Prognostic impact of lymph node metastasis along the left gastric artery in esophageal squamous cell carcinoma

Validation of the Node Reporting and Data System (Node-RADS) for standardized CT evaluation of regional lymph nodes in esophageal squamous cell carcinoma patients

OBJECTIVES

The accurate identification of positive lymph nodes in esophageal squamous cell carcinoma (ESCC) influences patient risk assessment and treatment decisions, but there is no standardized approach for radiological evaluation. The aim of this study was to verify the diagnostic performance of the new Node Reporting and Data System 1.0 (Node-RADS) in the assessment of lymph node metastasis in patients with ESCC, as verified by final histopathology.

METHODS

Node-RADS is a scoring system composed of different criteria for evaluating lymph node metastasis, with scores ranging from 1 to 5, corresponding to the degree of suspicion of lymph node involvement. In this single-center study, Node-RADS was used to retrospectively evaluate regional lymph nodes in 173 ESCC patients who underwent computed tomography (CT) before radical resection. In addition, the area under the ROC curve (AUC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for the Node-RADS score and individual criteria.

RESULTS

Node-RADS outperformed the individual assessment criteria (AUC: 94.3%, sensitivity: 96.5%, specificity: 92.0%), with scores ≥ 3 indicating the maximum diagnostic effectiveness. The diagnostic efficiency of the highest Node-RADS score surpassed that of the short axis score (AUC: 94.3% vs. 81.9%, p < 0.001). Our results indicated that the best diagnostic cut-off points for the short axis, long axis and short axis/long axis ratio were 9 mm, 11 mm, and 0.74, respectively.

CONCLUSION

Node-RADS has emerged as a practical, repetitive method for the early identification of high-risk metastatic lymph nodes, providing therapeutic guidance and predicting disease prognosis in ESCC patients.

KEY POINTS

Question How does the Node Reporting and Data System 1.0 (Node-RADS) perform in the assessment of lymph node metastasis in patients with esophageal squamous cell carcinoma (ESCC)? Findings The maximum diagnostic efficiency was achieved with a Node-RADS score of ≥ 3. Clinical relevance The Node-RADS has improved diagnostic efficiency for distinguishing lymph node metastasis in patients with ESCC.

Mapping of lymph node metastasis from esophageal squamous cell carcinoma after neoadjuvant treatment: a prospective analysis from a high-volume institution in China

The study aimed to describe the prevalence of lymph node metastases per lymph node station for esophageal squamous cell carcinoma (ESCC) after neoadjuvant treatment. Clinicopathological variables of ESCC patients were retrieved from the prospective database of the Surgical Esophageal Cancer Patient Registry in West China Hospital, Sichuan University. A two-field lymphadenectomy was routinely performed, and an extensive three-field lymphadenectomy was performed if cervical lymph node metastasis was suspected. According to AJCC/UICC 8, lymph node stations were investigated separately. The number of patients with metastatic lymph nodes divided by those who underwent lymph node dissection at that station was used to define the percentage of patients with lymph node metastases. Data are also separately analyzed according to the pathological response of the primary tumor, neoadjuvant treatment regimens, pretreatment tumor length, and tumor location. Between January 2019 and March 2023, 623 patients who underwent neoadjuvant therapy followed by transthoracic esophagectomy were enrolled. Lymph node metastases were found in 212 patients (34.0%) and most frequently seen in lymph nodes along the right recurrent nerve (10.1%, 58/575), paracardial station (11.4%, 67/587), and lymph nodes along the left gastric artery (10.9%, 65/597). For patients with pretreatment tumor length of >4 cm and non-pathological complete response of the primary tumor, the metastatic rate of the right lower cervical paratracheal lymph nodes is 10.9% (10/92) and 10.6% (11/104), respectively. For patients with an upper thoracic tumor, metastatic lymph nodes were most frequently seen along the right recurrent nerve (14.2%, 8/56). For patients with a middle thoracic tumor, metastatic lymph nodes were most commonly seen in the right lower cervical paratracheal lymph nodes (10.3%, 8/78), paracardial lymph nodes (10.2%, 29/285), and lymph nodes along the left gastric artery (10.4%, 30/289). For patients with a lower thoracic tumor, metastatic lymph nodes were most frequently seen in the paracardial station (14.2%, 35/247) and lymph nodes along the left gastric artery (13.1%, 33/252). The study precisely determined the distribution of lymph node metastases in ESCC after neoadjuvant treatment, which may help to optimize the extent of lymphadenectomy in the surgical management of ESCC patients after neoadjuvant therapy.

