Endoscopic Tumor Length Should Be Reincluded in the Esophageal Cancer Staging System: Analyses of 662 Consecutive Patients

The prognostic impact of tumor length on pathological stage IA-IC esophageal adenocarcinoma

This study was completed to evaluate the relationship between tumor length and the prognosis of patients with pathological stage IA-IC esophageal adenocarcinoma (EAC). Patients were identified from the Surveillance, Epidemiology, and End Results Program database (United States, 2006-2015). X-tile software and ROC analysis were mainly used to explore the best threshold of tumor length for dividing patients into different groups, and then propensity score matching (PSM) was used to balance other variables between groups. The primary outcome assessed was overall survival (OS). A total of 762 patients were identified, and 500 patients were left after PSM. Twenty millimeters were used as the threshold of tumor length. Patients with longer tumor lengths showed worse OS (median: 93 vs. 128 months; P = 0.006). Multivariable Cox regression analysis showed that longer tumor length was an independent risk factor (hazard ratio 1.512, 95% confidence interval, 1.158-1.974, P = 0.002). Tumor length has an impact on patients with pathological stage IA-IC EAC who undergo surgery alone. The prognostic value of the pathological stage group may be improved after combining it with tumor length and age.

Development and validation of a nomogram for prediction of cervical lymph node metastasis in middle and lower thoracic esophageal squamous cell carcinoma

Background

Estimates of cervical lymph node (LN) metastasis in patients with middle and lower thoracic esophageal squamous cell carcinoma (ESCC) are important. A nomogram is a useful tool for individualized prediction.

Methods

A total of 235 patients were enrolled in this study. Univariate and multivariate analyses were performed to screen for independent risk factors and construct a nomogram to predict the risk of cervical LN metastasis. The nomogram performance was assessed by discrimination, calibration, and clinical use.

Results

Totally, four independent predictors, including the maximum diameter of tumor, paraesophageal lymph node status, recurrent laryngeal nerve lymph node status, and the CT-reported cervical LN status, were enrolled in the nomogram. The AUC of the nomogram model in the training and validation dataset were 0.833 (95% CI 0.762–0.905), 0.808 (95% CI 0.696–0.920), respectively. The calibration curve demonstrated a strong consistency between nomogram and clinical findings in predicting cervical LN metastasis. Decision curve analysis demonstrated that the nomogram was clinically useful.

Conclusion

We developed a nomogram that could be conveniently used to predict the individualized risk of cervical LN metastasis in patients with middle and lower thoracic ESCC.

Prognostic impact of tumor length in esophageal Cancer: a systematic review and Meta-analysis

BACKGROUND

In clinical studies, it has been observed that esophageal cancer (EC) patient prognosis can be very different even for those patients with tumors of the same TNM stage. Tumor length has been analysed as a possible independent prognostic factor in many studies, but no unanimous conclusion has been reached. Therefore, this review used a meta-analysis to evaluate the association between tumor length and prognosis in EC patients.

METHODS

A systematic search for relevant articles was performed in PubMed, Web of Science, and Embase. Hazard ratios (HRs) and 95% confidence intervals (CIs) were used as effective measures to estimate the correlation between tumor length and prognosis, including overall survival, disease-free survival, progression-free survival, disease-specific survival, and cancer-specific survival. STATA 15.0 software was used to perform the meta-analysis and the data synthesis.

RESULTS

Finally, 41 articles with 28,973 patients were included in our study. The comprehensive statistical results showed that long tumors are an independent prognostic parameter associated with poor overall survival (OS) (HR = 1.30; 95% CI: 1.21-1.40, p < .001) and disease-free survival (DFS) (HR = 1.38; 95% CI: 1.18-1.61, p < .001) in EC patients. Subgroup analyses also suggested a significant correlation between long tumors and poor OS. Sensitivity analysis and publication bias evaluation confirmed the reliability and stability of the results. Similar results were obtained in the analyses of progression-free survival (PFS), disease-specific survival (DSS), and cancer-specific survival (CSS).

