Surgical management of submucosal esophageal cancer: extended or regional lymphadenectomy?

Lymph Node Metastasis for pN+ Superficial Esophageal Squamous Cell Carcinoma

OBJECTIVES

This study aimed to analyze lymph node metastasis (LNM) distribution in superficial esophageal squamous cell carcinoma (ESCC) and its impact factors on survival.

METHODS

We reviewed 241 pT1N+ ESCC cases between February 2012 and April 2022 from 10 Chinese hospitals with a high volume of esophageal cancer (EC). We analyzed clinicopathological data to identify overall survival (OS) risk factors and LNM distribution in relation to tumor invasion depth.

RESULTS

Of the 241 patients, 26 (10.8%) had pT1a cancer and 215 (89.2%) had pT1b cancer. We showed that N3 stage, ≤ 28 lymphadenectomies, and nerve infiltration (NI) were negative factors for OS in superficial pN+ ESCC, whereas the OS was not definitively affected by the tumor depth and the choice of adjuvant therapy. In general, the LNM rates of the 193 pT1N+ ESCC cases can be ranked in the following order: station 106recR > station 106recL > station 1 > station 7 > station 2. With deeper tumor invasion, the higher LNM rate was observed near the bilateral recurrent laryngeal nerves (RLN), but there was no statistically significant difference.

CONCLUSIONS

In superficial ESCC, LNM was frequently observed along the 106recR (35.8%) and 106recL (25.6%) stations. Advanced N-staging (N3) was a major negative impact factor in prognosis, and adequate lymph nodes dissected (LND) (N > 28) improved OS of pT1N+ ESCC. However, in superficial ESCC, tumor infiltration depth did not affect patients' OS or the distribution of positive LNs. The optimal adjuvant treatment that favors survival for these patients required further investigation.

Reducing Conduit Ischemia and Anastomotic Leaks in Transhiatal Esophagectomy: Six Principles

BACKGROUND

Transhiatal esophagectomy (THE) is an accepted approach for distal esophageal (DE) and gastroesophageal junction (GEJ) cancers. Its reported weaknesses are limited loco-regional resection and high anastomotic leak rates. We have used laparoscopic assistance to perform a THE (LapTHE) as our preferred method of resection for GEJ and DE cancers for over 20 years. Our unique approach and experience may provide technical insights and perhaps superior outcomes.

METHODS

We reviewed all patients who underwent LapTHE for DE and GEJ malignancy over 10 years (2011-2020). We included 6 principles in our approach: (1) minimize dissection trauma using laparoscopy; (2) routine Kocher maneuver; (3) division of lesser sac adhesions exposing the entire gastroepiploic arcade; (4) gaining excess conduit mobility, allowing resection of proximal stomach, and performing the anastomosis with a well perfused stomach; (5) stapled side-to-side anastomosis; and (6) routine feeding jejunostomy and early oral diet.

RESULTS

One hundred and forty-seven patients were included in the analysis. The median number of lymph nodes procured was 19 (range 5-49). Negative margins were achieved in all cases (95% confidence interval [CI] 98-100%). Median hospital stay was 7 days. Overall major complication rate was 24% (17-32%), 90-day mortality was 2.0% (0.4-5.8%), and reoperation was 5.4% (2.4-10%). Three patients (2.0%, 0.4-5.8%) developed anastomotic leaks. Median follow-up was 901 days (range 52-5240). Nine patients (6.1%, 2.8-11%) developed anastomotic strictures.

CONCLUSIONS

Routine use of LapTHE for DE and GEJ cancers and inclusion of these six operative principles allow for a low rate of anastomotic complications relative to national benchmarks.

Continuously sutured versus linear-stapled anastomosis in robot-assisted hybrid Ivor Lewis esophageal surgery following neoadjuvant chemoradiotherapy: a single-center cohort study

BACKGROUND

Esophageal cancer surgery is technically highly demanding. During the past decade robot-assisted surgery has successfully been introduced in esophageal cancer treatment. Various techniques are being evaluated in different centers. In particular, advantages and disadvantages of continuously sutured (COSU) or linear-stapled (LIST) gastroesophageal anastomoses are debated. Here, we comparatively analyzed perioperative morbidities and short-term outcomes in patients undergoing hybrid robot-assisted esophageal surgery following neoadjuvant chemoradiotherapy (nCRT), with COSU or LIST anastomoses in a single center.

METHODS

Following standardized, effective, nCRT, 53 patients underwent a hybrid Ivor Lewis robot-assisted esophagectomy with COSU (n = 32) or LIST (n = 21) gastroesophageal anastomoses. Study endpoints were intra- and postoperative complications, in-hospital morbidity and mortality. Duration of operation, intensive care unit (ICU) and overall hospital stay were also evaluated. Furthermore, rates of rehospitalization, endoscopies, anastomotic stenosis and recurrence were assessed in a 90-day follow-up.

