscopic resection techniques (eg, endoscopic mucosal resection) have demonstrated promising results. The significant morbidity and mortality of esophagectomy makes endoscopic treatment an attractive potential option.
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Affiliation(s)
| | - Sarah E. Hoffe
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | | | - Ravi Shridhar
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | | | - Akshay K. Gupta
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Ovrebo KK, Lie SA, Laerum OD, Svanes K, Viste A. Long-term survival from adenocarcinoma of the esophagus after transthoracic and transhiatal esophagectomy. World J Surg Oncol 2012; 10:130. [PMID: 22747995 PMCID: PMC3476969 DOI: 10.1186/1477-7819-10-130] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 05/07/2012] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The effects of transthoracic or transhiatal esophagectomy on the long-term survival of patients who had adenocarcinoma of the esophagus were compared, as were factors applicable in preoperative stratification of patient treatment. METHODS A cohort of 147 consecutive patients with adenocarcinoma of the esophagus was evaluated for esophagectomy between 1984 and 2000. The patients were followed prospectively and observed survival rates of patients with a transthoracic or transhiatal approach to esophagectomy were compared by standardized mortality ratio (SMR) and relative mortality ratio (RMR) using the expected survival of a matched Norwegian population. RESULTS A R0 resection was performed by transthoracic (n = 33) or a transhiatal (n = 55) esophagectomy in 88 (60%) patients with a median age of 61 (range: 35-77) and 70 (42-88) years, respectively (P <0.001). Tumor stages and other possible risk factors were similar in the two groups. Transthoracic or transhiatal esophagectomy resulted in a median survival time of 20.5 (95% confidence interval (CI): 10.4-57.6) and 16.4 (10.6-28.7) months, respectively. The respective survival rates were 31.2% and 27.8% by 5 years, and 21.3% and 16.6% by 10 years with an overall RMR of 1.14 (P = 0.63). Median survival time in the absence or presence of lymph node metastases was 74.0 (95% CI: 17.5-166.4) and 10.7 (7.9-14.9) months. The corresponding survival rates by 10 years with non-involved or involved nodes were 48.9% and 3.8% respectively (RMR 2.22, P = 0.007). Patients with a pT1-tumor were few and the survival rate was not very different from that of the general population (SMR = 1.7, 95% CI: 0.7-4.1). The median survival time of patients with a pT2-tumor was 30.4 (95% CI: 9.0-142) months and with a pT3-tumor 14 (9.2-16.4) months. The survival rates by 10 years among patients with a pT1 tumor were 57.0% (95% CI: 14.9-78.9), pT2 33.3% (11.8-52.2), and pT3 7.1% (1.9-15.5). The relative mortality for T3 stages compared to T1 stages was statistically significant (RMR = 3.22, P = 0.024). CONCLUSION Transthoracic and transhiatal esophagectomy are both effective approaches for treatment of adenocarcinoma of the esophagus and survival of more than 10 years can be expected without adjuvant chemotherapy. However, increasing depth of tumor invasion and lymph node metastases reduce life expectancy.
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Affiliation(s)
- Kjell K Ovrebo
- Department of Surgery, Haukeland University Hospital, Bergen 5021, Norway.
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Stiles BM, Nasar A, Mirza FA, Lee PC, Paul S, Port JL, Altorki NK. Worldwide Oesophageal Cancer Collaboration guidelines for lymphadenectomy predict survival following neoadjuvant therapy. Eur J Cardiothorac Surg 2012; 42:659-64. [PMID: 22491667 DOI: 10.1093/ejcts/ezs105] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES The Worldwide Oesophageal Cancer Collaboration (WECC) reported recommendations regarding the optimum number of lymph nodes to be removed during oesophagectomy based upon patients undergoing surgery alone. We sought to determine whether these recommendations are relevant in the case of oesophageal cancer (EC) patients receiving neoadjuvant therapy. METHODS Patients undergoing neoadjuvant chemotherapy followed by transthoracic en bloc oesophagectomy were reviewed. Patients were grouped by optimal versus suboptimal lymphadenectomy per WECC recommendations (pTis/T0/T1 ≥ 10; pT2 ≥ 20; pT3/T4 ≥ 30). Cohorts were compared for factors predicting optimal lymphadenectomy and for overall survival (OS). RESULTS During the time period, 135 patients (adeno = 100, squamous = 35) met the study criteria, of whom 94 patients (70%) had optimal lymphadenectomy. Optimal lymphadenectomy was more likely for tumours with lower ypT (P ≤ 0.001). Optimal lymphadenectomy predicted the OS (0.50, confidence intervals 0.29-0.85, P = 0.011), although it was collinear with ypT classification, which was also predictive. Patients not down-staged in ypT (n = 66, 49%) particularly experienced a trend towards improved 3-year survival with optimal lymphadenectomy (51 versus 29%, P = 0.144). Similarly, of patients with persistent nodal disease (n = 79, 59%), those who had optimal lymphadenectomy (n = 51) experienced improved 3-year OS compared with those with suboptimal lymphadenectomy (n = 28), (55 versus 36%, P = 0.087). CONCLUSIONS WECC recommendations regarding lymphadenectomy for EC may be applicable to patients undergoing oesophagectomy following neoadjuvant therapy, particularly those who are not down-staged by pathological tumour depth (T) classification and those with persistent nodal metastases. Techniques to enhance the extent of LAN should be pursued in this patient population.
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Affiliation(s)
- Brendon M Stiles
- Division of Thoracic Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York 10021, USA.