CONCLUSION

The results of this meta-analysis showed that long tumors were related to poor OS, DFS, PFS, DSS and CSS in EC patients. Tumor length might be an important predictor of prognosis in EC patients, and it can be used as an independent staging index. Further well-designed and large-scale prospective clinical studies are needed to confirm these findings.

Optimal Treatment of cT2N0 Esophageal Carcinoma: Is Upfront Surgery Really the Way?

BACKGROUND

Staging is inaccurate for cT2N0 esophageal cancer, and patients often are clinically mis-staged. This study aimed to evaluate the outcome after upfront surgery or neoadjuvant therapy, considering the impact of clinical "mis-staging."

METHODS

This study reviewed patients with squamous cell carcinoma (SCC) or adenocarcinoma (ADK) of the esophagus who underwent upfront surgery (S group) or neoadjuvant treatment (chemoradiotherapy [CRT] group) for cT2N0 cancer. Overall survival (OS), disease-free survival (DFS), morbidity, and mortality were evaluated. Correctly staged (cTNM = pTNM), understaged (cTNM < pTNM), and overstaged (cTNM > pTNM) patients in the S group and the CRT group were analyzed. Risk factors for unexpected lymph-node involvement were identified in the S group and for cancer-related death in the whole study cohort.

RESULTS

The study enrolled 229 patients with cT2N0 esophageal cancer. The 5-year OS rate was 34.2% in the S group versus 55.7% in the CRT group (p = 0.0088). The DFS also was significantly higher (p = 0.01). The morbidity and mortality rates were similar. In the S group, the cTNM was correctly staged for 21.4% and understaged for 63.4% of the patients, with 48.7% of the patients showing unexpected nodal involvement. A tumor length of 3 cm or more was an independent predictor of nodal metastases in SCC (p = 0.03), as was lymphovascular invasion (LVI) in ADK (p < 0.01). Cancer-related mortality was independently associated with lymph-node metastases (p = 0.03) and treatment by upfront surgery (p = 0.01).

CONCLUSION

Given the high rate of understaged patients in this study (63.4%), the authors advocate for combining the induction therapy with surgery in cT2N0, achieving better survival with similar morbidity and mortality.

The role of endoscopic tumor length in resected esophageal squamous cell carcinoma: a retrospective study

Background

In esophageal squamous cell carcinoma (ESCC), tumor status is assessed on the basis of latitudinal invasion. Endoscopic tumor length (ETL) may represent the longitudinal scope of the primary tumor, and whether it affects tumor stage or prognosis is not entirely clear. In this study, we evaluated the role of ETL in patients with resected ESCC.

Methods

The relationships of ETL with pathological parameters (pT status and pN status) and overall survival (OS) were analyzed using data from patients with resected ESCC who were treated at Fujian Cancer Hospital between January 1997 and December 2013. Odds ratios (ORs) and hazard ratios (HRs) were fitted with locally weighted scatterplot smoothing, and the structural breakpoints for ETL were determined using the Chow test.

Results

A total of 721 patients with resected ESCC were enrolled. As the ETL increased in these patients, a rise in the risk of advanced pT status, nodal metastasis, and mortality was observed. Cutpoint analysis showed a breakpoint of 7.0 cm. A negative impact of ETL ≥7.0 cm was also found (adjusted HR, 1.335; 95% CI, 1.004–1.774). Seven independent prognostic factors, including sex, age, number of nodes dissected, T stage, N stage, tumor location, and ETL, were identified and entered into the nomogram. The calibration curves for 1-, 3-, and 5-year OS showed optimal agreement between nomogram prediction and actual observation (c-index: 0.688).

Conclusions

Longer tumor length, with ETL ≥7.0 cm as the breakpoint, is a negative prognostic factor in patients with ESCC.

Tumor Size as a Critical Prognostic Factor in T1-2 Stage Esophageal Cancer

Background

Tumor size has been measured in esophageal cancer for decades, but the role of tumor size in relation to T stage in the prediction of survival is still underappreciated. Thus, the present study is aimed at investigating the influence of T stage on the predictive value of tumor size in clinical stage I–IV esophageal cancer patients.