RESULTS

Demographics, ASA scores and tumor characteristics were comparable in the two groups. Median duration of operation was similar in patients with COSU and LIST anastomosis (467 vs. 453 min, IQR 420-521 vs. 416-469, p = 0.0611). Major complications were observed in 4/32 (12.5%) and 4/21 (19%) patients with COSU or LIST anastomosis, respectively (p = 0.697). Anastomotic leakage was observed in 3/32 (9.3%) and 2/21 (9.5%) (p = 1.0) patients with COSU or LIST anastomosis, respectively. Pleural empyema occurred in 1/32 (3.1%) and 2/21 (9.5%) (p = 0.555) patients, respectively. Mortality was similar in the two groups (1/32, 3.1% and 1/21, 4.7%, p = 1.0). Median ICU stay did not differ in patients with COSU or LIST anastomosis (p = 0.255), whereas a slightly, but significantly (p = 0.0393) shorter overall hospital stay was observed for COSU, as compared to LIST cohort (median: 20 vs. 21 days, IQR 17-22 vs. 18-28).

CONCLUSIONS

COSU is not inferior to LIST in the performance of gastroesophageal anastomosis in hybrid Ivor Lewis operations following nCRT.

Identification of serum prognostic marker miRNAs and construction of microRNA-mRNA networks of esophageal cancer

Esophageal cancer is a common tumor of the digestive system with poor prognosis. This study was to gain a better understanding of the mechanisms involved in esophageal cancer and to identify new prognostic markers. We downloaded the esophageal cancer miRNA expression profile microarray data (GSE113740, GSE112264, GSE122497, GSE113486, and GSE106817) from the GEO database, extracted the esophageal cancer miRNA sequencing data from The Cancer Genome Atlas (TCGA) database, and then used a bioinformatics approach to select common differentially expressed miRNAs (DEMs). Differentially expressed genes (DEGs) were selected by predicting DEM target genes using the miRWalk database and intersecting with differential genes obtained from TCGA database for esophageal cancer. The STRING database was used to obtain protein-protein interaction (PPI) relationships to construct the DEM-DEG network. Furthermore, we selected core genes and core miRNAs associated with esophageal cancer prognosis by performing survival and univariate/multivariate COX analysis on DEMs and DEGs in the network and performed GSEA analysis on core genes alone, and finally the expression of the markers was verified by qPCR in esophageal cancer cell lines Eca109, SKGT-4 and normal esophageal epithelial cells HEEC. Nine DEMs were obtained, of which three were upregulated and six were downregulated, and 326 DEGs were obtained, of which 105 were upregulated and 221 were downregulated. Survival univariate/multivariate COX analysis revealed that five genes, ZBTB16, AQP4, ADCYAP1R1, PDGFD, and VIPR2, and two microRNAs, miR-99a-5p, and miR-508-5p, were related to esophageal cancer prognosis. GSEA analysis showed that the following genes may be involved in esophageal cancer prognosis: ZBTB16 may through the MTOR signaling pathway, AQP4 through the GNRH signaling pathway, ADCYAP1R1 through the PPAR signaling pathway, VIPR2 through the P53 signaling pathway and PDGFD through the PENTOSE-PHOSPHATE signaling pathway.

Prognostic value of the extent of lymphadenectomy for esophageal cancer-specific survival among T1 patients

Background

Clinically, there are no clear guidelines on the extent of lymphadenectomy in patients with T1 esophageal cancer. Studying the minimum number of lymph nodes for resection may increase cancer-specific survival.

Methods

Patients who underwent esophagectomy and lymphadenectomy at T1 stage were selected from the Surveillance, Epidemiology and End Results Program (United States, 1998–2014). Maximally selected rank and Cox proportional hazard models were used to examine three variables: the number of lymph nodes examined, the number of negative lymph nodes and the lymph node ratio.

Results

Approximately 18% had lymph node metastases, where the median values were 10, 10 and 0 for the number of lymph nodes examined, the number of negative lymph nodes and the lymph node ratio, respectively. All three examined variables were statistically associated with cancer-specific survival probability. Dividing patients into two groups shows a clear difference in cancer-specific survival compared to four or five groups for all three variables: there was a 29% decrease in the risk of death with the number of lymph nodes examined ≥14 vs < 14 (hazard ratio 0.71, 95% confidence interval: 0.57–0.89), a 35% decrease in the risk of death with the number of negative lymph nodes ≥13 vs < 13 (hazard ratio 0.65, 95% confidence interval: 0.52–0.81), and an increase of 1.21 times in the risk of death (hazard ratio 2.21, 95% confidence interval: 1.76–2.77) for the lymph node ratio > 0.05 vs ≤ 0.05.

Conclusions

The extent of lymph node dissection is associated with cancer-specific survival, and the minimum number of lymph nodes that need to be removed is 14. The number of negative lymph nodes and the lymph node ratio also have prognostic value after lymphadenectomy among T1 stage patients.

Comparison of long-term outcomes between radical esophagectomy and definitive chemoradiotherapy in patients with clinical T1bN0M0 esophageal squamous cell carcinoma

BACKGROUND

Long-term outcomes of patients with clinical T1bN0M0 thoracic esophageal squamous cell carcinoma (ESCC) treated using radical esophagectomy were compared with those treated using definitive chemoradiotherapy (dCRT).