Lymph node metastasis determined miRNAs in esophageal squamous cell carcinoma

PURPOSE

There is no golden noninvasive and effective technique to diagnose lymph node metastasis (LNM) for esophageal squamous cell carcinoma (ESCC) patients. Here, a classifier was proposed consisting of miRNAs to screen ESCC patients with LNM from the ones without LNM.

METHODS

miRNA expression and clinical data files of 93 ESCC samples were downloaded from TCGA as the discovery set and 119 ESCC samples with similar dataset GSE43732 as the validation set. Differentially expressed miRNAs (DE-miRNAs) were analyzed between patients with LNM and without LNM. LASSO regression was performed for selecting the DE-miRNA pair to consist the classifier. To validate the accuracy and reliability of the classifier, the SVM and AdaBoost algorithms were applied. The CCK-8 and wound healing assay were used to evaluate the role of the miRNA in ESCC cells.

RESULT

There were 43 DE miRNAs between the LNM+ group and LNM- group. Among them, miR-224-5p, miR-99a-5p, miR-100-5p, miR-34c-5p, miR-503-5p, and miR-452-5p were identified by LASSO to establish the classifier. SVM and AdaBoost showed that the model could classify the ESCC patients with LNM from the ones without LNM precisely and reliably in 2 data sets. miR-224-5p in the classifier as the top contributor to discriminate the two groups of patients based on AdaBoost, promoted ESCC cell proliferation and migration in vitro.

CONCLUSION

The classifier based on these 6 miRNAs could classify the ESCC patients with LNM from the ones without LNM successfully.

Longitudinal assessment of quality of life indicators and prognosis in esophageal cancer patients with curative resection

BACKGROUND

The relationship between quality of life and survival outcomes in esophageal cancer patients following curative resection is not well established. This study aimed to longitudinally assess quality of life indicators and their association with overall survival (OS) in these patients.

METHODS

A total of 232 patients were included in the study, and their quality of life was prospectively assessed at different time points using the European Organisation for Research and Treatment of Cancer (EORTC) 30-item core quality of life questionnaire (QLQ-C30) and the disease-specific esophageal module (QLQ-OES18). The scores of QLQ indicators at each time point were summarized, and changes in postoperative assessment were compared with preoperative assessments. The association of deterioration in certain indicators with OS was evaluated at each time point using Cox univariable analysis. Further confirmation of independent variables was carried out using Cox multivariable analysis.

RESULTS

The study cohort comprised 62 females (26.7%), and 113 patients (48.7%) aged over 60 years. The median follow-up time was 80 months (range, 8-118 months). At 24 months after discharge, patients reported improvements in role function, fatigue, cognition function, emotional function, social function, insomnia, appetite loss, nausea and vomiting, constipation, financial status, trouble swallowing saliva, and pain related to esophageal cancer. However, physical function, dyspnea, diarrhea, global health status, choking when swallowing, trouble talking, and reflux remained compromised. Multivariable regression analysis revealed deterioration in role function, emotional function, and coughing difficulty at 6 months, and dyspnea, pain, and cognitive function at 24 months post-discharge were identified as independent prognostic factors for OS.

CONCLUSIONS

Our findings underscore the importance of monitoring quality of life indicators in esophageal cancer patients as they may significantly influence survival outcomes. The identification of specific quality of life indicators as prognostic factors highlights the need for a patient-centered approach in clinical practice to enhance care and potentially improve survival.

Patterns of regional lymph node metastasis predict postoperative overall survival and disease-free survival in locally advanced esophageal squamous cell carcinoma

Background

Lymph nodal characteristics are highly significant in predicting the survival of patients with esophageal squamous cell carcinoma (ESCC). However, there is currently a scarcity of studies examining their role in locally advanced ESCC. In the present study, we attempted to depict the patterns of regional lymph node metastasis and investigate their predictive potential in locally advanced ESCC.

Methods

Patients with locally advanced ESCC underwent esophagectomy at the Department of Thoracic Surgery, The First Affiliated Hospital of Shantou University Medical College were included. Kaplan-Meier curve was used to compare the survival differences between groups. Cox regression was constructed to screen the independent risk factors.