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Reeh M, Nentwich MF, von Loga K, Schade J, Uzunoglu FG, Koenig AM, Bockhorn M, Rosch T, Izbicki JR, Bogoevski D. An attempt at validation of the Seventh edition of the classification by the International Union Against Cancer for esophageal carcinoma. Ann Thorac Surg 2012; 93:890-6. [PMID: 22289905 DOI: 10.1016/j.athoracsur.2011.11.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Revised: 11/13/2011] [Accepted: 11/14/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of our study was to investigate the ability of the Seventh edition of the classification by the International Union Against Cancer (UICC) to identify patients at higher risk and to predict the overall survival in patients with esophageal carcinoma. METHODS Demographic and clinical data of 605 patients, who underwent esophagectomy for esophageal carcinoma between 1992 and 2009, were analyzed. Tumor stage and grade were classified according to the sixth and seventh editions of the UICC classification. RESULTS Tumor depth (T), lymph node affection (N), and metastasis (M) status according to the seventh edition of the UICC classification showed significant differences in survival of each single status. Kaplan-Meier analysis of overall survival by the seventh edition of the UICC classification showed poor discrimination between stages Ib and IIa (p=0.098), stages IIIa and IIIb (p=0.672), and stages IIIc and IV (p=0.799). Further, the estimated median survival time between stages IIa and IIb was discordant. CONCLUSIONS The seventh edition of the UICC TNM classification cannot satisfactorily distinguish among different risk groups of patients with resected esophageal carcinoma. The new subgroups do not unify the different TNM stages with similar survival. We strongly propose that the next revision of the UICC classification should reduce the stages to groups with similar survival, without defining complex subgroups.
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Affiliation(s)
- Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
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Kayani B, Zacharakis E, Ahmed K, Hanna GB. Lymph node metastases and prognosis in oesophageal carcinoma--a systematic review. Eur J Surg Oncol 2011; 37:747-53. [PMID: 21839394 DOI: 10.1016/j.ejso.2011.06.018] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2010] [Revised: 02/09/2011] [Accepted: 06/28/2011] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- B Kayani
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, Praed Street, London W2 1NY, UK
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Stiles BM, Mirza F, Coppolino A, Port JL, Lee PC, Paul S, Altorki NK. Clinical T2-T3N0M0 esophageal cancer: the risk of node positive disease. Ann Thorac Surg 2011; 92:491-6; discussion 496-8. [PMID: 21704291 DOI: 10.1016/j.athoracsur.2011.04.004] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 03/29/2011] [Accepted: 04/01/2011] [Indexed: 12/31/2022]
Abstract
BACKGROUND No consensus exists on the optimal treatment strategy for clinical T2-T3N0M0 esophageal cancer. This study was conducted to determine rates of nodal positivity (N+) and to evaluate results of treatment strategies in this cohort. METHODS Surgically treated patients with cT2-T3N0M0 esophageal cancer were reviewed. Adequacy of lymph node dissection was assessed by guidelines applied to clinical stage. Survival was determined by Kaplan-Meier analysis. Univariate and multivariate analyses were done for predictors of N+ and survival. RESULTS We identified 102 patients, 51 cT2N0 and 51 cT3N0, 39 (38%) of whom had induction therapy. Despite being clinically node negative, 61 patients (60%) had nodal metastases. Applied to cT classification, adequate nodal dissection was achieved in 64 patients (63%). Transthoracic esophagectomy was more likely than transhiatal esophagectomy to achieve adequate nodal dissection (69% versus 31%, p=0.005). Adequate nodal dissection was more likely to document pN+ disease in both the surgery alone group (70% versus 50%, p=0.13) and induction therapy group (71% versus 33%, p=0.02). Five-year overall survival was 44% with surgery alone and 55% with induction therapy. On multivariate analysis, pN+ was the strongest predictor of overall survival (relative risk 2.73, confidence interval: 1.29 to 5.78). CONCLUSIONS Most cT2-T3N0M0 patients have pN+ disease. Despite induction therapy, more than 50% have persistent nodal disease. Transthoracic esophagectomy is more likely to detect pN+ disease and more likely to meet criteria of adequate nodal dissection than is transhiatal esophagectomy. Therefore, the majority of patients with cT2-T3N0M0 should be considered for neoadjuvant protocols and should be treated by transthoracic resection whenever possible.
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Affiliation(s)
- Brendon M Stiles
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York 10021, USA.
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Ratio of metastatic lymph nodes to total number of nodes resected is prognostic for survival in esophageal carcinoma. J Thorac Oncol 2010; 5:1467-71. [PMID: 20812404 DOI: 10.1097/jto.0b013e3181e8f6b1] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The role of the number of metastatic nodes in esophageal cancer surgery is of interest. We assess predictors of survival after oesophagectomy for esophageal and gastroesophageal junction malignancy. METHODS Prospective data of consecutive patients undergoing oesophagectomy and systematic lymphadenectomy between 1991 and 2007. RESULTS Of 224 patients, 148 patients (66%) had adenocarcinoma, 70 (31%) squamous cell carcinoma, and 6 (2.6%) were other tumor types. Five-year survival was 43% with hospital mortality of 3.5%. Locoregional recurrence occurred in 14%. The total number of affected nodes significantly reduced survival (four or more metastatic nodes). Further analysis of the ratio of nodes affected to the total number resected showed a significant decrease in survival as the percentage of positive nodes increased (p < 0.001). CONCLUSIONS Patients undergoing surgery for esophageal cancer should be staged according to a minimum total number of metastatic lymph nodes and ratios because this more accurately predicts survival than current staging systems.
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Pines G, Klein Y, Buyeviz V, Idelevich E, Kashtan H. Disease-Related Mortality within the First Year after Subtotal Esophagectomy for Cancer. Ann Surg Oncol 2010; 18:1139-44. [DOI: 10.1245/s10434-010-1386-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2009] [Indexed: 11/18/2022]
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Abstract
Although studies differ in their definition of the older patient, increasing age, when considered as a continuum, is associated with greater operative mortality. Complication rates also seem to be significantly higher with advancing age, possibly because of limited physiologic reserve. As the understanding of risk factors for perioperative morbidity and mortality following esophagectomy has improved, investigators have sought to develop models for risk stratification in which patient age is a significant but not the sole determinant of prospective assessment of risk for complication or mortality. Such prognostic indicators, if validated among independent patient cohorts, can serve as useful adjuncts in decision making with appropriate clinical judgment. In addition, reported patient survival differs dramatically between rates reported by single centers and rates observed in population-based studies, with operative mortality rates typically lower in single-center reports. Although such reports usually are issued from groups with higher operative volume that might be a surrogate for surgical experience, it also is possible that the association between operation volume and improved outcomes reflects optimization of institution-specific infrastructure and/or clinical care pathways. As these processes of care evolve, they should be tailored with attention to differences in the care of older patients who have esophageal cancer. Whether widespread application of such processes of care then can lead to less perioperative mortality and fewer complications and to improved long-term survival remains untested.