METHODS

A total of 320 consecutive patients with clinical T1bN0M0 thoracic ESCC who initially underwent radical esophagectomy or chemoradiotherapy during 2001-2011 were deemed eligible. Of these patients, 102 and 218 underwent radical esophagectomy and dCRT, respectively. Overall survival (OS) and causes of death were compared between the esophagectomy group and the chemoradiotherapy group.

RESULTS

Five-year OS in the esophagectomy group was significantly better than that of the chemoradiotherapy group in both the overall sample and a subset of patients aged ≥70 years (P=0.004 and P=0.040). Male patients appeared to benefit more from radical esophagectomy (P=0.005). Until 2006, radical esophagectomy yielded superior results relative to dCRT (P=0.009). However, the survival outcomes after chemoradiotherapy were non-inferior to those after esophagectomy since 2007 (P=0.255). Up to 2006, esophagectomy and chemoradiotherapy groups exhibited significant differences in the causes of death (P=0.024), such that the latter group had a significantly higher rate of deaths due to respiratory complications (P=0.025). However, the introduction of 3-dimensional radiation with CT guided planning in 2007 resolved this inter-group difference (P=0.460).

CONCLUSIONS

The appreciable developments in radiation technology have enabled the achievement of comparable long-term outcomes in the chemoradiotherapy group compared with the esophagectomy group in patients with clinical T1bN0M0 thoracic ESCC.

A model based on endoscopic morphology of submucosal esophageal squamous cell carcinoma for determining risk of metastasis on lymph nodes

BACKGROUND

It is important to identify patients with esophageal squamous cell carcinoma (ESCC) in T1b stage that are the least likely to metastasize on the lymph nodes, to undergo endoscopic resection, especially for the patients unfit for esophagectomy. The relationship between endoscopic morphology and frequency of nodal metastasis has never been well studied. The aims of the study were to investigate the predictive value of endoscopic morphology for lymphatic metastasis, and to develop a risk stratification model in submucosal (T1b) ESCC.

METHODS

Pathologic variables of patients with T1b ESCC who underwent esophagectomy from 2006 through 2016 were collected and divided into training sets (patients between 2006 and 2011) and validation sets (patients between 2012 and 2016). The endoscopic morphology of the tumor was determined by analyzing endoscopic reports according to the Paris classification. The correlation between the clinicopathological factors and nodal metastasis was examined. A prediction model was developed to estimate the risk of metastasis using these predictors.

RESULTS

A total of 175 patients were included in this study. A tumor with an endoscopic shape of flat type (0-II type as Paris classification was defined) was significantly related to lower risk of lymphatic metastasis with the frequency of 15.5% (OR: 3.049, 95% CI: 1.363-6.819, P=0.005). The combination of endoscopic morphology with other pathologic characteristics including lymphovascular invasion, length of tumor, depth of tumor invasion into submucosa, and tumor differentiation improved the predictive value of the nodal metastasis. The risk stratification model was developed with a C-index of 0.726 (95% CI: 0.702-0.751), which identified a low risk subgroup with a lymph node rate of 7.2%.

CONCLUSIONS

Our results suggest that when a tumor is in flat shape (0-II type) it is related to a less lymphatic metastasis, and the combination of the endoscopic morphology with the other four pathologic variables can yield a more robust approach to predict the risk of lymphatic metastasis in submucosal ESCC.

A nomogram for predicting lymph node metastasis in surgically resected T1 esophageal squamous cell carcinoma

Background

Endoscopic therapies for T1 esophageal carcinoma have been increasingly used around the world. However, the procedures are limited by without lymph nodes harvested. The risk of lymph node metastasis (LNM) should been established. Our objective was to construct a nomogram model for predict risks of LNM in patients with pT1 esophageal squamous cell carcinoma (ESCC).

Methods

We reviewed the records of 221 patients with pT1 ESCC who underwent surgical resection and radical lymphadenectomy. Clinicopathological variables were analyzed univariate and multivariate logistic regression analysis. A nomogram for predicting risk of LNM was constructed and validated using bootstrap resampling.

Results

Of the 221 patients, 53 patients had been examined as LNM. Following multivariate analysis, poor differentiation (P=0.0006), lymphovascular invasion (P<0.0001) and SM3 (tumor invades the lower third of the submucosal layer) (P=0.0192) cancer were significantly independent risk factors for LNM and were entered into the nomogram. The nomogram showed a robust discrimination, with an area under the receiver operating characteristic curve (AUC) of 0.8667. The calibration curves for the probability of LNM showed optimal agreement between the probability as predicted by the nomogram and the actual probability.

Conclusions

We established a nomogram that can provide individual predicting for LNM in T1 ESCC, and this model has the potential clinical utility in making therapeutic procedures.

