Three-field lymphadenectomy and pattern of lymph node spread in T3 adenocarcinoma of the distal esophagus and the gastro-esophageal junction

History and evidence for state of the art of lymphadenectomy in esophageal cancer surgery

The current curative multimodal treatment of advanced esophageal cancers consists of neoadjuvant or perioperative chemo(radio)therapy followed by a radical surgical resection of the primary tumor and a 2- or 3-field lymphadenectomy. One of the most important predictors of long-term survival of esophageal cancer patients is lymph node involvement. The distribution pattern of lymph node metastases in esophageal cancer is unpredictable and depends on the primary tumor location, histology, T-stage and application of neoadjuvant or perioperative treatment. The optimal extent of the lymphadenectomy remains controversial; there is no global consensus on this topic yet. Some surgeons advocate an aggressive and extended lymph node dissection to remove occult metastatic disease, to optimize oncological outcomes. Others promote a more restricted lymphadenectomy, since the benefit of an extended lymphadenectomy, especially after neoadjuvant chemoradiotherapy, has not been clearly demonstrated, and morbidity may be reduced. In this review, we describe the development of lymphadenectomy, followed by a summary of current evidence for lymphadenectomy in esophageal cancer treatment.

Today's Mistakes and Tomorrow's Wisdom in the Surgical Treatment of Barrett's Adenocarcinoma

Background

Barrett's esophagus is a premalignant condition caused by longstanding gastroesophageal reflux disease and may progress to low-grade dysplasia, high-grade dysplasia (HGD), and finally esophageal adenocarcinoma.

Summary

Barrett's adenocarcinoma can be treated either by endoscopic or surgical resection, depending on the clinical staging. Endoscopic resection is a safe and adequate treatment option for HGD, mucosal tumors, and low-risk submucosal tumors. Its role in the treatment of high-risk submucosal tumors and the role of organ-preserving sentinel node navigated surgery are still under investigation. Esophagectomy with neoadjuvant chemoradiation or perioperative chemotherapy is considered the standard of care for locally advanced Barrett's adenocarcinoma. Regarding operative technique, there is no proven superiority of one technique over another, although a minimally invasive transthoracic technique seems most commonly applied nowadays. In this review, state-of-the-art evidence and future expectations are presented regarding indications for resection, neoadjuvant or perioperative therapy, type of surgery, and postoperative follow-up for Barrett's adenocarcinoma.

Key Messages

In Barrett's adenocarcinoma, endoscopic resection is the standard treatment option for low-risk mucosal and submucosal tumors. For high-risk submucosal tumors, endoscopic submucosal dissection with close surveillance and sentinel node navigated surgery are currently being studied. For locally advanced cancer, a multimodal therapy including esophagectomy is the standard of care. Nowadays, in high-volume centers, a minimally invasive transthoracic esophagectomy with an intrathoracic anastomosis is the most common procedure for Barrett's adenocarcinoma.

Spontaneous Regression of Metastatic Lesions of Adenocarcinoma of the Gastro-Esophageal Junction

Spontaneous regression of cancer is a rarely recognized entity in modern medicine. Historically, this was recognized and hypothesized that an infection causes immune activation, indirectly stimulating the body to destroy tumor cells. Similarly, immune-oncology has now become a major modality in the treatment of solid and some liquid malignancies. However, now with improved therapeutic modalities in the oncology world, one does not get to appreciate our own immune system's ability to fight cancer. We present a patient who had spontaneous regression of metastatic adenocarcinoma of the gastroesophageal junction (GEJ). The patient is a 58-year-old female who had presented with early satiety and dysphagia for which she underwent esophagogastroduodenoscopy which showed an esophageal mass and endoscopic ultrasounds (EUSs) confirmed adenocarcinoma of the GEJ with metastasis to the regional lymph nodes and left supraclavicular lymph nodes. The patient had refused to undergo any surgical, medical oncological, or holistic treatments. Interim disease monitoring positron emission tomography-computed tomography (PET-CT) showed resolution of the metastatic sites of gastroesophageal cancer with clinical improvement of her symptoms. She continues to have this distant regression of metastatic gastroesophageal cancer six months after the initial diagnosis. In literature, spontaneous cancer regression has been reported in melanoma, renal cell carcinoma, and basal cell carcinoma. To our knowledge, this is the first case reported of spontaneous regression of metastatic lesions involving adenocarcinoma of the GEJ with no medical or surgical intervention.

Distribution of lymph node metastases in esophageal adenocarcinoma after neoadjuvant chemoradiation therapy: a prospective study

BACKGROUND

The distribution of lymph node metastases in esophageal adenocarcinoma following neoadjuvant chemoradiation (nCRTx) is unclear, but may have consequences for radiotherapy and surgery. The aim of this study was to define the distribution of lymph node metastases and relation to the radiation field in patients following nCRTx and esophagectomy.

METHODS

Between April 2014 and August 2015 esophageal adenocarcinoma patients undergoing transthoracic esophagectomy with 2-field lymphadenectomy following nCRTx were included in this prospective observational study. Lymph node stations according to AJCC 7 were separately investigated. The location of lymph node metastases in relation to the radiation field was determined. The primary endpoint was the distribution of lymph node metastases and relation to the radiation field, the secondary endpoints were high-risk stations and risk factors for lymph node metastases and relation to survival.

RESULTS

Fifty consecutive patients were included. Lymph node metastases were found in 60% of patients and most frequently observed in paraesophageal (28%), left gastric artery (24%), and celiac trunk (18%) stations. Fifty-two percent had lymph node metastases within the radiation field. The incidence of lymph node metastases correlated significantly with ypT-stage (p = 0.002), cT-stage (p = 0.005), lymph angioinvasion (p = 0.004), and Mandard (p = 0.002). The number of lymph node metastases was associated with survival in univariable analysis (HR 1.12, 95% CI 1.068-1.173, p < 0.001).

CONCLUSIONS

Esophageal adenocarcinoma frequently metastasizes to both the mediastinal and abdominal lymph node stations. In this study, more than half of the patients had lymph node metastases within the radiation field. nCRTx is therefore not a reason to minimize lymphadenectomy in patients with esophageal adenocarcinoma.