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Affiliation(s)
- Andrew C Chang
- Section of General Thoracic Surgery, University of Michigan Health Systems, TC2120G/5344, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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Prognostic value of lymph node metastases and lymph node ratio in esophageal squamous cell carcinoma. Eur J Surg Oncol 2009; 36:155-9. [PMID: 19854606 DOI: 10.1016/j.ejso.2009.09.005] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2008] [Revised: 09/09/2009] [Accepted: 09/17/2009] [Indexed: 02/07/2023] Open
Abstract
AIMS Although the positive lymph node (LN) metastasis in patients with thoracic esophageal squamous cell carcinoma carcinoma (SCC) has been reported to be a risk factor to reduce long-term survival, only a few studies have so far evaluated the lymph node metastasis among this group of patients. The purpose of this study was to evaluate the impact of lymph node positivity and ratio on survival of esophageal SCC. METHODS All patients undergoing esophagectomy at the Forth Hospital of Hebei Medical University between January 1986 and December 2002 were reviewed. Survival curves were estimated using the Kaplan-Meier method. RESULTS Of 1,325 patients with invasive cancer, had squamous cell cancer of the esophagus. Median overall survival (OS) of the entire group was 36.7 months and 5-year OS was 39.3%. The most significant prognostic factor for overall survival was the presence of positive LN (P<0.01). Additionally, patients with zero involved LN had a 5-year survival of 49.1%, while patients with 1-3 positive LN and >3 positive LN had 5-year survival of 19.5% and 11.0%, respectively (P<0.01). Finally, an increasing ratio of positive to examined LN was linearly associated with a worsening 5-year survival, patients with <25%, 25%-50% and >50% positive LN had 5-year survival of 47.53%, 14.6% and 8.9%, respectively (P<0.01). CONCLUSION Increasing number of positive LN in patients with esophageal cancer and increasing ratio of metastatic to examine LN portend a poor prognosis. These factors should play an important role in predicting prognosis of patients.
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Prognostic significance of SUV on PET/CT in patients with esophageal cancer: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2009; 21:1008-15. [PMID: 19352191 DOI: 10.1097/meg.0b013e328323d6fa] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Esophageal cancer is the third most common gastrointestinal malignancy with a poor long-term survival and high mortality. Surgical resection provides the only chance of cure. The tumor-node metastasis stage classification system is a strong prognostic parameter predicting the prognosis. We performed the present meta-analysis to comprehensively review the evidence for use of standardized uptake value (SUV) measured on tumor to predict prognosis of esophageal cancer. METHODS We searched for articles published in English or Chinese; limited to esophageal cancer; F-fluoro-2-deoxy-glucose (F-FDG) uptake on positron emission tomography (PET) performed on a dedicated device; dealt with the impact of SUV on survival. We extracted an estimate of the log hazard ratios (HR) and their variances and performed meta-analysis. RESULTS Without the study dealt by the pretreatment SUV measured on metastasis sites, there were seven studies dealt by the prognostic value of SUV measured on FDG-PET for overall survival. The combined HR was 1.86, meaning that high SUV indicated worse survival prognosis; and there were three studies dealt with the prognostic value of SUV measured on FDG-PET for disease-free survival. The combined HR was 2.52, indicating that high SUV was associated with more significantly higher risk for recurrence than low SUV. CONCLUSION SUV measured in patients with esophageal cancer, reflecting the metabolic activity of tumor and malignancy, could serve as a prognostic factor. Considering that the FDG-PET can add important information of metabolism in detection and staging to conventional imaging modality, we anticipate that SUV could be used in patients with esophageal carcinoma.
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Peters CJ, Hardwick RH, Vowler SL, Fitzgerald RC. Generation and validation of a revised classification for oesophageal and junctional adenocarcinoma. Br J Surg 2009; 96:724-33. [PMID: 19526624 DOI: 10.1002/bjs.6584] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Oesophageal adenocarcinoma is the commonest oesophageal malignancy in the West, but is staged using a system designed for squamous cell carcinoma. The aim was to develop and validate a staging system for oesophageal and junctional adenocarcinoma. METHODS Patients with oesophageal adenocarcinoma (Siewert types I and II) undergoing oesophagectomy with curative intent were randomly assigned to generation (313 patients) and validation (131) data sets. Outcome in the generation data set was associated with histopathological features; a revised node (N) classification was derived using recursive partitioning and tested on the validation data set. RESULTS A revised N classification based on number of involved lymph nodes (N0, none; N1, one to five; N2, six or more) was prognostically significant (P < 0.001). Patients with involved nodes on both sides of the diaphragm, regardless of number, had the same outcome as the N2 group. When applied to the validation data set, the revised classification (including nodal number and location) provided greater discrimination between node-positive patients than the existing system (P < 0.001). CONCLUSION A revised N classification based on number and location of involved lymph nodes provides improved prognostic power and incorporates features that may be useful before surgery in clinical management decisions.
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Affiliation(s)
- C J Peters
- Medical Research Council (MRC) Cancer Cell Unit, Hutchison/MRC Research Centre, Cambridge, UK
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Extracapsular Lymph Node Involvement Is a Negative Prognostic Factor After Neoadjuvant Chemoradiotherapy in Locally Advanced Esophageal Cancer. J Thorac Oncol 2009; 4:534-9. [DOI: 10.1097/jto.0b013e31819c862d] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Esophageal cancer is the third most common malignancy of the alimentary tract. The incidence of esophageal cancer has steadily increased over the past three decades. Almost all therapeutic modalities for esophageal cancer are associated with a considerable mortality and morbidity. Consequently, there has been growing concern regarding effective management of esophageal cancer. 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) is playing an increasing role in the management of esophageal cancer, offering potential advantages in the accuracy of disease assessment at a number of decision points in the management pathway. This review evaluates the critical role of FDG-PET in (i) diagnosis, (ii) preoperative staging, (iii) monitoring of response to neoadjuvant therapy, (iv) assessment of recurrence and (v) prediction of prognosis of esophageal cancer. We have also compared diagnostic performance of FDG-PET and other current technologies such as computed tomography scan and endoscopic ultrasonography based on available evidence.