Clinicopathologic Features of Submucosal Esophageal Squamous Cell Carcinoma

BACKGROUND

The prognoses of submucosal esophageal squamous cell carcinoma patients vary. Patients with favorable prognoses may receive less invasive or nonsurgical interventions, whereas patients with poor prognoses or advanced esophageal cancer may require aggressive treatments. We sought to identify prognostic factors for patients with submucosal esophageal squamous cell carcinoma, focusing on lymph node metastasis and recurrence.

METHODS

We included 137 submucosal esophageal squamous cell carcinoma patients who had undergone transthoracic esophagectomy with systematic extended lymph node dissection. Submucosal tumors were classified as SM1, SM2, and SM3 according to the depth of invasion. Prognostic factors were determined by univariable and multivariable analyses.

RESULTS

Lymph node metastasis was observed in 18.8%, 30.5%, and 50.0% of SM1, SM2, and SM3 cases, respectively. The overall 5-year recurrence rate was 21.9%; the rates for SM1, SM2, and SM3 tumors were 9.4%, 18.6%, and 34.8%, respectively. The SM1 tumors all recurred locoregionally; distant metastasis occurred in SM2 and SM3 cases. The 5-year overall survival rates were 83%, 77%, and 59% for SM1, SM2, and SM3 cases, respectively. On univariable analysis, lymph node metastasis, depth of submucosal invasion (SM3 versus SM1/2), and tumor location (upper thoracic versus mid/lower thoracic) were poor prognostic factors for overall survival. Multivariable Cox regression analyses identified depth of submucosal invasion (hazard ratio 2.51, 95% confidence interval: 1.37 to 4.61) and tumor location (hazard ratio 2.43, 95% confidence interval: 1.18 to 4.63) as preoperative prognostic factors.

CONCLUSIONS

Tumor location (upper thoracic) and infiltration (SM3) are the worse prognostic factors of submucosal esophageal squamous cell carcinoma, but lymph node metastasis is not a predictor of poorer prognosis.

Extent of Mediastinal Lymphadenectomy and Survival in Superficial Esophageal Squamous Cell Carcinoma

BACKGROUND

The aim of this study is to investigate the utility of total mediastinal lymphadenectomy (ML) in superficial esophageal squamous cell carcinoma (ESCC).

METHODS

The medical records of 129 patients who underwent esophagectomy and lymph node dissection for pathologically confirmed pT1 ESCC between July 2006 and December 2014 were retrospectively reviewed. Limited ML, such as traditional 2-field or transhiatal esophagectomy, was performed in 42 patients (group 1), and total ML, including the bilateral recurrent laryngeal nerve nodes, was performed in 87 patients (group 2).

RESULTS

R0 resection was achieved in all patients, and the number of dissected nodes was 28.0 ± 11.4 and 44.8 ± 16.1 in groups 1 and 2 (p < 0.001), respectively. The complication profile was similar in the two groups, but there were two operative mortalities in group 2. During a median follow-up of 32.4 months, loco-regional failure was found in 14.3% of group 1 and 3.5% of group 2 (p = 0.001). There was a significant difference in the 3-year overall survival (95.1% in group 2 vs. 83.3% in group 1, p = 0.043), and the 3-year disease-free survival rates (92.3% in group 2 vs. 73.7% in group 1, p = 0.001). On multivariate analysis, the extent of ML (HR, 5.200; 95% CI, 1.532 ~ 17.645; p = 0.008) and pT1b lesion classification (HR, 4.747; 95% CI, 1.024 ~ 21.997; p = 0.047) was a factor predictive of disease-free survival.

CONCLUSIONS

Total ML might be beneficial, especially in cases of pT1b ESCC, because it could lead to a lower incidence of recurrence and longer survival times.

Efficacy of docetaxel, cisplatin, and 5-fluorouracil chemotherapy for superficial esophageal squamous cell carcinoma

The anticancer efficacy of docetaxel, cisplatin, and 5-fluorouracil (DCF) chemotherapy has been reported to be better than that of conventional regimens for advanced or relapsed esophageal squamous cell carcinoma (ESCC), and may become a standard therapy for this disease. Because it is extremely rare for chemotherapy to be administered as treatment for early cancer alone, the efficacy of DCF for superficial ESCC remains unknown. However, from a clinical oncological standpoint, it is important to investigate the anticancer efficacy of chemotherapy for early cancer, which may be useful for understanding the development of treatment resistance against chemotherapy in cancer. This retrospective, single-center analysis included 28 patients with superficial ESCC who received DCF for synchronous head and neck squamous cell carcinoma between June 2007 and July 2013. The response rate to DCF was 60.7%. In 14 of 17 patients who had been judged to have a complete response, local recurrence was eventually confirmed by follow-up esophagogastroduodenoscopy. The median progression-free survival for all 28 patients was 6.0 months. The anticancer efficacy of DCF was not found to be dependent on tumor progression stage or on the volume of local and metastatic tumors but on the drug sensitivity of the individual. Our results suggest that the efficacy of DCF against superficial esophageal squamous cell carcinoma appears to be limited to local lesions and metastases of regional lymph nodes, and the expected effect of DCF for early ESCC is similar to that for advanced, metastatic, or recurrent esophageal cancer.