Materials and Methods

Data were obtained from the Surveillance, Epidemiology, and End Results Program (SEER) cancer registry program. Cox proportional hazards regression was utilized to identify the independent prognostic ability of the factor. Kaplan-Meier analysis was used to estimate the distribution of survival outcome. Harrell's concordance index (c-index) was used to quantify the predictive ability of the prognostic model and prognostic factor.

Results

According to the T stage, subgroup analysis showed that tumor size was not an independent risk factor in T3 and T4 stage esophageal cancer patients. Furthermore, the predictive power of tumor size was negatively impacted by the increase in T stage. Furthermore, the discriminative ability of the Cox model based on the tumor-node-metastasis (TNM) system with tumor size outperformed the model based on the TNM system only.

Conclusion

The current study identified tumor size as a critical clinical prognostic signature for esophageal cancer with considerable discriminatory ability and prognostic value. Therefore, tumor size should be included in the American Joint Committee on Cancer (AJCC) TNM staging of T1-2 esophagus cancer patients.

Esophageal Cancer: An Updated Surveillance Epidemiology and End Results Database Analysis

Background

Esophageal cancer is the sixth leading cause of cancer-related deaths and the eighth most common cancer worldwide with a 5-year survival rate of less than 25%. Here we report the incidence, risk factors and treatment options that are available currently, and moving into the future.

Methods

We retrospectively analyzed the Surveillance Epidemiology and End Results (SEER) database made available by the National Cancer Institute in the USA. Specifically we extracted data from the years 2004 - 2015.

Results

In total we identified 23,804 patients with esophageal adenocarcinoma and 13,919 patients with esophageal squamous cell carcinoma. Males were at an increased risk of developing both types of esophageal cancer when compared to females. Most cases of adenocarcinoma were diagnosed as poorly differentiated grade III (42%), and most cases of squamous cell carcinoma were diagnosed as moderately differentiated grade II (39.5%). The most common stage of presentation for both adenocarcinoma (36.9%) and squamous cell (26.8%) carcinoma was stage IV. The worst outcomes for adenocarcinoma were noted with grade III tumors (hazard ratio (HR): 1.56, 95% confidence interval (CI): 1.44 - 1.68, P value: < 0.01), stage IV tumors (HR: 3.58, 95% CI: 3.33 - 3.85, P value: < 0.01) and those not treated with surgery (HR: 2.54, 95% CI: 2.44 - 2.65, P value: < 0.01). For squamous cell carcinoma, the worst outcomes were noted with grade III tumors (HR: 1.35, 95% CI: 1.23 - 1.49, P value: < 0.01), stage IV tumors (HR: 2.12, 95% CI: 1.94 - 2.32, P value: <0.01).

Conclusions

The incidence of esophageal adenocarcinoma in the USA is steadily on the rise. Conversely, the incidence of squamous cell carcinoma has been continually declining. While white males had an increased incidence of both types of esophageal cancer, a higher proportion of African Americans suffered from squamous cell carcinoma. Despite the wide spread use of proton pump inhibitors, adenocarcinoma continues to be a major public health concern.

Prognostic value of tumor length and diameter for esophageal squamous cell cancer patients treated with definitive (chemo)radiotherapy: Potential indicators for nonsurgical T staging

PURPOSE

The aim of this work was to evaluate the prognostic value of tumor length and diameter for patients with esophageal squamous cell cancer (ESCC) treated with definitive (chemo)radiotherapy to identify potential indicators for separate nonsurgical T staging, which are needed in clinical practice.

MATERIALS AND METHODS

A total of 682 patients with ESCC who underwent definitive (chemo)radiotherapy between 2009 and 2015 were reviewed. Esophageal tumor length and diameter were determined by barium esophagography and computed tomography before treatment. Univariate and multivariate analyses were used to assess the impact of tumor length and diameter on long-term overall survival (OS) and progression-free survival (PFS). Propensity score matching (PSM) analysis was also used to control intergroup heterogeneity.