Distribution of Lymph Node Metastases in Esophageal Carcinoma Patients Undergoing Upfront Surgery: A Systematic Review

Metastatic lymphatic mapping in esophageal cancer is important to determine the optimal extent of the radiation field in case of neoadjuvant chemoradiotherapy and lymphadenectomy when esophagectomy is indicated. The objective of this review is to identify the distribution pattern of metastatic lymphatic spread in relation to histology, tumor location, and T-stage in patients with esophageal cancer. Embase and Medline databases were searched by two independent researchers. Studies were included if published before July 2019 and if a transthoracic esophagectomy with a complete 2- or 3-field lymphadenectomy was performed without neoadjuvant therapy. The prevalence of lymph node metastases was described per histologic subtype and primary tumor location. Fourteen studies were included in this review with a total of 8952 patients. We found that both squamous cell carcinoma and adenocarcinoma metastasize to cervical, thoracic, and abdominal lymph node stations, regardless of the primary tumor location. In patients with an upper, middle, and lower thoracic squamous cell carcinoma, the lymph nodes along the right recurrent nerve are often affected (34%, 24% and 10%, respectively). Few studies describe the metastatic pattern of adenocarcinoma. The current literature is heterogeneous in the classification and reporting of lymph node metastases. This complicates evidence-based strategies in neoadjuvant and surgical treatment.

Distribution of lymph node metastases in esophageal carcinoma [TIGER study]: study protocol of a multinational observational study

BACKGROUND

An important parameter for survival in patients with esophageal carcinoma is lymph node status. The distribution of lymph node metastases depends on tumor characteristics such as tumor location, histology, invasion depth, and on neoadjuvant treatment. The exact distribution is unknown. Neoadjuvant treatment and surgical strategy depends on the distribution pattern of nodal metastases but consensus on the extent of lymphadenectomy has not been reached. The aim of this study is to determine the distribution of lymph node metastases in patients with resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed. This can be the foundation for a uniform worldwide staging system and establishment of the optimal surgical strategy for esophageal cancer patients.

METHODS

The TIGER study is an international observational cohort study with 50 participating centers. Patients with a resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed in participating centers will be included. All lymph node stations will be excised and separately individually analyzed by pathological examination. The aim is to include 5000 patients. The primary endpoint is the distribution of lymph node metastases in esophageal and esophago-gastric junction carcinoma specimens following transthoracic esophagectomy with at least 2-field lymphadenectomy in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and (disease free) survival.

DISCUSSION

The TIGER study will provide a roadmap of the location of lymph node metastases in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and survival. Patient-tailored treatment can be developed based on these results, such as the optimal radiation field and extent of lymphadenectomy based on the primary tumor characteristics.

TRIAL REGISTRATION

NCT03222895 , date of registration: July 19th, 2017.

Differences in Esophageal Cancer Surgery in Terms of Surgical Approach and Extent of Lymphadenectomy: Findings of an International Survey

INTRODUCTION

Esophagectomy and lymphadenectomy are essential parts of the multimodal treatment of esophageal carcinoma with curative intent. Treatment regimens vary globally and are subject to debate. A global survey was designed to gain insight into current practice.

METHODS

Fifty-seven international expert upper gastrointestinal surgeons received a personal invitation to participate in the survey, which focused on demographics and experience; extent of lymphadenectomy in adeno and squamous cell carcinoma; use of classification systems; neoadjuvant therapy; surgical approach; and specimen handling.

RESULTS

The response rate was 88% (50/57 surgeons), with a mean age of 51.6 years and a median number of 15 years of experience in esophageal surgery. The variety in the extent of lymphadenectomy in proximal, middle and distal squamous cell carcinoma, and Siewert I, II and III adenocarcinoma, was considerable. The number of different combinations of lymph node (LN) stations that were resected in the same tumor was high, while the number of surgeons who removed the exact same combination of LN stations was low. Illustrative is Siewert I adenocarcinoma, in which 27 unique combinations of LN stations were resected, with a maximum of two surgeons performing the exact same dissection. Use of neoadjuvant therapy, surgical approach, and specimen handling also show great variety among participants.

CONCLUSION

There is no uniform, worldwide strategy for surgical treatment of esophageal cancer. The extent of lymphadenectomy shows great variation for both histologic types. An international observational study is needed to provide evidence on the distribution pattern of lymph node metastases in esophageal cancer and the necessary extent of lymphadenectomy.

Hybrid 99mTc-magnetite tracer for dual modality sentinel lymph node mapping

Accuracy of sentinel lymph node identification using radioactive tracers in non-superficial cancers can be limited by radiation shine through and low spatial resolution of detection systems such as intraoperative gamma probes. By utilising a dual radioactive/magnetic tracer, sensitive lymphoscintigraphy can be paired with high spatial resolution intraoperative magnetometer probes to improve the accuracy of sentinel node detection in cancers with complex multidirectional lymphatic drainage. Dextran-coated magnetite nanoparticles (33 nm mean hydrodynamic diameter) were labelled with ^99mTc and applied as a lymphotropic tracer in small and large animal models. The dual tracer could be radiolabelled with 98 ± 2% efficiency after 10 min of incubation at room temperature. Biodistribution studies of the tracer were conducted in normal rats (subdermal and intravenous tail delivery, n = 3) and swine (subdermal hind limb delivery, n = 5). In rats the dual tracer migrated through four tiers of lymph node, 20 min after subdermal injection. Results from intravenous biodistribution test for radiocolloids demonstrated no aggregation in vivo, however indicated the presence of some lower-molecular weight radioactive impurities (^99mTc-dextran). In swine, the dual tracer could be effectively used to map lymphatic drainage from hind hoof to popliteal and inguinal basins using intraoperative gamma and magnetometer probes. Of the eight primary nodes excised, eight were positively identified by gamma probe and seven by magnetometer probe. The high-purity dual tracer shows early promise for sentinel node identification in complex lymphatic environments by combining sensitive preoperative lymphoscintigraphy with a high-resolution intraoperative magnetometer probe.

Lymph node metastases near the celiac trunk should be considered separately from other nodal metastases in patients with cancer of the esophagus or gastroesophageal junction after neoadjuvant treatment and surgery

Background

The aim of the present study is to identify the incidence and prognostic significance of lymph node metastases near the celiac trunk in patients who underwent neoadjuvant chemo(radio)therapy followed by esophagectomy.

Methods

Between March 1994 and September 2013 a total of 462 consecutive patients with cancer of the esophagus or gastroesophageal junction (GEJ) who underwent potentially curative esophageal resection after neoadjuvant chemotherapy (N=88; 19.0%) or neoadjuvant chemoradiotherapy (CRT) (N=374; 81.0%) were included.

Results

Seventy one (15.4%) patients had truncal node metastases in the resection specimen. Metastases to these nodes occurred more frequently in male patients with adenocarcinoma and in tumors at the gastro-esophageal junction. A lower response to neoadjuvant treatment, higher ypT and ypN stages and a poorer grade of differentiation were significantly related with truncal node metastases. Patients with tumor positive truncal nodes had a worse median overall survival (17 vs. 55 months). In multivariate analysis, truncal node metastases were independently associated with a worse survival. Only 22 (31.0%) of the 71 patients with tumor positive truncal nodes were identified preoperatively with EUS or CT. In contrast, 37 patients had suspicious truncal nodes on EUS or CT, but metastases in the pathology specimen were absent.