Current Status and Future Prospects for Esophageal Cancer Treatment

The local control effect of esophagectomy with three-field lymph node dissection (3FLD) is reaching its limit pending technical advancement. Minimally invasive esophagectomy (MIE) by thoracotomy is slowly gaining acceptance due to advantages in short-term outcomes. Although the evidence is slowly increasing, MIE is still controversial. Also, the results of treatment by surgery alone are limiting, and multimodality therapy, which includes surgical and non-surgical treatment options including chemotherapy, radiotherapy, and endoscopic treatment, has become the mainstream therapy. Esophagectomy after neoadjuvant chemotherapy (NAC) is the standard treatment for clinical stages II/III (except for T4) esophageal cancer, whereas chemoradiotherapy (CRT) is regarded as the standard treatment for patients who wish to preserve their esophagus, those who refuse surgery, and those with inoperable disease. CRT is also usually selected for clinical stage IV esophageal cancer. On the other hand, with the spread of CRT, salvage esophagectomy has traditionally been recognized as a feasible option; however, many clinicians oppose the use of surgery due to the associated unfavorable morbidity and mortality profile. In the future, the improvement of each treatment result and the establishment of individual strategies are important although esophageal cancer has many treatment options.

Transthoracic Anastomotic Leak After Esophagectomy: Current Trends

INTRODUCTION

Leaks from intrathoracic esophagogastric anastomosis are thought to be associated with higher rates of morbidity and mortality than leaks from cervical anastomosis. We challenge this assumption and hypothesize that there is no significant difference in mortality based on the location of the esophagogastric anastomosis.

METHODS

A systematic literature search was conducted using PubMed and Embase databases on all studies published from January 2000 to June 2015, comparing transthoracic (TTE) and transhiatal (THE) esophagectomies. Studies using jejunal or colonic interposition were excluded. Outcomes analyzed were leak rate, leak-associated mortality, overall 30-day mortality, and overall morbidity. Meta-analyses were performed using Mantel-Haenszel statistical analyses on studies reporting leak rates of both approaches. Nominal data are presented as frequency and interquartile range (IQR); measures of the association between treatments and outcomes are presented as odds ratio (OR) with 95 % confidence interval.

RESULTS

Twenty-one studies (3 randomized controlled trials) were analyzed comprising of 7167 patients (54 % TTE). TTE approach yields a lower anastomotic leak rate (9.8 %; IQR 6.0-12.2 %) than THE (12 %; IQR 11.6-22.1 %; OR 0.56 [0.34-0.92]), without any significant difference in leak associated mortality (7.1 % TTE vs. 4.6 % THE: OR 1.83 [0.39-8.52]). There was no difference in overall 30-day mortality (3.9 % TTE vs. 4.3 % THE; OR 0.86 [0.66-1.13]) and morbidity (59.0 % TTE vs. 66.6 % THE; OR 0.76 [0.37-1.59]).

DISCUSSION

Based on meta-analysis, TTE is associated with a lower leak rate and does not result in higher morbidity or mortality than THE. The previously assumed higher rate of transthoracic anastomotic leak-associated mortality is overstated, thus supporting surgeon discretion and other factors to influence the choice of thoracic versus cervical anastomosis.

Therapeutic value of lymph node dissection for esophageal squamous cell carcinoma after neoadjuvant chemotherapy

BACKGROUND AND OBJECTIVES

The optimal extent of lymphadenectomy in patients with esophageal cancer is controversial. This study aimed to examine the therapeutic value of lymph node (LN) dissection for each LN station in patients with esophageal squamous cell carcinoma (ESCC) who receive neoadjuvant chemotherapy.

METHODS

In 304 patients with ESCC who underwent neoadjuvant chemotherapy, Efficacy Index (EI) was calculated by multiplying the incidence of metastasis by the 3-year survival rate of patients with positive nodes for each LN station.

RESULTS

Prognosis was better in responders to neoadjuvant chemotherapy than non-responders (3-year survival; 66.3% vs 48.1%, P = 0.0035). The total number of resected LNs did not affect survival although the number of positive LNs did. The number of resected LNs did not correlate with the number of metastatic LNs. Cardiac LN and recurrent nerve LN showed high EI, irrespective of tumor location. EI for each LN station did not vary according to the response to neoadjuvant therapy.

CONCLUSIONS

The present study showed that therapeutic value of each LN was not affected by preoperative chemotherapy. The location of resected LNs rather than the total number of resected LNs may be more important to maximize the survival benefit of lymphadenectomy.

CC-Chemokine receptor CCR7: a key molecule for lymph node metastasis in esophageal squamous cell carcinoma

BACKGROUND

CC-chemokine receptor 7 (CCR7), a known lymph node homing receptor for immune cells, has been reported as a key molecule in lymph node metastasis. We hypothesized a clinicopathological correlation and functional causality between CCR7 expression and lymph node metastasis in patients with esophageal squamous cell carcinoma (ESCC).