Results

A total of 439 patients were included. We identified 10% as the optimal cutoff value for positive lymph node ratio (PLNR) with X-tile software. Statistically significant differences were found in both overall survival (OS, P<0.001) and disease-free survival (DFS, P<0.001) among different PLNR groups. PLNR [hazard ratio (HR): 1.85, P<0.001] and metastatic lymph nodes along the left gastric artery (HR: 1.63, P=0.02) were the independent prognostic factors for OS. While PLNR (HR: 1.77, P<0.001) and metastatic total main bronchus lymph nodes (HR: 2.78, P=0.047) were the independent prognostic factors for DFS.

Conclusions

We discovered that higher PLNR is associated with poorer OS and DFS of locally advanced ESCC. The lymph nodes along the left gastric artery and the total main bronchus lymph nodes were independent prognosticators for OS and DFS, respectively.

The molecular characteristics could supplement the staging system of pT2/T3N0M0 esophageal squamous cell carcinoma: a translational study based on a cohort with over 20 years of follow-up

OBJECTIVE

This study aimed to construct a model based on 23 enrolled molecules to evaluate prognoses of pT2/3N0M0 esophageal squamous cell carcinoma (ESCC) patients with up to 20 years of follow-up.

METHODS

The lasso-Cox model was used to identify the candidate molecule. A nomogram was conducted to develop the survival model (molecular score, MS) based on the molecular features. Cox regression and Kaplan-Meier analysis were used in this study. The concordance index (C-index) was measured to compare the predicted ability between different models. The primary endpoint was overall survival (OS).

RESULTS

A total of 226 patients and 23 proteins were enrolled in this study. Patients were classified into high-risk (MS-H) and low-risk (MS-L) groups based on the MS score of 227. The survival curves showed that the MS-L cohort had better 5-year and 10-year survival rates than the MS-H group (5-year OS: 51.0% vs. 8.0%; 10-year OS: 45.0% vs. 5.0%, all p < 0.001). Furthermore, multivariable analysis confirmed MS as an independent prognostic factor after eliminating the confounding factors (Hazard ratio 3.220, p < 0.001). The pT classification was confirmed to differentiate ESCC patients' prognosis (Log-rank: p = 0.029). However, the combination of pT and MS could classify survival curves evidently (overall p < 0.001), which showed that the prognostic prediction efficiency was improved significantly by the combination of the pT and MS than by the classical pT classification (C-index: 0.656 vs. 0.539, p < 0.001).

CONCLUSIONS

Our study suggested an MS for significant clinical stratification of T2/3N0M0 ESCC patients to screen out subgroups with poor prognoses. Besides, the combination of pT staging and MS could predict survival more accurately for this cohort than the pT staging system alone.

Pararespiratory and paradigestive lymph node metastases in esophageal squamous cell carcinoma: predicting survival and refining the N staging system

BACKGROUND

The site of lymph node metastasis (LNM) may affect the prognosis of patients with esophageal squamous cell carcinoma (ESCC). To investigate the prognoses of pararespiratory and paradigestive LNM and to propose a novel N (nN) staging system that integrates both the LNM site and count.

METHODS

This study was a multicenter, large-sample, retrospective cohort study that included ESCC patients with LNM between January 2014 and December 2019 from three Chinese institutes. Patients were set into training (two institutes) and external validation (one institute) cohorts. The primary outcomes were survival differences in LNM site and the development of novel nodal staging system. The overall survival (OS) of patients with pararespiratory LNM only (Group A), paradigestive LNM only (Group B), and both sites (Group C) was evaluated by Kaplan-Meier. Cox proportional hazards models were used to identify the independent prognostic factors. An nN staging system considering both the LNM site and count was developed and evaluated by the area under the receiver operating characteristic curve (AUC).