Conclusions

In the present study, it is demonstrated that positive truncal nodes in the resection specimen after neoadjuvant therapy, are associated with advanced tumor stages and are an independent factor for inferior survival.

Clinical outcomes and benefits for staging of surgical lymph node mapping after esophagectomy

Dissection of lymph nodes (LN) immediately after esophagectomy is utilized by some surgeons to aid determination of LN stations involved in esophageal cancer. Some suggest that this increases LN yield and gives information regarding the pattern of lymphatic spread, others feel that this may compromise a circumferential resection margin (CRM) assessment. The aim of this study is to evaluate the effect of ex vivo dissection on the assessment of the CRM and the pattern of lymph node dissemination in patients with adenocarcinoma of the esophagus and gastroesophageal junction (GEJ) undergoing radical surgery after neoadjuvant chemotherapy and their prognostic impact. Data from consecutive patients with potentially curable adenocarcinoma of the distal esophagus and GEJ who received neoadjuvant treatment followed by surgery were analyzed. Clinical and pathological findings were reviewed and LN burden and location correlated with clinical outcome. Pathology specimens were dissected into individual LN groups 'ex-vivo' by the surgeon. A total of 301 patients were included: 295 had a radical proximal and distal resection margin however in 62(20.6%) CRM could not be assessed. A median of 33(10-77) nodes were recovered. A 117(38.9%) patients were ypN0 while 184(61.1%) were LN positive (ypN1-N3). LN stations close to the tumor were most frequently involved. Twenty-seven (14.7%) patients had only thoracic stations involved, 48(26.1%) only abdominal stations and 109 (59.2%) had both. Median survival for yN0 patients was 171 months compared to 24 months for those LN positive (P< 0.001). Multivariate analyses identified ypT-category, ypN-category, male gender, and nonradical resection (proximal or distal) margin as significant prognostic factors. Surgical dissection of nodes after esophagectomy enables accurate LN assessment, but may compromise CRM assessment in up to 20% of cases. It also provides valuable information regarding the pattern of nodal spread.

The extent of lymphadenectomy in esophageal resection for cancer should be standardized

The incidence of esophageal cancer increases, with approximately 482,000 patients diagnosed with esophageal cancer each year. Despite the growing incidence of esophageal carcinoma, the extent of the lymphadenectomy is still under discussion. Lymph node status is an important prognostic parameter in esophageal cancer and an independent predictor of survival. Surgical strategy depends on the distribution pattern of nodal metastases but consensus on the extent of lymphadenectomy differs worldwide. For squamous cell cancer, Japanese surgeons have standardized the 2- or 3-field lymphadenectomy according to the location of the tumor. For adenocarcinoma, in the Western World accounting for 85% of all esophageal cancers, the type of lymphadenectomy to perform is not clear. Moreover, the use of neoadjuvant therapy may influence the mediastinal lymph nodes and the significance of the lymphadenectomy for survival. These aspects have challenged the traditional policy concerning lymphadenectomy, at least in the Western World. Furthermore, an extensive lymphadenectomy may improve survival but, on the other hand, may cause significant more morbidity. An overview of the literature on the extent of lymphadenectomy for esophageal cancer with respect to the supposed lymph node distribution patterns for squamous cell carcinoma and adenocarcinoma, the different lymph node classification systems, the commonly used surgical techniques and outcomes, and the proposal of observational cohort study to standardize the type of lymphadenectomy according to the type of tumor, location and use of neoadjuvant therapy will be provided.

Safety and feasibility of near-infrared image-guided lymphatic mapping of regional lymph nodes in esophageal cancer

OBJECTIVE

To assess safety and feasibility of an intraoperative, minimally invasive near-infrared (NIR) image-guided approach to lymphatic mapping in patients with esophageal cancer.

METHODS

Although local lymph nodes (LNs) are removed with the esophageal specimen, no techniques are available to identify the regional LNs (separate from the esophagus) during esophagectomy. We hypothesize that NIR imaging can identify regional LNs with the potential to improve staging and guide the extent of lymphadenectomy. Nine of the 10 patients enrolled had resectable esophageal adenocarcinoma and underwent NIR mapping following peritumoral submucosal injection of indocyanine green (ICG) alone or premixed in human serum albumin (ICG:HSA) before resection. NIR imaging was performed in situ and ex vivo.

RESULTS

In 6 of the 10 patients, intraoperative NIR imaging demonstrated an NIR signal at all tumors and in 2 to 6 NIR(+) regional LNs. NIR(+) LNs were not identified in 4 patients: 1 patient with occult stage IV disease, for whom further imaging was not performed and thus was excluded from analysis, and 3 patients in whom ICG was used without HSA. Identification of local LNs on the esophagus was obscured by a peritumoral background. Importantly, the pathological status of NIR(+) regional LNs reflected overall regional nodal status.

CONCLUSIONS

NIR lymphatic mapping is safe and feasible in patients with esophageal cancer and can identify regional LNs when ICG:HSA is used. Although more work is needed to improve background signals and local LN identification, intraoperative detection of regional NIR(+) LNs allows an in-depth histological analysis of LN basins not commonly scrutinized as part of the specimen and may improve the detection of occult nodal disease.

Gastric tube reconstruction prevents postoperative recurrence and metastasis of esophageal cancer

Esophagectomy is the main method of treating patients with esophageal cancer. Tubular stomach and whole stomach approaches may be used for esophagectomy. However, it is not known to what extent these surgical methods are associated with postoperative recurrence and metastasis. Therefore, we aimed to investigate the effect of the tubular and whole stomach approaches on postoperative recurrence and metastasis in esophageal cancer patients. One hundred and twenty-one patients that were diagnosed with esophageal cancer by gastroscopic biopsy between March 2010 and March 2011 in Taian Central Hospital, China, were recruited into this study. There were 67 cases in the gastric tube group and 54 cases in whole stomach group. All of the patients underwent esophagectomy and there were no mortalities during surgery. All patients completed the follow-up period. The rates of recurrence or metastasis 1 and 2 years after surgery in the gastric tube group were observed to be lower than those in the whole stomach group. The two-year survival rates of the gastric tube group and whole stomach group were 80 and 61%, respectively. There was a significant difference in the survival rate between the two groups (P=0.016). In conclusion, this study suggests that esophageal cancer patients may gain a mid-term benefit from gastric tube reconstruction.