METHODS

We performed immunohistochemical analysis of 105 consecutive and 61 exclusive pathological T1 ESCC patients, followed by adhesion assay and in vivo experiment using a newly developed lymph node metastasis mouse model. The adhesive ability in response to CC-chemokine ligand 21/secondary lymphoid-tissue chemokine (CCL21/SLC) was assessed in the presence or absence of lymphatic endothelial cells and anti-CCR7 antibody. We established a heterotopic transplantation mouse model and analyzed lymph node metastasis by quantitative real-time RT-PCR.

RESULTS

Positive CCR7 expression in immunohistochemistory was detected in 28 (27%) of 105 consecutive patients and 17 (28%) of 61 T1 patients, which significantly correlated with lymph node metastasis (p = 0.037 and p = 0.040, respectively) and poor five-year survival (p = 0.013 and p = 0.012, respectively). Adhesion assay revealed an enhanced adhesive ability of CCR7-expressing cells in response to CCL21/SLC, in particular, in the presence of lymphatic endothelial cells (p = 0.005). In the mouse model, lymph nodes from mice transplanted with CCR7-expressing cells showed significantly higher DNA levels at 5 weeks (p = 0.019), indicating a high metastatic potential of CCR7-expressing cells.

CONCLUSION

These results demonstrated the significant clinicopathological relationship and functional causality between CCR7 expression and lymph node metastasis in ESCC patients.

Minimally invasive surgery for esophageal cancer: a review on sentinel node concept

BACKGROUND

Lymphoadenectomy is a cornerstone of esophageal cancer treatment, and sentinel node (SN) biopsy (SNB) might provide surgeons with an extra tool to limit unnecessarily extended lymphadenectomy and to implement a minimally invasive approach. The aim of our study was to review all the available literature on the use of SNB in esophageal surgery for malignancy.

METHODS

The review was conducted according to the PRISMA guidelines. A systematic search was performed in PubMed, EMBASE, and the Cochrane database to identify all original articles on the role of SNB in esophageal cancer. Data on methodologies, tumor stage and localization, and results were summarized and used to address relevant clinical questions related to the application of the SNB technique in esophageal cancer.

RESULTS

Twelve studies were included, with a total of 492 patients. Different methods for SN identification were used (radionuclide, blue dye, computed tomography [CT] lymphography). The pooled values estimated using the random-effects model were, respectively: technetium-99 m overall detection rate (DR) 0.970 (95 % CI 0.814-0.996), accuracy (ACC) 0.902 (95 % CI 0.736-0.968); blue-dye DR 0.971 (95 % CI 0.890-0.993), ACC 0.790 (95 % CI 0.681-0.870); and CT lymphoscintigraphy DR 0.970 (95 % CI 0.814-0.996), ACC 0.902 (95 % CI 0.736-0.968).

CONCLUSION

Based on these results, the concept of SN in esophageal cancer is technically feasible with an acceptable DR and ACC, and it might be applicable in the event of early-stage adenocarcinoma of the gastroesophageal junction in patients with a high surgical risk or in a patient where an endoscopic resection is taken into consideration. Further studies focused on a single tumor type and localizations are needed in order to predict the correct utilization of this concept in minimally invasive treatment of esophageal cancer.

Extent of lymphadenectomy does not predict survival in patients treated with primary esophagectomy

BACKGROUND

The number of lymph nodes resected and its impact on survival for patients with esophageal cancer remains undefined. Current guidelines recommend extended lymphadenectomy in patients not receiving neoadjuvant therapy. We reviewed our single institutional experience with nodal harvest for esophageal cancer in a non-neoadjuvant therapy setting.

METHODS

Patients who underwent esophagectomy as primary therapy were indentified from a prospectively maintained database consisting of 704 patients who underwent esophagectomy. Patients were stratified by number of lymph nodes (LN) resected: >5, 10, 12, 15, or 20. Survival, clinical, and pathologic parameters were analyzed with Kaplan-Meier curves, chi-square, or Fisher's exact tests where appropriate.

RESULTS

We identified 246 patients who underwent esophagectomy as initial treatment. The mean age was 65 ±10 years. The majority of patients were male (87%). Ivor-Lewis esophagectomy was performed for 71%, minimally invasive esophagectomy for 15%, transhiatal esophagectomy for 12%, and three-field esophagectomy for 2%. At 60 months follow-up, there was no statistically significant difference in overall survival (OS) or disease-free survival (DFS) between patients with < vs. >5 LN resected (p = 0.74 and p = 0.67, respectively) or in the < vs. >10 (p = 0.33, p = 0.11), 12 (p = 0.82, p = 0.90), 15 (p = 0.45, p = 0.79), or 20 (p = 0.72, p = 0.86) resected LN groups. Patients were then subdivided into node-positive and node-negative cohorts and stratified by nodal harvest. In the subgroups of patients with node-negative and node-positive disease, OS and DFS also did not significantly differ between groups with respect to number of nodes resected (p > 0.05). A total of 49 (20%) patients developed recurrent disease; however, recurrence was not statistically associated with number of LN resected (p > 0.05).