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Scheepers JJG, van der Peet DL, Veenhof AAFA, Cuesta MA. Influence of circumferential resection margin on prognosis in distal esophageal and gastroesophageal cancer approached through the transhiatal route. Dis Esophagus 2009; 22:42-8. [PMID: 19196265 DOI: 10.1111/j.1442-2050.2008.00898.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We studied the influence of circumferential resection margin (CRM) involvement on survival in patients with malignancies of the distal esophagus and gastroesophageal junction. One hundred ten consecutive patients undergoing a laparoscopic or open transhiatal esophagectomy for malignancy of the distal 5 cm of the esophagus, or a Siewert I gastroesophageal junction tumor were analyzed, retrospectively. Only patients with potentially resectable tumors were included. CRM status was defined as clear or involved (microscopic tumor within 1 mm of the resection margin). Statistical analysis was done by means of univariate and multivariate analysis using the Kaplan-Meier method and Cox proportional hazard model. One hundred ten patients were analyzed. Sixty patients underwent open transhiatal esophagectomy, and 50 patients underwent laparoscopic transhiatal esophagectomy. There were 6 (5%) T(1), 18 (16%) T(2), and 86 (89%) T(3) tumors. CRM was clear in 68 (62%) patients and involved in 42 (38%) patients. Median survival in these groups was 50 vs. 20 months (P = 0.000). Since CRM involvement was only seen in T(3) tumors, this group was analyzed in detail. Median survival in the T(3)CRM(-) and T(3)CRM(+) group was 33 vs. 19 months (P = 0.004). For T(3)N(0) tumors, median survival in CRM(-) and CRM(+) was 40 and 22 months, respectively (P = 0.036). Median survival for T(3)N(1) tumors in CRM(-) and CRM(+) was 22 and 13 months, respectively (P = 0.049). Involvement of the circumferential resection margin was found to be an independent prognostic factor on survival in our study. It predicts a poor prognosis in patients with potentially resectable malignancies of the distal 5 cm of the esophagus and Siewert I adenocarcinomas of the gastro esophageal junction.
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Affiliation(s)
- J J G Scheepers
- Department of Surgery, Vrije Universiteit Medical Center (VUmc), Amsterdam, The Netherlands.
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Lu JC, Tao H, Chen ZZ, Qian PD. Prognostic factors of radiotherapy in patients with node-positive thoracic esophageal squamous cell carcinoma after radical surgery. Dis Esophagus 2009; 22:490-5. [PMID: 19191849 DOI: 10.1111/j.1442-2050.2008.00936.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The aim of this study was to retrospectively analyze and assess the outcomes and prognostic factors of radiotherapy in patients with node-positive thoracic esophageal squamous cell carcinoma after radical surgery. One hundred twenty-six patients with node-positive thoracic esophageal squamous cell carcinoma who had undergone adjuvant therapy (postoperative radiotherapy alone or postoperative sequential chemoradiotherapy without receiving postoperative concurrent chemoradiotherapy) after radical surgery, were retrospectively reviewed from January 1996 to December 2003. Univariate and multivariate analyses were performed using log-rank and Cox proportional hazard models, and survival curves were estimated using the Kaplan-Meier method. The 1-, 3- and 5-year overall survival rates of all 126 patients were 71.4, 39.1, and 22.0%, and disease-free survival rates were 64.3, 36.4, and 21.5%, respectively. Lymph node ratio (the ratio of the number of metastatic lymph nodes to the number of lymph nodes removed, LNR) > or = 0.2 (P= 0.006), pT3 + pT4 (P= 0.06) and sequential chemoradiotherapy (P= 0.08) were associated with a poorer survival by univariate analysis. In multivariate analysis, LNR (P= 0.01, hazard ratio = 0.57, 95% confidence interval, 0.37-0.87) and tumor depth of invasion (P= 0.03, hazard ratio = 0.62, 95% confidence interval, 0.41-0.96) were the independent predictors of survival. Sequential chemoradiotherapy receded survival tendency without significant difference (P= 0.09, hazard ratio = 0.64, 95% confidence interval, 0.37-1.08). Therefore, LNR and tumor depth of invasion were the independent prognostic factors of radiotherapy in patients with node-positive thoracic esophageal squamous cell carcinoma after radical surgery. The addition of chemotherapy does not seem to confer a survival benefit.
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Affiliation(s)
- Jin-Cheng Lu
- Department of Radiotherapy, Jiangsu Cancer Hospital, Nanjing 210009, China.
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WHITFIELD GA, JACKSON A, MOORE C, PRICE P. Radical chemoradiotherapy for adenocarcinoma of the distal oesophagus and oesophagogastric junction: what planning margins should we use? Br J Radiol 2008; 81:921-34. [DOI: 10.1259/bjr/23903754] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Koenig AM, Prenzel KL, Bogoevski D, Yekebas EF, Bubenheim M, Faithova L, Vashist YK, Gawad KA, Baldus SE, Pantel K, Schneider PM, Hölscher AH, Izbicki JR. Strong impact of micrometastatic tumor cell load in patients with esophageal carcinoma. Ann Surg Oncol 2008; 16:454-62. [PMID: 19015923 DOI: 10.1245/s10434-008-0169-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2007] [Revised: 08/22/2008] [Accepted: 08/23/2008] [Indexed: 01/26/2023]
Abstract
BACKGROUND To assess the role of immunohistochemically detectable nodal microinvolvement of patients with "curatively" resected esophageal carcinoma. METHODS In 73 patients with resectable esophageal carcinoma [squamous cell carcinoma (SCC), n = 45 (61.6%); adenocarcinoma (AC), n = 28 (38.4%)] a total of 2174 lymph nodes (LN) were removed. In each of the 1958 LN classified as negative on conventional histopathology, immunohistochemistry was performed using the anticytokeratin antibody AE1/AE3. To determine the role of the amount of residual tumor load, the patients were grouped according to the percentage of LN affected with micrometastasis (0%, <11%, and > or =11%). RESULTS Tumor cells were immunohistochemically detected in 47 LN (2.4%) from 25 (34.2%) patients. Five-year overall survival probability (5-YSP) of 30% in pN(0 )patients with detected occult tumor cells in LN was significantly worse than that in those without nodal microinvolvement (76%, P = 0.021), hereby resembling that of pN1-patients (24%, P = 0.84). Median overall survival in patients with no (0%), low (<11%), and high (>11%) micrometastatic tumor load was 43, 27, and 11 months, respectively. Substratification according to histological type showed that, in patients with AC, the presence of nodal microinvolvement had a significant impact on 5-YSP (0% versus 65%; P = 0.03), whereas in patients with SCC, differences of 5-YSP were only of borderline significance (24% versus 53%; P = 0.081). CONCLUSION Minimal tumor cell load as assessed by the ratio of micrometastatically affected LN is a complementary tool for better risk stratification of patients with esophageal carcinoma.