RESULTS

The median OS and PFS were 22.2 months and 15.4 months, respectively, in the tumor length ≤ 6 cm group, which were significantly longer than those in the tumor length > 6 cm group (13.4 and 8.5 months, respectively). The median OS and PFS were 23.3 months and 15.9 months, respectively, in the tumor diameter ≤ 3.5 cm group, which were also significantly longer than those in the tumor diameter > 3.5 cm group (13.3 and 8.8 months, respectively). Similar results were found after PSM. Univariate and multivariate analyses showed that tumor length and diameter were both independent predictors of long-term survival.

CONCLUSION

Tumor length and diameter are both independent prognostic factors for ESCC patients treated with definitive (chemo)radiotherapy. These two imaging parameters have the potential for development and use in nonsurgical T staging.

Prognostic significance of tumor length in patients with esophageal cancer undergoing radical resection: A PRISMA-compliant meta-analysis

BACKGROUND

The prognostic significance of tumor length in esophageal cancer (EC) remains controversial. Hence, we conducted a meta-analysis to quantitatively assess the prognostic significance of tumor length in EC patients.

METHOD

A systematic literature search was conducted in the PubMed, EMBASE, and Web of Science. Hazard ratios (HRs) with their 95% confidence intervals (CIs) were used to assess the prognostic significance of tumor length for overall survival (OS), and disease-free survival (DFS) in EC patients.

RESULTS

A total of 21 articles with 22 eligible studies involving 9271 patients were included in this meta-analysis. The results of our pooling analyses demonstrated that tumor length was an independent prognostic parameter for OS (HR = 1.38, 95% CI: 1.24-1.54, P < .01) and DFS (HR = 1.29, 95% CI: 1.11-1.50, P < .01) in EC patients. Moreover, our subgroup analysis and sensitivity analysis showed that the pooled HRs assessing the prognostic significance of tumor length did not significantly fluctuated, suggesting our pooling analyses were stable and reliable.

CONCLUSION

The results of this meta-analysis demonstrated that long tumor is an independent risk of poor OS and DFS in EC patients, suggesting that it may provide additional prognostic information and thus contribute to a better stratification of EC patients, especially for those with no lymph node metastasis. However, more well-designed prospective clinical studies with large sample size are needed to strength our conclusion due to several limitations in this meta-analysis.

Prognostic Value of Tumor Length for Cause-Specific Death in Resectable Esophageal Cancer

BACKGROUND

The current esophageal cancer American Joint Committee on Cancer TNM staging system may not capture the full prognostic implications of the primary tumor. A study is needed to explore the prognostic value of tumor size on esophageal cancer-specific death.

METHODS

Patients who underwent surgical resection for non-metastatic esophageal cancer were selected from the Surveillance, Epidemiology and End Results Program database (United States, 1988 to 2014). With the use of statistics methods, maximally selected rank and two hazard models (Cox model and Fine-Gray model), the optimum cutoff point for tumor length in each T classification was estimated and the prognostic value of tumor size on esophageal cancer-specific death was analyzed.

RESULTS

A total of 4,447 patients were identified. The median tumor size was significantly correlated with T classification, with the correlation coefficient of 0.43 (p < 0.001). Patients in the T1 to T3 classifications who had larger tumor size showed a larger probability of cancer-specific death. The multivariate Cox model showed that tumor size was significantly associated with an increase in cancer-specific death in T1 (2.15, 95% confidence interval [CI]: 1.72 to 2.69) and T2 (1.31, 95% CI: 1.06 to 1.62) but was marginally significantly associated in T3 (1.12, 95% CI: 1.00 to 1.27) and insignificantly associated in T4 classification (p > 0.1). Similar results were found by using the multivariate Fine-Gray model.

CONCLUSIONS

We have found that combining T classification with tumor size can increase the precision in identifying the high-risk groups in T1 to T2 classifications. On the basis of esophageal cancer-specific death our study explores the prognostic cutoff point of tumor size by T classification.