Predictors of Disease Recurrence and Survival in Esophageal Adenocarcinomas With Complete Response to Neoadjuvant Therapy

Complete response to neoadjuvant therapy, determined by pathologic examination of the resection specimen (pCR), is associated with a favorable outcome in esophageal adenocarcinomas (EAC), but there is significant heterogeneity in survival reported within this group. Our aim was to determine predictors of disease recurrence (DR) and survival in EAC patients with pCR to neoadjuvant therapy. A total of 93 EAC patients with pCR to neoadjuvant therapy were identified, and a predetermined set of clinicopathologic variables was examined, including patient age, sex, tumor location, pretreatment tumor size, endoscopic ultrasound T and N stage, histologic tumor type, and grade in pretreatment biopsies. The esophagectomy specimens were evaluated for the extent of sampling of the tumor bed, depth of treatment-related changes, presence of treatment effect in lymph nodes, and the total number of lymph nodes examined. Complete histologic examination of the tumor bed was the most significant predictor of favorable outcome for both DR (hazard ratio [HR]=0.42; 95% confidence interval [CI]: 0.21-0.82; P=0.011) and disease-specific mortality (HR=0.40; 95% CI: 0.22-0.70; P<0.01). The presence of a high-grade adenocarcinoma component in pretreatment biopsies (HR=2.19; 95% CI: 1.22-3.94; P<0.01) was associated with a higher disease-specific mortality, and involvement of the gastroesophageal junction (HR=2.37; 95% CI: 1.11-5.06; P=0.026) was associated with a higher rate of DR. Heterogeneity in outcomes for EAC patients with pCR to therapy can be explained by adequacy of histologic examination of the tumor bed, high tumor grade, and involvement of the gastroesophageal junction.

Novel handheld magnetometer probe based on magnetic tunnelling junction sensors for intraoperative sentinel lymph node identification

Using magnetic tunnelling junction sensors, a novel magnetometer probe for the identification of the sentinel lymph node using magnetic tracers was developed. Probe performance was characterised in vitro and validated in a preclinical swine model. Compared to conventional gamma probes, the magnetometer probe showed excellent spatial resolution of 4.0 mm, and the potential to detect as few as 5 μg of magnetic tracer. Due to the high sensitivity of the magnetometer, all first-tier nodes were identified in the preclinical experiments, and there were no instances of false positive or false negative detection. Furthermore, these preliminary data encourage the application of the magnetometer probe for use in more complex lymphatic environments, such as in gastrointestinal cancers, where the sentinel node is often in close proximity to other non-sentinel nodes, and high spatial resolution detection is required.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sentinel lymph node biopsy in esophageal cancer: an essential step towards individualized care

Lymph node status is the most important prognostic factor in esophageal cancer. Through improved detection of lymph node metastases, using the sentinel lymph node concept, accurate staging and more tailored therapy may be achieved. This review article outlines two principle ways in which the sentinel lymph node concept could dramatically influence current standard of care for patients with esophageal cancer. We discuss three limitations to universal acceptance of the technique, and propose next steps for increasing enthusiasm amongst physicians and surgeons including the development of a universal tracer, and improved contrast agents with novel dual-modality 'visibility'.

Clinical relevance of novel imaging technologies for sentinel lymph node identification and staging

The sentinel lymph node (SLN) concept has become a standard of care for patients with breast cancer and melanoma, yet its clinical application to other cancer types has been somewhat limited. This is mainly due to the reduced accuracy of conventional SLN mapping techniques (using blue dye and/or radiocolloids as lymphatic tracers) in cancer types where lymphatic drainage is more complex, and SLNs are within close proximity to other nodes or the tumour site. In recent years, many novel techniques for SLN mapping have been developed including fluorescence, x-ray, and magnetic resonant detection. Whilst each technique has its own advantages/disadvantages, the role of targeted contrast agents (for enhanced retention in the SLN, or for immunostaging) is increasing, and may represent the new standard for mapping the SLN in many solid organ tumours. This review article discusses current limitations of conventional techniques, limiting factors of nanoparticulate based contrast agents, and efforts to circumvent these limitations with modern tracer architecture.

Preoperative assessment of tumor location and station-specific lymph node status in patients with adenocarcinoma of the gastroesophageal junction

BACKGROUND

In esophageal cancer patients preoperative staging will determine the type of surgical procedure and use of neoadjuvant therapy. Tumor location and lymph node status play a pivotal role in this tailored strategy. The aim of the present study was to prospectively evaluate the accuracy of preoperative assessment of tumor location according to the Siewert classification and lymph node status per station with endoscopy/endoscopic ultrasound (EUS) and computed tomography (CT).

METHODS

In 50 esophagectomy patients with adenocarcinoma of the gastroesophageal junction (GEJ), tumor location according to Siewert and N-stage per nodal station as determined preoperatively by endoscopy/EUS and CT were compared with the histopathologic findings in the resection specimen.

RESULTS

Overall accuracy in predicting tumor location according to the Siewert classification was 70 % for endoscopy/EUS and 72 % for CT. Preoperative data could not be compared with the pathologic assessment in 11 patients (22 %), as large tumors obscured the landmark of the gastric folds. The overall accuracy for predicting the N-stage in 250 lymph node stations was 66 % for EUS and 68 % for CT. The accuracy was good for those stations located high in the thorax, but poor for celiac trunk nodes.

CONCLUSIONS

Given the frequent discrepancy between the endoscopic and pathologic location of the GEJ and the common problem of advanced tumors obscuring the landmarks used in the assessment of the Siewert classification, its usefulness is limited. The overall accuracy for EUS and CT in predicting the N-stage per station was moderate.

Lack of independent significance of a close (<1 mm) circumferential resection margin involvement in esophageal and junctional cancer

BACKGROUND

For rectal cancer, an involved circumferential resection margin (CRM), defined as tumor cells within 1 mm of the CRM, is of established prognostic significance. This definition for the esophagus, however, is controversial, with the UK Royal College of Pathologists (RCP) recommending the 1 mm definition, while the College of American Pathologists (CAP) advises that only tumor cells at the cut margin (0 mm) define an incomplete (R1) resection. The aim of this study was to compare the clinical significance of both definitions in patients with pT3 tumors.

METHODS

CAP- and RCP-defined CRM status in patients treated by surgery only or by multimodal therapy was recorded prospectively in a comprehensive database from May 2003 to May 2011. Kaplan-Meier survival curves were generated, and factors affecting survival were assessed by univariate and multivariate analysis.