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Affiliation(s)
- Alexandra M Koenig
- Department of General, Visceral and Thoracic Surgery, University Medical Centre of Hamburg-Eppendorf, Germany.
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Abstract
PURPOSE To investigate the importance of lymph node yield (LNY) and the ratio of afflicted lymph nodes in esophageal carcinoma patients. PATIENTS AND METHODS Between 1992 and 2004, 368 patients with esophageal carcinoma underwent surgery. Esophagectomy with curative intent was performed in 255 patients. Subtotal esophagectomy was performed either by thoracoabdominal (104 patients, 40.8%) or by transhiatal approach (151 patients, 59.2%). RESULTS According to the LNY, patients were grouped into 3 groups. Twenty-six patients had < or =5, 96 had 6 to 18, and 113 had > or =19 dissected lymph nodes. In patients with nodal involvement (pN1), no significant overall survival differences were identified when stratifying subgroups according to the LNY. However, LNY had striking prognostic relevance in pN0 patients. The median overall survival was 23 (< or =5 LN), 36 (6-18 LN), and 88 months (> or =19). Even for patients with tripled LNY than the proposed minimum by the International Union Against Cancer (UICC) (18 LN), the rate of patients with detected lymph node metastases was only 46%, compared with 61% for patients with a LNY of > or =19 (P = 0.002). In pN1 patients classified according to the ratio of afflicted lymph nodes, median overall survival was 27 months in patients with a ratio <11%, compared with 15 and 13 months in patients with a ratio of 11% to 33% and >33%, respectively (P < 0.001). Multivariate Cox regression modeling identified ratio as the strongest independent prognostic factor for overall survival in pN1 and the LNY in pN0 patients. CONCLUSIONS The minimal regional LNY of 6 lymph nodes as recommended by the UICC for esophageal carcinoma is far too low to appropriately stage the disease. The LNY and the ratio should be reflected in the next version of the UICC classification.
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Greenstein AJ, Litle VR, Swanson SJ, Divino CM, Packer S, Wisnivesky JP. Effect of the number of lymph nodes sampled on postoperative survival of lymph node-negative esophageal cancer. Cancer 2008; 112:1239-46. [PMID: 18224663 DOI: 10.1002/cncr.23309] [Citation(s) in RCA: 169] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The presence of lymph node (LN) metastases in esophageal cancer has important prognostic and treatment implications. However, the optimal number of LNs that should be examined for accurate staging is controversial. In the current study, the association between survival and the number of LNs evaluated was examined in patients who underwent resection of lymph node-negative (American Joint Committee on Cancer [AJCC] TNM stage I-IIA) esophageal cancer. METHODS All patients were identified who underwent surgery for lymph node-negative esophageal cancer between 1988 and 2003 from the Surveillance, Epidemiology, and End Results cancer registry. Patients were classified into 3 groups by the number of negative LNs sampled during surgery (<or=10 LNs, 11-17 LNs, and>or=18 LNs). Esophageal cancer-specific survival was compared among these LN groups using Kaplan-Meier curves. Stratified and Cox regression analyses were used to evaluate the association between survival and the number of negative LNs after adjusting for potential confounders. RESULTS A total of 972 patients were included in the study. Disease-specific survival rates increased with a higher number of negative LNs. The 5-year disease-specific survival rate was 55% among patients with<or=10 negative LNs, compared with 66% and 75%, respectively, for those with 11 to 17 negative LNs and>or=18 negative LNs. The number of negative LNs was found to be significantly associated with survival in analyses stratified by tumor status. On multivariate regression controlling for age, race/ethnicity, sex, histology, tumor status, and postoperative radiotherapy, a higher number of negative LNs was found to be independently associated with higher disease-specific survival. CONCLUSIONS The presence of LN metastases in patients with esophageal cancer appears to have important prognostic and treatment implications. Data from the current study suggest that patients undergoing surgical resection for esophageal cancer should have at least 18 LNs removed.
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Affiliation(s)
- Alexander J Greenstein
- Department of General Surgery, Mount Sinai School of Medicine, New York, New York 10029, USA
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The number of metastatic lymph nodes and the ratio between metastatic and examined lymph nodes are independent prognostic factors in esophageal cancer regardless of neoadjuvant chemoradiation or lymphadenectomy extent. Ann Surg 2008; 247:365-71. [PMID: 18216546 DOI: 10.1097/sla.0b013e31815aaadf] [Citation(s) in RCA: 315] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate whether the number of lymph nodes metastasis (LNMs) and the ratio between metastatic and examined lymph nodes (LNs) are better prognostic factors when compared with traditional staging systems in patients with esophageal carcinoma. SUMMARY BACKGROUND DATA The accuracy of the 6th UICC/TNM classification is suboptimal, especially when not taking into account neoadjuvant therapy and lymphadenectomy extent. METHODS For 536 patients who underwent curative en bloc esophagectomy, in whom 51.5% (n = 276) received neoadjuvant chemoradiation, LNMs were classified according to the 6th UICC/TNM classification and systems based on the number (< or =4 and >4) or the ratio (< or =0.2 and >0.2) of LNMs. Survival of the respective stages, predictors of survival, and influence of both chemoradiation and number of examined LNs were studied. RESULTS After a median follow-up of 50 months, the 5-year survival rates were 47% for the entire population, significantly poorer for patients with >4 LNMs (8% vs. 53%, P < 0.001) or a ratio of LNMs >0.2 (22% vs. 54%, P < 0.001). After adjustment for confounding variables, a number of LNMs >4 and a ratio of LNMs >0.2 were the only predictors of poor prognosis. The prognostic role of both the number and the ratio of LNMs was maintained whether patients received neoadjuvant chemoradiation or not. Moreover, LN ratio is shown to be more accurate for inadequately staged patients (<15 examined LNs), whereas the number of LNMs is pertinent for adequately staged patients (> or =15 examined LNs). CONCLUSION Staging systems for esophageal cancer that use the number (< or =4 or >4) and the ratio (< or =0.2 or >0.2) of LNMs have greater prognostic importance than the current staging systems because of the good stratification of the groups and their clinical utility, taking into account neoadjuvant therapy and lymphadenectomy extent.