Expression of serum AMPD1 in thyroid carcinoma and its clinical significance

This study investigated the expression of adenosine monophosphate deaminase 1 (AMPD1) in serum of patients with papillary thyroid carcinoma (PTC) and its clinical significance. The expression levels of AMPD1 mRNA in serum of 157 patients with PTC and 100 normal controls were detected by real-time fluorescent quantitative polymerase chain reaction (PCR), and the relationships between expression level of AMPD1 in serum of PTC patients and clinicopathological factors as well as prognosis were analyzed. The results of real-time fluorescent quantitative PCR showed that the expression of AMPD1 mRNA in serum of PTC patients was lower than that in normal human serum (P<0.01). The expression of AMPD1 in serum of PTC patients was not significantly different from the clinicopathological features such as sex, age, lymph node metastasis and the number of lesions (P>0.05); there were distinct differences between its expression and tumor-node-metastasis (TNM) staging and tumor diameter (P<0.05). The single factor Cox analysis revealed that sex, age, number of lesions, TNM staging and the occurrence of lymph node metastasis were significantly correlated with the prognosis of patients (P<0.05). Multivariate Cox analysis showed that TNM staging hazard ratio (HR)=2.93, 95% confidence interval (CI): 1.52-7.04, P=0.015 was an independent prognostic factor in PTC patients. Survival analysis indicated that there was a statistically significant difference in the 5-year overall survival rate between patients with high expression of AMPD1 and those with low expression (P=0.007). In conclusion, the expression of AMPD1 in serum of patients with PTC is closely related to the malignant evolution of PTC and clinical prognosis of patients. AMPD1 is expected to become an important molecule in judging the clinical prognosis of PTC patients, and may become a new target for molecular targeted therapy of PTC.

Survival based radiographic-grouping for esophageal squamous cell carcinoma may impact clinical T stage

Most patients diagnosed with thoracic esophageal squamous cell carcinoma (ESCC) have progressed beyond surgical resection as a therapeutic option. Difficulties in the proper assessment of tumor invasion depth before treatment complicate determination of the type and extent of therapy. Therefore, accurate tumor clinical staging is a necessity for identifying treatment options and aiding in patient prognosis. We investigated radiographic factors as prognostic indicators for survival in ESCC. Between July 2006 - July 2010, 324 thoracic ESCC patients who underwent surgery were selected. All patients received contrast enhanced preoperative chest CT scans and esophageal barium swallow examinations. Measurement of maximal lesion cross-sectional area, the largest long diameter, largest short diameter, CT-indicated lesion length, barium-indicated lesion length and the length of pericardial fat reduction were performed. Relationships between these indicators and post-surgical survival time and the cutoff values of related factors were analyzed. Maximum long diameter, maximum lesion area and lesion length, as measured by CT imaging, were correlated with survival. Survival effects were clearly associated with group intervals, calculated by a genetic algorithm, and tumor stages. Risk-stratification intervals of esophageal lesions from radiographic imaging included: maximum long diameter < 28.7, 28.7-34.6mm, 34.6-41.4mm and >41.4mm; maximum lesion area < 355.8mm2, 355.8-568.0mm2, 568.0-907.3mm2 and >907.3mm2; and CT-indicated lesion length <30.9mm, 30.9-57.3mm, 57.3-70.6mm and > 70.6mm. The reasonable stratification of maximum esophageal lesion area, largest long diameter and lesion length measured in CT is valuable for clinical T staging of ESCC. Radiographic parameters may have prognostic clinical value in the staging of esophageal carcinoma.

miR302a inhibits the proliferation of esophageal cancer cells through the MAPK and PI3K/Akt signaling pathways