RESULTS

A total of 157 of 340 patients had pT3 esophageal tumors, with RCP-positive CRM in 60 %, and 18 % by CAP. There were no significant differences between RCP-positive CRM and negative margins for node-positive disease, local recurrence, and survival. CAP-positive CRM was associated with positive nodes (P = 0.036) and poorer survival (P = 0.023). Multivariate analysis revealed nodal invasion to be the only independent prognostic variable (P = 0.004).

CONCLUSIONS

A CRM margin of <1 mm is common in pT3 esophageal tumors, a finding consistent with other reports. The <1 mm definition was not associated with node positivity, local recurrence, or survival, in contrast to actual involvement at the margin, suggesting lack of independent prognostic significance of the RCP definition and possible superiority of the CAP criteria for prospective registration of CRM.

Management of Barrett's esophageal carcinoma

Barrett's esophagus (BE) is the premalignant lesion from which esophageal adenocarcinoma near the esophagogastric junction arises. The management of BE and the treatment of Barrett's esophageal adenocarcinoma (BEA) are important clinical issues in Europe and the United States. As the Helicobacter pylori infection rate in Japan is decreasing in the younger population, the incidence of BE and adenocarcinoma arising from BE may start increasing. Thus, we review the current status of BEA and its management. Magnifying endoscopy with narrow-band imaging is important for diagnosing dysplasia arising from BE. In Japan, adenocarcinoma arising from BE is managed the same way as squamous cell carcinoma in the same location. Strategies to prevent BEA may include medication such as non-steroidal anti-inflammatory drugs and proton pump inhibitors, and anti-reflux surgery. Understanding the pathophysiology of BE will help to reduce the incidence of BEA.

Immunospecific targeting of CD45 expressing lymphoid cells: towards improved detection agents of the sentinel lymph node

This study was designed to demonstrate the potential of small nanoparticulate lymphotropic contrast agents designed to bind with high affinity to lymphoid cells overexpressing the CD45 antigen. To this end, small gold nanoparticles used as model were conjugated to anti-CD45 antibodies and injected in mice in the dorsal toe of the fore/hind paw. Chemical analysis demonstrated rapid uptake and transport of the nanoparticles in the lymphatic as well as significant retention of the nanoparticles with high binding affinity to lymphoid cells in the popliteal and axillary lymph nodes in comparison to non-targeted nanoparticles.

Long-term outcomes of extended proximal gastrectomy for oesophagogastric junctional tumours

BACKGROUND

There is no consensus on the optimum approach for resection of oesophagogastric junctional (OGJ) tumours. We prospectively evaluated the efficacy of transabdominal radical extended proximal gastrectomy with oesophagogastric anastomosis (EPGOG) for selected tumours of the OGJ.

METHODS

Between 1998 and 2007, 66 selected consecutive patients with tumours of the OGJ underwent successful EPGOG. Selection was limited to tumours where the maximal proximal extent was 36 cm ab oral. Pre-, peri-, and postoperative outcomes together with long-term survival data for these patients were prospectively collected.

RESULTS

Median theatre time was 242 min (range = 120-480), with a median blood loss of 300 ml (range = 50-1720). Eighty-nine percent of patients were extubated in theatre; major complications occurred in 9 (14%) patients, with an overall in-hospital mortality rate of 8%. Thirty-five (53%) patients had nodal disease and the median lymph node yield was 13 (range = 4-36), with an R0 resection rate of 80%. In terms of long-term outcomes, the 2- and 5-year actuarial survival rates were 54 ± 6% and 41 ± 6%.

CONCLUSION

Extended radical proximal gastrectomy with oesophagogastric anastomosis for selected junctional tumours is a feasible technique which does not compromise oncological principles as evidenced by an excellent long-term survival rate.

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

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

Sentinel lymph node biopsy in esophageal cancer: should it be standard of care?

INTRODUCTION

Sentinel node mapping is established in some superficial cancers but remains controversial in harder-to-access solid tumors. There are an increasing number of recent studies suggesting that isolated tumor cells have prognostic significance in predicting poor survival, in breast cancer, esophageal cancer, and others. It is for this reason that we have persevered with the sentinel lymph node concept in our esophagectomy cancer patients, and we report our results since 2008.

METHODS

Thirty-one of 32 consecutive patients underwent resection for invasive esophageal cancer along with sentinel lymph node retrieval (resection rate, 97%). Peritumoral injection of (99m)Tc antimony colloid was performed by upper endoscopy prior to the operation. A two-surgeon synchronous approach via a right thoracotomy and laparotomy was performed with a conservative lymphadenectomy. Sentinel lymph nodes were identified with a gamma probe both in and ex vivo, and sent off separately for three serial sections and immunohistochemistry with AE1/AE3.

RESULTS

The median patient age was 63.4 years (range, 45-75 years). Most patients (81%) had an adenocarcinoma, and 61% had received neoadjuvant therapy. At least one sentinel lymph node (median, 3) was identified in 29 of 31 patients (success rate, 94%). Sentinel nodes were present in more than one nodal station in 16 patients (55%). One false negative case led to a sensitivity of 90%. In 28 of 29 patients, the sentinel lymph node accurately predicted findings in non-sentinel nodes (accuracy, 96%).

CONCLUSIONS

Sentinel lymph node biopsy is both feasible and accurate in esophageal resections with conservative lymphadenectomy. It allows targeted serial sectioning and immunohistochemical studies of those nodes and should become standard of care in patients undergoing esophagectomy for esophageal cancer.

Dissection of lymph node metastases in esophageal cancer

There has been much recent debate regarding the best surgical procedure to treat esophageal cancer, in particular with regard to the optimum extent of lymphadenectomy to improve survival while minimizing morbidity. No results obtained by prospective, randomized studies on the comparison of radical esophagectomy and extended lymphadenectomy with limited or less invasive resections following neoadjuvant therapy with regard to perioperative morbidity and prognosis are available to date. Until now, there has been no evidence suggesting the usefulness of sentinel lymph node navigation in esophageal cancers, regardless of the cell type. Furthermore, the question as to the benefits and risks of two-field and three-field lymphadenectomy in esophageal cancer has not yet been conclusively answered. This article will discuss the recent status of lymph node-dissection procedures stage-dependently according to the two different tumor entities and with regard to minimally invasive esophagectomy, including the novel 2010 Tumor, Node, Metastasis-staging system.

Nodal metastasis from locally advanced esophageal cancer: how neoadjuvant therapy modifies their frequency and distribution

BACKGROUND

Neoadjuvant chemoradiotherapy (CT-RT) before esophagectomy seems to affect the number of nodal metastasis and to alter the distribution of those that remain. The aim of this study was to define how neoadjuvant chemoradiotherapy changes nodal metastasis patterns in locally advanced esophageal cancer.