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Chang AC, Ji H, Birkmeyer NJ, Orringer MB, Birkmeyer JD. Outcomes after transhiatal and transthoracic esophagectomy for cancer. Ann Thorac Surg 2008; 85:424-9. [PMID: 18222237 DOI: 10.1016/j.athoracsur.2007.10.007] [Citation(s) in RCA: 180] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2007] [Revised: 10/01/2007] [Accepted: 10/02/2007] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although single-center series evaluating esophagectomy for cancer have demonstrated that this operation can be performed safely and with excellent outcomes, controversy remains regarding the comparable oncologic efficacy of the transhiatal and transthoracic approaches. This study was performed to determine outcomes after transhiatal and transthoracic esophagectomy for patients undergoing resection nationwide. METHODS Using the Surveillance, Epidemiology, and End Results-Medicare linked database (1992 to 2002), we identified registered patients undergoing esophagectomy for esophageal cancer. We evaluated operative mortality, late survival, and length of stay while adjusting for patient characteristics, tumor grade, and stage. As a surrogate for postoperative quality of life, we also assessed subsequent need for anastomotic dilation. RESULTS Of 868 patients undergoing either approach, for whom distinct Current Procedural Technology codes could be identified, 225 underwent transhiatal and 643 received transthoracic esophagectomy. Lower operative mortality rate was observed after a transhiatal than transthoracic approach (6.7% versus 13.1%, p = 0.009). Observed 5-year survival was higher for patients undergoing transhiatal rather than transthoracic esophagectomy (30.5% versus 22.7%, p = 0.02). After adjusting for differences in tumor stage, patient, and provider factors, this survival advantage was no longer statistically significant (adjusted hazard ratio for mortality, 0.95, 95% confidence interval: 0.75 to 1.20). Patients undergoing transhiatal esophagectomy were more likely to require endoscopic dilatation within 6 months of surgery (43.1% versus 34.5% for transthoracic operations, p = 0.02). CONCLUSIONS In the largest population-based study to date assessing long-term outcome after esophagectomy for esophageal cancer, transhiatal esophagectomy confers an early survival advantage, but long-term survival does not appear to differ according to surgical approach.
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Affiliation(s)
- Andrew C Chang
- Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA.
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Ferry DR, Anderson M, Beddard K, Tomlinson S, Atherfold P, Obszynska J, Harrison R, Jankowski J. A phase II study of gefitinib monotherapy in advanced esophageal adenocarcinoma: evidence of gene expression, cellular, and clinical response. Clin Cancer Res 2007; 13:5869-75. [PMID: 17908981 DOI: 10.1158/1078-0432.ccr-06-1970] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE At presentation, most cases of adenocarcinoma of the esophagus (ACE) are inoperable. Although chemotherapy can prolong survival, patients eventually die as a result of refractory disease. Epidermal growth factor receptor (EGFR) is almost universally expressed in ACE and is a negative prognostic factor. EXPERIMENTAL DESIGN This open-label, two-center, noncomparative, two-part phase II trial assessed the EGFR tyrosine kinase inhibitor gefitinib (500 mg/d) in patients with advanced, inoperable ACE. The primary end point was tumor response. The effect of EGFR inhibition was also evaluated by gene expression analysis of tumor biopsies taken before gefitinib treatment and 28 days after. RESULTS Twenty-seven patients were recruited and evaluable for tumor response and safety. Three patients had a partial response and seven had stable disease, giving a disease control rate (partial response + stable disease) of 37%. Drug-related adverse events were generally mild: diarrhea in 19 (grade 3 in three) and rash in 19 (grade 3 in five) patients, and there were no grade 4 drug-related adverse events. Microarray experiments on tumor biopsies showed that gefitinib also down-regulated oncogenes associated with tumor progression. Ki67 (a marker of tumor growth) expression decreased in five of seven biopsies taken before and after treatment. CONCLUSION Gefitinib (500 mg/d) is an active and generally well-tolerated treatment for ACE. Studies on endoscopic biopsies are feasible and indicate that gefitinib inhibits both gene expression and cellular biology at 500 mg/d, and these may provide surrogate end points for predictive biomarkers. Further trials of gefitinib are warranted, particularly as patient response seems to be durable and current second-line chemotherapy options have no proven ability to prolong life.
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Affiliation(s)
- David R Ferry
- Department of Oncology, New Cross Hospital, Wolverhampton, United Kingdom.