RESULTS

In total, 1313 patients were included and split into training (n = 1033) and external validation (n = 280) cohorts. There were 342 (26.0%), 568 (43.3%) and 403 (30.7%) patients in groups A, B and C, respectively. The OS of patients with pararespiratory and patients with paradigestive LNM presented significant differences in the training and validation cohorts (P < 0.050). In the training cohort, LNM site was an independent prognostic factor (hazard ratio: 1.58, 95% confidence intervals: 1.41-1.77, P < 0.001). The nN staging definition: nN1 (1-2 positive pararespiratory/paradigestive LNs), nN2 (3-6 pararespiratory LNs or 1 pararespiratory with 1paradigestive LN), nN3 (3-6 LNs with ≥ 1 paradigestive LN), nN4 (≥ 7 LNs). Subsets of patients with different nN stages showed significant differences in OS (P < 0.050). The prognostic model of the nN staging system presented higher performance in the training and validation cohorts at 3-year OS (AUC, 0.725 and 0.751, respectively) and 5-year OS (AUC, 0.740 and 0.793, respectively) than the current N staging systems.

CONCLUSIONS

Compared to pararespiratory LNM, the presence of paradigestive LNM is associated with worse OS. The nN staging system revealed superior prognostic ability than current N staging systems.

The survival benefit from surgery on patients with large-cell neuroendocrine carcinoma in the lung: a propensity-score matching study

PURPOSE

This study aimed to investigate the prognostic significance of surgery in large-cell neuroendocrine carcinoma (LCNC) patients.

METHODS

A total of 453 patients from the Surveillance, Epidemiology, and End Results database diagnosed with stage T1-4N0-2M0 LCNC from 2010 to 2015 were analyzed. The propensity-score matching analysis with a ratio of 1:1 was used to minimize the bias effect of other clinical characteristics, and 77 pairs of patients' data were performed for subsequent statistical analysis. The Cox proportional hazards model, Kaplan-Meier analysis, and Log-rank test were used in the present study. The primary observational endpoint was cancer-specific survival (CSS).

RESULTS

The 1-year, 3-year, and 5-year CSS rates were 60.0%, 45.0%, and 42.0% in those 453 LCNC patients. Compared with patients who underwent surgical resection, patients without surgery had a lower 5-year CSS rate (18.0% vs. 52.0%, P < 0.001). After analyses of multivariable Cox regression, chemotherapy, T stage, N stage, and surgery were identified as independent prognostic indicators (all P < 0.05). In the cohort of old patients, the median survival time was longer in cases after surgery than those without surgery (13.0 months vs. NA, P < 0.001). Besides, in patients with different clinical characteristics, the receiving surgery was a protective prognostic factor (all hazard ratio < 1, all P < 0.05). In addition, for the cohort with stage T1-2N0-2M0, patients after the operation had more improved outcomes than patients without surgery (P < 0.001).

CONCLUSIONS

We proposed that the surgery could improve the survival outcomes of LCNC patients with stage T1-4N0-2M0. Moreover, old patients could benefit from surgery.

A Study on Risk Factors Associated with Reflux Esophagitis in Patients Undergoing Esophageal Cancer Surgery

Objective

To investigate the risk factors associated with reflux esophagitis in patients undergoing esophageal cancer surgery and to provide reference for the prevention and treatment of reflux esophagitis.

Methods

In the manner retrospective study, the data of 300 patients with esophageal cancer who received the surgical treatment in our hospital (January 2018-December 2020) were retrospectively reviewed. The 300 patients were divided into the occurrence group (n = 45) and nonoccurrence group (n = 255) depending on whether they had reflux esophagitis after surgery. The social demographic data and clinical data of the patients in the two groups were collected. These data were classified into the personal factors and surgical factors. The single-factor analysis method was adopted to analyze the effects of the personal and surgical factors on reflux esophagitis. The factors with statistically significant differences in the single-factor analysis were analyzed by logistic regression to verify the factors were the risk factors associated with reflux esophagitis in patients undergoing esophageal cancer surgery.

Results

The differences in the bodyweight, body mass index (BMI), length of the resected esophagus, surgical approach, intraoperative blood loss, gastrointestinal decompression volume, and surgery time between the two groups were of statistical significance (P < 0.05). After being tested by the logistics multivariate analysis, length of the resected esophagus, whole stomach reconstruction, intraoperative blood loss, and surgery time were identified as the risk factors associated with reflux esophagitis in patients undergoing esophageal cancer surgery.

Conclusion

The length of the resected esophagus, whole stomach reconstruction, intraoperative blood loss, and surgery time were the risk factors associated with reflux esophagitis in patients undergoing esophageal cancer surgery. It is necessary to choose the appropriate surgical approach according to the patients' conditions in practice and to strengthen the prevention and treatment of reflux esophagitis.