METHODS

A total of 402 consecutive patients with cancer of the esophagus or esophagogastric junction (181 adenocarcinoma [AC] and 221 squamous cell carcinoma [SCC]) (evaluated at clinical stage T1N1, T2N1, T3N0, or T3N1 and pathological stage M0) presenting in our Department between 1992 and 2007 and who underwent complete resection (R0) were included in this retrospective study on a prospectively collected database. All dissected lymph nodes were retrieved and microscopically analyzed. Nodal metastasis patterns in patients who underwent chemotherapy (CT) or chemoradiotherapy (CT-RT) neoadjuvant therapy were compared with those in patients who underwent surgery alone.

RESULTS

Almost 30% of the adenocarcinoma patients and approximately 40% of the SCC patients showed effective tumor downstaging after neoadjuvant therapy. There were fewer paracardial node metastases (P = .002) in the AC patients who underwent CT-RT neoadjuvant therapy. There were, likewise, significantly fewer paraesophageal, paracardial, and subcarinal node metastases in the SCC patients in whom the perigastric nodes became the second-most frequent site of metastasis.

CONCLUSION

Not only was frequency of lymph node metastases decreased after neoadjuvant therapy, but nodal localization and pattern were also significantly modified.

The prognostic importance of pathologically involved celiac node metastases in node-positive patients with carcinoma of the distal esophagus or gastroesophageal junction: a surgical series from the Mayo Clinic

The management of esophageal cancer with involvement of celiac lymph nodes is controversial. The purpose of this retrospective study was to evaluate the clinical importance of metastases to celiac lymph nodes in patients with carcinoma of the distal esophagus or gastroesophageal junction (GEJ) who undergo surgical treatment with curative intent. We reviewed the medical records of 310 patients who underwent definitive esophagectomy at the Mayo Clinic, Rochester, Minnesota, between 1976 and 1999 for carcinoma of the distal esophagus or GEJ. The disease location was distal esophagus in 163 and GEJ in 147. Fifty-two patients (17%) were found to have celiac node involvement. The survival of these patients was compared with that of 97 N0 patients and 161 N1 patients without celiac node involvement. Squamous cell carcinoma and adenocarcinomas were found in 24% and 76%, respectively. Ivor Lewis esophagectomy was the most common surgical procedure (76%), followed by transhiatal resection (14%) and modified Ivor Lewis procedure (5%). The median number of nodes resected was 15 (range, 2-45). The median survival of the entire group was 18.8 months. The median survival was 48 months (range, 1.6 months-22 years) for N0 patients and 15.9 months (range, 0.03 months-14.4 years) for N1 patients without celiac node disease (P < 0.001). The median survival was 11.7 months (range, 2.2 months-15.7 years) for celiac node-positive patients, and this difference was statistically significant when compared with survival in N0 patients (P= 0.001) but not when compared with that in N1 patients without celiac node disease (P= 0.57). Survival at 3 and 5 years was 61% and 45% for N0 patients, 21% and 9% for N1 patients without celiac node disease, and 18% and 11% for patients with celiac node disease, respectively. At 10 years, 7% of patients with celiac node involvement in their resected specimen were alive. By multivariate analysis, patients with 4 or more positive lymph nodes had the worst prognosis (risk ratio [RR], 2.63; 95% confidence interval [CI], 1.98-3.48), regardless of their location. We concluded that celiac node metastases were not an adverse prognostic indicator in patients with celiac node involvement compared with N1 patients without celiac node disease. Overall, the number of positive nodes, not their location, correlated best with survival. Although median survival was poor, a small number of patients with resected celiac node disease had long-term survival. Patients with undetected celiac node disease at the time of surgical resection who were subsequently found to have celiac node involvement appeared to have a prognosis similar to that of patients with stage III disease. Therefore, treatment with curative intent should be considered for fit patients with celiac node disease.

International survey on esophageal cancer: part I surgical techniques

In patients with esophageal cancer, radical surgical resection of the esophagus and surrounding lymph nodes is the only curative treatment option. Nevertheless, no standard surgical procedure exists. The aims of the present study were to gain insight into the frequencies of the various surgical techniques in esophageal cancer surgery as applied by surgeons throughout the world and to identify intercontinental differences regarding surgical techniques. Surgeons with particular interest in esophageal surgery, including members of the International Society for Diseases of the Esophagus, the European Society of Esophagology Group d'Etude Européen des Maladies de l'Oesophage and the OESO, were invited to participate in an online questionnaire. Questions were asked regarding approach to esophagectomy, extent of lymphadenectomy (LND), type of reconstruction, and anastomotic techniques. Subanalyses were performed for the surgeons' case volume per year, years of experience in esophageal cancer surgery, and continent. Of 567 invited surgeons, 269 participated, resulting in an overall response rate of 47%. The responders currently performing esophagectomies (n= 250; 44%), represented 41 countries across the six continents. Fifty-two percent of responders favor open transthoracic esophagectomy (TTE) over transhiatal esophagectomy (THE) or minimally invasive esophagectomy (MIE). THE is preferred by 26%, whereas MIE is favored by 14%. Eight percent have no preference for one approach to esophagectomy over the other. The extent of LND is most frequently the 2-field, routinely performed by 73% of surgeons. The continuity of the digestive tract is most frequently restored with a gastric conduit (85%). In open TTE, the anastomosis is routinely created in the neck by 56% of responders and in the chest by 40%. Cervical anastomoses are routinely fashioned by means of a handsewn technique by 65% of responders, while 35% favor the stapled technique. The cervical incision is predominantly performed vertically on the left side of the neck (routinely by 66%). A horizontal neck incision is routinely carried out by 19% of responders and a vertical right-sided incision by 11%. Significant differences in surgical techniques could be detected between low- and high-volume surgeons, between surgeons with <or=10 versus >or=21 years of experience, and between surgeons from different continents. In conclusion, currently the most commonly applied surgical procedure is the open right-sided transthoracic approach with a two-field lymphadenectomy, using a gastric tube anastomosed at the left side of the neck by means of a handsewn, end-to-side technique. The results of this survey provide baseline data for future research and for the development of international guidelines.

Health-related quality of life among patients with adenocarcinoma of the gastro-oesophageal junction treated by gastrectomy or oesophagectomy

Background

Tumours of the gastro-oesophageal junction may be resected by total gastrectomy (TG) or transthoracic oesophagectomy (TTO). This study compared health-related quality of life (HRQL) following these procedures.

Methods

Prospective clinical and HRQL data (European Organization for Research and Treatment of Cancer QLQ-C30) were collected from 63 consecutive patients (20 TG and 43 TTO) before and 6 months after surgery for Siewert type I–III gastro-oesophageal tumours.