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41
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Prasad GA, Buttar NS, Wongkeesong LM, Lewis JT, Sanderson SO, Lutzke LS, Borkenhagen LS, Wang KK. Significance of neoplastic involvement of margins obtained by endoscopic mucosal resection in Barrett's esophagus. Am J Gastroenterol 2007; 102:2380-6. [PMID: 17640326 PMCID: PMC2646408 DOI: 10.1111/j.1572-0241.2007.01419.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Although EMR has been used for elimination of neoplasia in BE, the significance of positive carcinoma margins and depth of invasion on endoscopic resection pathology has not been assessed using a valid standard. The aim of this study was to assess the accuracy of tumor staging by EMR using esophagectomy as the standard. METHODS Medical records of patients, who underwent endoscopic resection for esophageal carcinoma or high-grade dysplasia in BE followed by esophagectomy, were reviewed. Data were abstracted from a prospectively maintained EMR database. Endosonography and endoscopic resection were performed by a single experienced endoscopist. Two experienced GI pathologists interpreted all histological results. Standard statistical tests were used to compare continuous and categorical variables. RESULTS Twenty-five patients were included in the study. Three patients had mucosal carcinoma and 16 had submucosal carcinoma following endoscopic resection. Surgical pathology staging was consistent with preoperative EMR staging in all patients. No patient with negative mucosal resection margins had residual tumor at the resection site at esophagectomy. In patients with submucosal carcinoma, 8 had residual carcinoma at the EMR site at surgery and 5 patients had metastatic lymphadenopathy. CONCLUSIONS Tumor staging using EMR pathology is accurate when compared with surgical pathology following esophagectomy. Negative margins on EMR pathology correlate with absence of residual disease at the EMR site at esophagectomy. Submucosal carcinoma on EMR specimens was associated with a high prevalence of residual disease at surgery (50%) and metastatic lymphadenopathy (31%).
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Affiliation(s)
- Ganapathy A Prasad
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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42
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Pedrazzani C, de Manzoni G, Marrelli D, Giacopuzzi S, Corso G, Minicozzi AM, Rampone B, Roviello F. Lymph node involvement in advanced gastroesophageal junction adenocarcinoma. J Thorac Cardiovasc Surg 2007; 134:378-85. [PMID: 17662776 DOI: 10.1016/j.jtcvs.2007.03.034] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2006] [Revised: 01/24/2007] [Accepted: 03/08/2007] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Corrado Pedrazzani
- Department of Human Pathology and Oncology, Unit of Surgical Oncology, University of Siena, Siena, Italy
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43
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Wilson M, Rosato EL, Chojnacki KA, Chervoneva I, Kairys JC, Cohn HE, Rosato FE, Berger AC. Prognostic significance of lymph node metastases and ratio in esophageal cancer. J Surg Res 2007; 146:11-5. [PMID: 18028955 DOI: 10.1016/j.jss.2007.07.028] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2007] [Revised: 07/02/2007] [Accepted: 07/17/2007] [Indexed: 12/24/2022]
Abstract
BACKGROUND The incidence of carcinoma of the distal esophagus and GE junction is rapidly increasing. A large single-center experience was reviewed to determine the impact of lymph node positivity and ratio on survival. METHODS All patients undergoing esophagogastrectomy at Thomas Jefferson University Hospital between January 1994 and December 2004 were reviewed. Univariate and multivariate analyses were performed using log-rank and Cox proportional hazard models, and survival curves were estimated using the Kaplan-Meier method. RESULTS Of 173 patients with invasive cancer, 123 (71%) underwent preoperative chemoradiation therapy. The largest number of patients (45%) had adenocarcinoma of the GE junction; 29% of patients had esophageal adenocarcinoma while 14% had squamous cell cancer of the esophagus. Perioperative mortality was 5.7%. Median overall survival of the entire group was 22 months and 5-year overall survival was 27%. The most significant prognostic factor for overall survival was the presence of positive LN (P = 0.01). Additionally, patients with zero involved LN had a 5-year survival of 34%, while patients with 1 to 3 positive LN and >3 positive LN had 5-year survival of 27% and 9%, respectively (P = 0.01). Finally, an increasing ratio of positive to examined LN was linearly associated with a worsening 5-year survival, (P = 0.153). CONCLUSIONS Increasing number of positive LN in patients with esophageal cancer and increasing ratio of metastatic to examined LN portend a poor prognosis. These factors should play an important role in determining which patients receive adjuvant therapy.
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Affiliation(s)
- Matthew Wilson
- Department of Surgery, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA 19107, USA
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44
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Kobayashi M, Kawachi H, Takizawa T, Uchida K, Sekine M, Kumagai J, Momma K, Nemoto T, Akashi T, Funata N, Eishi Y, Koike M. p53 Mutation analysis of low-grade dysplasia and high-grade dysplasia/carcinoma in situ of the esophagus using laser capture microdissection. Oncology 2007; 71:237-45. [PMID: 17652955 DOI: 10.1159/000106448] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2006] [Accepted: 02/17/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aim of this study was to determine the prevalence and to analyze the characteristics of p53 point mutation in esophageal intraepithelial lesions. METHODS p53 Immunohistochemical and genetic analyses were performed on histopathologically and morphometrically diagnosed lesions. Laser capture microdissection samples were used for increased accuracy. RESULTS Of the 70 lesions studied, 21 were high-grade dysplasia/carcinoma in situ (HGD/CIS), 21 low-grade dysplasia (LGD), 16 reactive atypical epithelia (RAE) and 12 normal epithelia (NE). Immunohistochemical staining showed p53 protein accumulation in 86% (18/21) of HGD/CIS, 81% (17/21) of LGD, and in none of RAE and NE. p53 point mutation was detected in 71% (15/21) of HGD/CIS, 67% (14/21) of LGD, but in none of RAE and NE. Of HGD/CIS and LGD with p53 protein accumulation, similar percentages had mutations: 83% (15/18) and 82% (14/17), respectively. Of lesions with mutations, 72% (21/29) had mutations at hot spots such as codons 238, 248, 273 and 282. CONCLUSIONS p53 Point mutation prevalent in HGD/CIS was also present in a large number of LGD. This is strong evidence that LGD is a neoplastic lesion and that p53 point mutation is deeply involved in esophageal carcinogenesis.