CONCLUSION

We found no impact of extent of lymphadenectomy on overall or disease-free survival in patients treated with esophagectomy without neoadjuvant therapy. In addition, the number of nodes resected at esophagectomy did not affect recurrence rates. Current recommendations for increased nodal resection during esophagectomy in patients not receiving neoadjuvant therapy may not improve patient outcomes, and this phenomenon warrants further investigation.

Cervical lymph node dissection for clinically submucosal carcinoma of the thoracic esophagus

BACKGROUND

The purposes of this study were to clarify the risk factors for supraclavicular lymph node (SCLN) metastasis and the survival benefit from cervical lymph node (LN) dissections in patients with clinically submucosal (cT1b) carcinoma of the thoracic esophagus.

METHODS

A total of 86 patients with this disease who underwent esophagectomy with 3-field lymph node dissection were retrospectively reviewed. Multivariate logistic regression and Cox proportional hazard model were used to identify the independent risk factors for SCLN metastasis and prognostic factors, respectively. An index calculated by multiplying the frequency of metastasis at nodal basin and the 5-year overall survival rate of patients with metastasis at that basin were used to assess the therapeutic outcomes.

RESULTS

A total of 40 patients (47%) were found to have pathological LN metastasis. Also, 13 patients (15%) had cervical LN metastasis: 6 and 7 with carcinoma of the upper and mid-thoracic esophagus, respectively. SCLN metastasis was found in 6 patients (7%); however, there was no independent risk factor for SCLN metastasis. The 5-year overall survival rate was 72.5%. Cervical LN metastasis was an independent prognostic factor (p = .04; odds ratio 2.55; 95% confidence interval 1.03-6.31); however, there was no significant difference in survival between patients with SCLN metastasis and those without (p = .06). The calculated index of estimated benefit from cervical LN dissections was 6.9, following upper mediastinal LN of 15.6 and perigastric LN of 8.3.

CONCLUSIONS

We could not identify risk factors to predict SCLN metastasis. Cervical LN dissection should not be omitted in patients with cT1b carcinoma, especially of the upper and mid-thoracic esophagus.

Oesophageal cancer--an overview

Oesophageal carcinoma is one of the most virulent malignant diseases and a major cause of cancer-related deaths worldwide. Diagnosis and accuracy of pretreatment staging have substantially improved throughout the past three decades. Therapy is challenging and the optimal approach is still debated. Oesophagectomy is considered to be the procedure of choice in patients with operable oesophageal cancer. Endoscopic measures and limited surgical procedures provide an alternative in patients with early carcinomas confined to the oesophageal mucosa. Chemotherapy and radiotherapy or concurrent chemoradiotherapy are also frequently applied, either as definitive treatment or as neoadjuvant therapy within multimodal approaches. The question of whether multimodal treatment offers improved results has been the focus of many studies since the 1990s. Although results are discordant and even some meta-analyses remain inconclusive, it is now widely accepted that multimodal therapy leads to a modest survival benefit. The role of minimally invasive oesophagectomy is not yet defined. Endoscopic stent insertion, radiotherapy and other palliative measures provide relief of tumour-related symptoms in advanced, unresectable tumour stages.

Lymph node dissection for esophageal cancer

The prevalence of lymph node (LN) metastasis in esophageal cancer (EC) is widely spread to all three fields, namely, to the neck region, the mediastinal region and the abdominal region. Furthermore, the status of LN metastasis has been recognized as a key factor that influences the outcome after EC surgery. Therefore, the latest version of the UICC/AJCC TNM classification (7th edition) applied the number of metastatic LNs as an N factor. However, the precise clinical diagnosis of metastatic LNs is still difficult. This is mainly because there are many micrometastases in EC. Therefore, the Japanese Classification of Esophageal Cancer (10th edition) has not incorporated the number of LN metastases into the N factor for its staging system and the accurate preoperative diagnosis of LN status is currently one of the most important issues to be resolved for EC. Given the frequency and extent of LN metastasis and its significance for the survival, controlling LN metastasis is a rational therapeutic strategy, and an extended LN dissection, such as three-field lymph node dissection may be logical, although appropriate patient selection is necessary. On the other hand, recent arguments have supported a reduction of unnecessary LN dissection in esophagectomy. To curtail unnecessary LN dissection, one of the current topics is sentinel lymph node-guided surgery and is being investigated as part of the next generation surgeries for EC. In this article, recent literatures were reviewed and we discuss the current status of lymph node dissection in EC.