Results

Questionnaire response rates exceeded 90 per cent. Patients were similar with respect to disease stage, treatment-related mortality and survival, but those selected for TTO were younger with less co-morbidity than those undergoing TG. These differences were reflected in baseline HRQL scores, which were better in patients selected for TTO. Six months after surgery, however, HRQL showed a greater deterioration after TTO than after TG in terms of role and social function, global quality of life and fatigue. Symptom scores for pain and diarrhoea increased in both groups.

Conclusion

TTO had a greater negative impact on HRQL than TG for tumours of the gastro-oesophageal junction.

Extramural lymphatic drainage from the thoracic esophagus based on minute cadaveric dissections: fundamentals for the sentinel node navigation surgery for the thoracic esophageal cancers

In order to elucidate the lymphatic pathways from the thoracic esophagus, minute dissection of five adult cadavers, from the neck through the diaphragm, was performed. Peri-esophageal lymphatics were dissected from both the anterior and posterior aspects. The topographical differences between the right and left lymphatic drainage were revealed. The right lymphatic drainage system (RDS) was basically longitudinal and multi-stationed. Longitudinal lymphatics were relatively poorly developed in the left lymphatic drainage system (LDS), and direct drainage to the thoracic duct from the left wall of the thoracic esophagus, was frequently observed. The right uppermost thoracic paratracheal node received almost all levels of the right esophageal wall, and this node was thought to be the key node in the RDS. A contralateral lymphatic pathway was relatively frequently observed in the middle and lower thoracic esophagus. These results seemed to be in agreement with the anatomical and clinicopathological data in the literature, and might serve as a basis for sentinel node navigation surgery for the thoracic esophageal cancers.

Adenocarcinoma of the gastroesophageal junction: influence of esophageal resection margin and operative approach on outcome

OBJECTIVE

To determine whether the length of esophageal resection or the operative approach influences outcome for patients with adenocarcinoma of the gastroesophageal junction (GEJ).

SUMMARY BACKGROUND DATA

While R0 resection remains the mainstay of curative treatment of patients with GEJ cancer, the optimal length of esophageal resection remains controversial.

METHODS

Patients with Siewert I, II, or III adenocarcinoma who underwent complete gross resection without neoadjuvant therapy were identified from a prospectively maintained database. Proximal margin lengths were recorded ex vivo as the distance from the gross tumor edge to the esophageal transection line. Operative approaches were grouped into gastrectomy (limited esophagectomy) or esophagectomy (extended esophagectomy).

RESULTS

From 1985 through 2003, 505 patients underwent R0/R1 gastrectomy (n = 153) or esophagectomy (n = 352) without neoadjuvant treatment. There were no differences in R1 resection rate, number of nodes examined or operative mortality between gastrectomy and esophagectomy. Univariate analysis found >3.8 cm to be the ex vivo proximal margin length (approximately 5 cm in situ) most predictive of improved survival. Multivariable analysis in patients who underwent R0 resection with >or=15 lymph nodes examined (n = 275) found the number of positive lymph nodes, T stage, tumor grade, and ex vivo proximal margin length >3.8 cm to be independent prognostic factors. Subset analysis found that the benefit associated with >3.8 cm margin was limited to patients with T2 or greater tumors and <or=6 positive lymph nodes.

CONCLUSIONS

In patients not receiving neoadjuvant therapy, the goal for patients with adenocarcinoma of the GEJ should be R0 resection including at least 15 lymph nodes, preferably with 5 cm of grossly normal in situ proximal esophagus for those with <or=6 positive lymph nodes. The operative approach may be individualized to achieve these goals.

Proposal for a new definition of true cardia carcinoma

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

Emerging aspects of oesophageal and gastro-oesophageal junction cancer histopathology - an update for the surgical oncologist

Adenocarcinoma of the oesophagus and gastro-oesophageal junction are rapidly increasing in incidence and have a well described sequence of carcinogenesis: the Barrett's metaplasia-dysplasia-adenocarcinoma sequence. During recent years there have been changes in the knowledge surrounding disease progression, cancer management and histopathology specimen reporting. Tumours around the gastro-oesophageal junction (GOJ) pose several specific challenges. Numerous difficulties arise when the existing TNM staging systems for gastric and oesophageal cancers are applied to GOJ tumours. The issues facing the current TNM staging and GOJ tumour classification systems are reviewed in this article. Recent evidence regarding the importance of several histopathologically derived prognostic factors, such as circumferential resection margin status and lymph node metastases, have implications for specimen reporting. With the rising use of multimodal treatments for oesophageal cancer it is important that the response of the tumour to this therapy is carefully documented pathologically. In addition, several controversial and novel areas such as endoscopic mucosal resection, lymph node micrometastases and the sentinel node concept are being studied. We aim to review these aspects, with special relevance to oesophageal and gastro-oesophageal cancer specimen reporting, to update the surgical oncologist with an interest in upper gastrointestinal cancer.

Lymphadenectomy for Adenocarcinoma of the Gastroesophageal Junction (GEJ): Impact of Adequate Staging on Outcome

INTRODUCTION

Adequate staging of gastric cancer requires examination of at least 15 lymph nodes. Most resected patients are inadequately staged potentially confounding the interpretation of clinical data. The aim of this study was to determine whether adequate staging revealed different prognostic factors or improved survival compared with patients with <15 nodes examined after R0 resection for GEJ cancer.

METHODS

A prospectively maintained database identified 366 patients with Siewert types II and III adenocarcinoma of the GEJ who underwent R0 resection without neoadjuvant therapy at a single institution. Patients were grouped into adequately (>or=15 nodes examined) or inadequately staged (<15 nodes examined). Median follow up was 51 months.

RESULTS

From 1985 through 2003, 250/366 (68%) patients were adequately staged and 116/366 (32%) were inadequately staged. There was no difference in operative mortality between adequately staged (5.2%) and inadequately staged patients (4.3%, P = NS). Adequately staged patients had more positive lymph nodes (median 2) compared with inadequately staged patients (median 1, P < 0.01). Multivariable analysis of adequately staged patients found the number of positive lymph nodes, T stage, and lymphovascular invasion to be independent prognostic factors for overall survival (OS). For inadequately staged patients only the number of positive lymph nodes and T stage were independent prognostic factors. Adequate staging was an independent prognostic factor for patients with advanced (T >or= 2 Nany) tumors. For T1 tumors adequate staging was not associated with improved survival.

CONCLUSIONS

Patients with GEJ cancer should undergo adequate lymphadenectomy to permit examination of >or=15 lymph nodes allowing the accurate identification of prognostic variables. Removal of >or=15 lymph nodes is associated with more accurate survival estimates for patients with advanced disease.