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Affiliation(s)
- Maki Kobayashi
- Department of Pathology, Tokyo Medical and Dental University, Tokyo, Japan
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45
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Prasad GA, Buttar NS, Wongkeesong LM, Lewis JT, Sanderson SO, Lutzke LS, Borkenhagen LS, Wang KK. Significance of neoplastic involvement of margins obtained by endoscopic mucosal resection in Barrett's esophagus. Am J Gastroenterol 2007. [PMID: 17640326 DOI: 10.1111/j.1572-0241.2007.01419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
OBJECTIVES Although EMR has been used for elimination of neoplasia in BE, the significance of positive carcinoma margins and depth of invasion on endoscopic resection pathology has not been assessed using a valid standard. The aim of this study was to assess the accuracy of tumor staging by EMR using esophagectomy as the standard. METHODS Medical records of patients, who underwent endoscopic resection for esophageal carcinoma or high-grade dysplasia in BE followed by esophagectomy, were reviewed. Data were abstracted from a prospectively maintained EMR database. Endosonography and endoscopic resection were performed by a single experienced endoscopist. Two experienced GI pathologists interpreted all histological results. Standard statistical tests were used to compare continuous and categorical variables. RESULTS Twenty-five patients were included in the study. Three patients had mucosal carcinoma and 16 had submucosal carcinoma following endoscopic resection. Surgical pathology staging was consistent with preoperative EMR staging in all patients. No patient with negative mucosal resection margins had residual tumor at the resection site at esophagectomy. In patients with submucosal carcinoma, 8 had residual carcinoma at the EMR site at surgery and 5 patients had metastatic lymphadenopathy. CONCLUSIONS Tumor staging using EMR pathology is accurate when compared with surgical pathology following esophagectomy. Negative margins on EMR pathology correlate with absence of residual disease at the EMR site at esophagectomy. Submucosal carcinoma on EMR specimens was associated with a high prevalence of residual disease at surgery (50%) and metastatic lymphadenopathy (31%).
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Affiliation(s)
- Ganapathy A Prasad
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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46
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Lagarde SM, Reitsma JB, de Castro SMM, Ten Kate FJW, Busch ORC, van Lanschot JJB. Prognostic nomogram for patients undergoing oesophagectomy for adenocarcinoma of the oesophagus or gastro-oesophageal junction. Br J Surg 2007; 94:1361-8. [PMID: 17582230 DOI: 10.1002/bjs.5832] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Abstract
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 < 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 < 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.
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Affiliation(s)
- S M Lagarde
- Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands.
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Wijnhoven BPL, Tran KTC, Esterman A, Watson DI, Tilanus HW. An evaluation of prognostic factors and tumor staging of resected carcinoma of the esophagus. Ann Surg 2007; 245:717-25. [PMID: 17457164 PMCID: PMC1877056 DOI: 10.1097/01.sla.0000251703.35919.02] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate prognostic factors and tumor staging in patients after esophagectomy for cancer. SUMMARY BACKGROUND DATA Several reports have questioned the appropriateness of the sixth edition of the International Union Against Cancer (UICC) TNM guidelines for staging esophageal cancer. Additional pathologic characteristics, besides the 3 basic facets of anatomic spread (tumor, node, metastases), might also have prognostic value. METHODS All patients who underwent resection of the esophagus for carcinoma between January 1995 and March 2003 were extracted from a prospective database. Univariate and multivariate analysis was performed to identify prognostic factors for survival. The goodness of fit and accuracy of 3 staging models (UICC-TNM, Korst classification, Rice classification) predicting survival were assessed. RESULTS A total of 292 patients (mean age, 63 years) underwent esophagectomy. The 5-year overall survival rate was 29% (median, 21 months). pT-, pN-, pm-stage, and radicality of the resection were independent prognostic factors. Subdivision of T1 tumors into mucosal and submucosal showed significant differences in 5-year survival between both groups: 90% versus 47%, respectively (P = 0.01). Subdivision of pN-stage into 3 groups based on the number of positive nodes (0, 1-2, and >3 nodes positive) or the lymph node ratio (0, 0.01-0.2, and >0.2) also refined staging (P = 0.001 and P < 0.001, respectively). The current subclassification of M1 (M1a and M1b) is not warranted (P = 0.41). The staging model of Rice was more accurate than the UICC-TNM classification in predicting survival. CONCLUSION This study supports the view that the current (6th edition) UICC-TNM staging model for esophageal cancer needs to be revised.
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Affiliation(s)
- Bas P L Wijnhoven
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia 5042, Australia.
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Pedrazzani C, de Manzoni G, Marrelli D, Roviello F. It is time for a proper staging system for adenocarcinoma of the gastroesophageal junction. J Clin Oncol 2007; 25:907-8; author reply 908-9. [PMID: 17327616 DOI: 10.1200/jco.2006.10.3770] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
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.
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Affiliation(s)
- J R Siewert
- Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaningerstr. 22, D-81675 München, Germany.
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Wind J, Lagarde SM, Ten Kate FJW, Ubbink DT, Bemelman WA, van Lanschot JJB. A systematic review on the significance of extracapsular lymph node involvement in gastrointestinal malignancies. Eur J Surg Oncol 2006; 33:401-8. [PMID: 17175130 DOI: 10.1016/j.ejso.2006.11.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2006] [Accepted: 11/01/2006] [Indexed: 12/13/2022] Open
Abstract
AIMS The impact of extracapsular lymph node involvement (LNI) has been studied for several malignancies, including gastrointestinal malignancies. Aim of this study was to assess the current evidence on extracapsular LNI as a prognostic factor for recurrence in gastrointestinal malignancies. METHODS The Cochrane Database of systematic reviews, the Cochrane central register of controlled trials, and MEDLINE databases were searched using a combination of keywords relating to extracapsular LNI in gastrointestinal malignancies. Primary outcome parameters were incidence of extracapsular LNI and overall five-year survival rates. FINDINGS Fourteen manuscripts were included, concerning seven oesophageal, three gastric, one colorectal, and three rectal cancer series with a total of 1528 node positive patients. The pooled incidence of extracapsular LNI was 57% (95% CI: 53-61%) for oesophageal cancer, 41% (95% CI: 36-47%) for gastric cancer, and 35% (95% CI: 31-40%) for rectal cancer. In nine of the 14 studies a multivariate analysis was performed. In eight of these nine studies extracapsular LNI was identified as an independent risk factor for recurrence. CONCLUSION Extracapsular LNI is a common phenomenon in patients with gastrointestinal malignancies. It identifies a subgroup of patients with a significantly worse long-term survival. This systematic review highlights the importance of assessing extracapsular LNI as a valuable prognostic factor. Pathologists and clinicians should be aware of this important feature.
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Affiliation(s)
- J Wind
- Department of Surgery, Academic Medical Centre, Post-box 22660, Meibergdreef 9, 1100 DD Amsterdam, The Netherlands.
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