Surgical treatment for early esophageal squamous cell carcinoma

More studies are needed to clarify treatments and prognosis of early esophageal squamous cell carcinoma (ESCC). This retrospective study was designed to review the outcome of surgical treatment for early ESCC, evaluate the results of a left thoracotomy for selected patients with early ESCC, and identify factors affecting lymph node metastases and survival. The clinicopathological data of 228 patients with early ESCC who underwent transthoracic esophagectomy with lymphadenectomy without preoperative adjuvant treatment were reviewed. The χ(2) test or Fisher's exact test were used to detect factors related to lymph node metastasis. Univariate and multivariate analyses were performed to identify prognostic factors. There were 152 males and 76 females with a median age of 55 years. Two hundred and eight patients underwent a left thoracotomy, and the remaining 20 patients with lymph nodes in the upper mediastinum more than 5 mm in short-axis diameter by computed tomography scan underwent a right thoracotomy. No lymph node metastasis was found in the 18 patients with carcinoma in situ, while lymph node metastases were detected in 1.6% (1/62) of patients with mucosal tumours and 18.2% (27/148) of patients with submucosal tumours. Only 7 patients showed upper mediastinal lymph node metastases in the follow-up. The 5- and 10-year overall survival rates were 81.4% and 70.1%, respectively. Only histologic grade (P<0.001) and pT category (P=0.001) significantly correlated with the presence of lymph node metastases. In multivariate analysis, only histologic grade (P=0.026) and pT category (P=0.008) were independent prognostic factors. A left thoracotomy is acceptable for selected patients with early ESCC. Histologic grade and pT category affected the presence of lymph node metastases and were independent prognostic factors for early ESCC.

Management of stage 1 esophageal cancer

Barrett esophagus surveillance programs and more liberal use of upper endoscopy are leading to the identification of more patients with high-grade dysplasia or early stage esophageal adenocarcinoma. These patients have several options for therapy, including endoscopic mucosal resection, vagal-sparing esophagectomy, and a combination of endoscopic resection and ablation. Factors that should be considered include the length of the Barrett segment, the presence of a nodule or ulcer within the Barrett segment, and the age and overall physical condition of the patient. Of particular importance will be the incidence of recurrent Barrett esophagus or cancer in the long-term in patients that were initially successfully treated endoscopically.

Significant variation of resected meso-esophageal tissue volume in two-stage subtotal esophagectomy specimens: a retrospective morphometric study

BACKGROUND

Differences in the extent and quality of surgical resection for esophageal cancer may influence the pathological staging and patient outcome. There are no data in the literature qualitatively and/or quantitatively characterizing esophagectomy specimens.

METHODS

Macroscopic images of 161 esophagectomy specimens were analyzed retrospectively. The extent of resection was qualitatively classified as "muscularis propria," "intra-meso-esophageal," or "meso-esophageal." The volume of meso-esophageal tissue was quantified morphometrically. The number of muscle defects per specimen was counted. Results were related to clinicopathological variables, including survival.

RESULTS

Sixty-two (39%) specimens were classified as "muscularis propria," 65 (40%) as "intra-meso-esophageal," and 34 (21%) as "meso-esophageal." The morphometrically measured meso-esophageal tissue volume was different between the three types (P < 0.001). The specimen type was related to the total number of lymph nodes (P = 0.02), number of metastatic lymph nodes (P = 0.024), and depth of tumor invasion (P = 0.013), but not related to extramural tumor volume, circumferential resection margin status, or the surgeon performing the resection. The number of muscle defects per specimen was similar in all resection types. The resection specimen classification was related to survival in patients treated by surgery alone (P = 0.027).

CONCLUSIONS

This is the first study to quantify and classify the volume of tissue resected during esophagectomy. Our study shows significant variation of the resected tissue volume impacting pathological tumor staging. This variation was not associated with individual surgeon performance. A prospective, multicenter study is needed to validate our results and to investigate the potential biological mechanisms influencing the resectable volume of meso-esophageal tissue in cancer patients.

Esophageal submucosa: the watershed for esophageal cancer

OBJECTIVES

Submucosal esophageal cancers (pT1b) are considered superficial, implying good survival. However, some are advanced, metastasizing to regional lymph nodes. Interplay of cancer characteristics and lymphatic anatomy may create a watershed, demarcating low-risk from high-risk cancers. Therefore, we characterized submucosal cancers according to depth of invasion and identified those with high likelihood of lymph node metastases and poor survival.

METHODS

From 1983 to 2010, 120 patients underwent esophagectomy for submucosal cancers at Cleveland Clinic. Correlations were sought among cancer characteristics (location, dimensions, histopathologic cell type, histologic grade, and lymphovascular invasion [LVI]), and their associations with lymph node metastasis were identified by logistic regression. Associations with mortality were identified by Cox regression.

RESULTS

As submucosal invasion increased, cancer length (P < .001), width (P < .001), area (P < .001), LVI (P = .007), and grade (P = .05) increased. Invasion of the deep submucosa (P < .001) and LVI (P = .06) predicted lymph node metastases: 45% (23/51) of deep versus 10% (3/29) of middle-third and 7.5% (3/40) of inner-third cancers had lymph node metastases, as did 46% (12/26) with LVI versus 18% (17/94) without. Older age and lymph node metastases predicted worse 5-year survival: 94% for younger pN0 patients, 62% for older pN0 patients, and 36% for pN1-2 patients regardless of age.

CONCLUSIONS

Submucosal cancer characteristics and lymphatic anatomy create a watershed for regional lymph node metastases in the deep submucosa. This previously unrecognized divide distinguishes superficial submucosal cancers with good survival from deep submucosal cancers with poor survival. Aggressive therapy of more superficial cancers is critical before submucosal invasion occurs.