The Range of Tumor Extension Should Have Precedence over the Location of the Deepest Tumor Center in Determining the Regional Lymph Node Grouping for Widely Extending Esophageal Carcinomas

BACKGROUND

The Japanese Guide Lines for the Clinical and Pathologic Studies on Carcinoma of the Esophagus (9th edn) give precedence to the location of the deepest tumor center rather than the range of tumor extension when determining regional lymph node grouping. We evaluated the validity of this recommendation.

METHODS

The subjects were 49 patients with carcinomas of the distal thoracic esophagus and cardia who had undergone esophagectomy with three-field lymph node dissection. We measured variables defining tumor location, such as the distance from the esophagogastric junction (EGJ) to the proximal margin of the tumor (DJP), the distance from the EGJ to the distal margin of the tumor (DJD), and the distance from the EGJ to the deepest tumor center (DJC). To examine the relation of tumor location to lymph node metastasis in the proximal direction, the patients were divided into two groups according to the presence (14 patients) or absence (35 patients) of middle-upper mediastinal and/or cervical lymph node metastases. These two groups were compared with respect to the above variables. To analyze lymph node metastasis in the distal direction, the patients were also divided into two groups according to the presence (12 patients) or absence (37 patients) of distant abdominal lymph node metastases. These two groups were similarly compared with respect to the above variables.

RESULTS

DJP was significantly longer in the patients with middle-upper mediastinal and/or cervical lymph node metastases than in those without such metastases. Multiple logistic regression analysis showed that the DJP was a better predictor of middle-upper mediastinal and/or cervical lymph node metastases than was the DJC. The DJD was significantly longer in the patients with distant abdominal lymph node metastases. Multiple logistic regression analysis also showed that the DJD was a better predictor of distant abdominal lymph node metastases than was the DJC.

CONCLUSIONS

The range of tumor extension is a more reliable predictor of the risk of distant lymph node metastases than is the location of the deepest tumor center in esophageal carcinoma.

Prognostic factors in adenocarcinoma of the esophagus or gastroesophageal junction

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

Radiation and chemoradiation therapy for esophageal adenocarcinoma

The aims of preoperative chemoradiation therapy (preop-CRT) for esophageal adenocarcinoma are to reduce incomplete local resection (R1,R2), local and systemic recurrences that are reported in up to 30% of patients who undergo surgery alone. Phase II studies of preop-CRT, with radiation doses in the 40-50 Gy range, and concurrent chemotherapy with 5-fluorouracil (5-FU)-cisplatin +/- paclitaxel, or cisplatin-paclitaxel, have reported subsequent RO resection rates of 80%-100%, with tumor sterilization achieved in 8%-49% of cases, and consequently improved local control. New chemotherapy regimens omitting 5-FU have reduced the incidence of severe esophagitis, unplanned hospitalization, with comparable efficacy. Among three randomised trials that compared preop-CRT to surgery alone, one shown a debatable survival advantage. Reducing local recurrence rates lead to a switch to more distant failures, and increasing the radiation dose beyond 45 Gy appears to be of little value. However, it should be remembered that preop-CRT has associated toxicity, and may increase postoperative mortality. Novel strategies, which include induction with chemotherapy followed by preop-CRT, and for radiation therapy, three dimensional conformation techniques, image fusioning, and improved definition of treatment volumes, are still considered experimental and should be tested in specialized centers.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Transhiatal and transthoracic resection in adenocarcinoma of the esophagus: does the operative approach have an influence on the long-term prognosis?

Background

The goal of the present analysis was to investigate the long-term prognosis for adenocarcinoma of the esophagus treated with either the transhiatal (TH) or the transthoracic (TT) operative approach.

Methods

Between September 1985 and March 2004, esophageal resection due to carcinoma was performed on a total of 424 patients. This manuscript takes into account the 150 patients suffering from adenocarcinoma of the esophagus in whom a transhiatal resection of the esophagus was performed. In the event of transmural tumor growth and a justifiable risk of surgery, the transthoracic resection was selected. An extended mediastinal lymph node dissection, however, was only carried out in the course of the transthoracic approach.

Results

The transthoracic resection of the esophagus demonstrated a higher rate of general complications (p = 0.011) as well as a higher mortality rate (p = 0.011). The mediastinal dissection of the lymph nodes, however, revealed no prognostic influence. Considering all of the 150 patients with adenocarcinoma, as well as only those patients who had undergone curative resections (R0), the transhiatal approach was seen to demonstrate a better five-year survival rate of 32.1% versus 35.1%, with a median survival time of 24 versus 28 months, as compared with those who had undergone a transthoracic approach with a five-year survival rate of 13.6% (all patients) versus 17.7% (R0 resection) with a median survival time of 16 versus 17 months (p < 0.05).

Conclusion

The prognosis in patients with adenocarcinoma of the esophagus is influenced by the depth of the tumor (pT) and the pM-category, as shown in the multivariate analysis. The present analysis did not demonstrate a relevant difference in survival for patients with N0 and N1 stages undergoing transhiatal or transthoracic esophagectomy. It is questionable, if a more extensive mediastinal lymph node dissection, in addition to the clearance of abdominal lymph nodes, offers prognostic advantages in adenocarcinoma of the esophagus. However, the morbidity and mortality associated with the transthoracic approach is higher.

Lymph node counts in indians in relation to lymphadenectomy for carcinoma of the oesophagus and stomach

OBJECTIVE

Systemic lymphadenectomy for carcinoma of the oesophagus and stomach is increasingly accepted as effective surgical treatment. A review of available literature reveals a great variety in the number of lymph nodes removed during standard lymphadenectomy. The present study was conducted to find the normal number of lymph nodes in the Indian population in relation to lymphadenectomy for oesophageal and gastric carcinoma.

METHODS

Lymph nodes situated at stations 1-16, relevant to lymphadenectomy for gastric cancer, were removed by lymph node dissection according to the recommendations of the Japanese Research Society for Gastric Cancer and those at the 22 stations, relevant to lymphadenectomy in oesophageal cancer, were removed according to the International Society for Diseases of the Esophagus recommendations in 10 cadavers without a history of any abdominal pathology or haematological lymphatic disease. Nodes were cleared by dissolving fatty tissue. All lymph nodes were histologically confirmed and the diameter of each lymph node was recorded.

RESULTS

An average of 52.0 nodes (range, 37-78 nodes) was found at Stations 1-16, while an average of 183.6 nodes (range, 118-234 nodes) was found at the 22 stations. These numbers are higher than those in the literature.

CONCLUSION

This anatomical study addresses the dual issues of determining the number of dissectable lymph nodes in a particular population as well as assessing the quality of nodal dissection by providing quantitative surgical guidelines.