MicroRNAs (miRNAs/miRs) are involved in the regulation of various types of cancer, either as oncogenes or tumor suppressors. miR302a has been reported that it could suppress tumor cell proliferation by inhibiting Akt in prostate cancer. The present study examined the effect of miR302a on proliferation and invasion in esophageal cancer cell lines. The expression levels of miR302a in esophageal cancer cell lines was determined by reverse transcription-polymerase chain reaction. Subsequently, miR302a mimics were transfected into esophageal cancer cells, and cell viability and invasion were assessed by MTT and Transwell assays. In addition, the effects of miR302a on the mitogen-activated protein kinase (MAPK) and phosphoinositide 3-kinase (PI3K)/protein kinase B (Akt) signaling pathways were investigated by western blot analysis. The results revealed that miR302a expression was significantly decreased in the esophageal cancer cell lines compared with a healthy esophagus epithelium cell line. Upregulation of miR302a inhibited the proliferation and invasion of esophageal cancer cells, and decreased the phosphorylation of extracellular signal-regulated kinase 1/2 and Akt. Taken together, the results of the present study indicated that miR302a overexpression inhibited the proliferation and invasion of esophageal cancer cells through suppression of the MAPK and PI3K/Akt signaling pathways, indicating the potential value of miR302a as a treatment target for human esophageal cancer.

Prognostic significance of tumor length in patients receiving esophagectomy for esophageal cancer

AIMS

We investigated the prognostic value of tumor length measurements acquired both from pre-operative imaging and post-operative pathology in esophageal cancer.

METHODS

Tumor lengths were examined retrospectively for 389 esophagectomy patients with respect to Endoscopy, EUS (Endoscopic Ultrasound), CT and PET-CT, and pathology. Correlations between the measurements on the different approaches were assessed, and associations between tumor length and survival were analyzed.

RESULTS

Only the tumor lengths assessed on pathology were found to be significantly associated with overall (P = 0.001) and recurrence free (P < 0.001) survival on univariable analysis. The median overall survival was 47.1 months in those patients with tumor lengths <3.0 cm, falling to 19.6 and 18.0 months in those with 3.0-4.4 and 4.5+ cm tumors, respectively, demonstrating a reduction in patient survival at a tumor length of around 3 cm. Tumor length on pathology was significantly correlated with tumor differentiation and both T- and N-categories. After accounting for these factors, tumor length on pathology was a significant independent predictor of recurrence-free (P = 0.016), but not overall (P = 0.128) survival.

CONCLUSIONS

Tumor lengths on pathology were found to be the most predictive of patient outcome. However, after accounting for other tumor-related factors, tumor length only resulted in a marginal improvement in predictive accuracy.

Novel BRCA2-Interacting Protein, LIMD1, Is Essential for the Centrosome Localization of BRCA2 in Esophageal Cancer Cell

Mutation of breast cancer 2, early onset (BRCA2) has been identified as a vital risk factor for esophageal cancer (EC). To date, several proteins have been reported as BRCA2-interacting proteins and are associated with multiple biological processes. This study’s aim was to identify a novel interactive protein of BRCA2 and to explore its functional roles in EC. A yeast two-hybrid screening was performed to identify a novel BRCA2-interacting protein. Glutathione-S-transferase (GST) pull-down analysis was performed to find out how the binding domain of BRCA2 interacts with LIM domains containing 1 (LIMD1). The interaction between LIMD1 and BRCA2 at the endogenous level was confirmed by using coimmunoprecipitation and immunobloting. Furthermore, two different sequences of short hairpin RNAs (shRNAs) against LIMD1 were transfected into the human EC cell line ECA109. Afterward, the effects of LIMD1 suppression on the centrosome localization of BRCA2 and cell division were analyzed using an immunofluorescence microscope. Results showed that LIMD1 was a novel BRCA2-interacting protein, and LIMD1 interacted with the conserved region of BRCA2 (amino acids 2,750–3,094) in vitro. Importantly, after interfering with the protein expression of LIMD1 in ECA109 cells, the centrosome localization of BRCA2 was significantly abolished and abnormal cell division was significantly increased. These results suggested that LIMD1 is a novel BRCA2-interacting protein and is involved in the centrosome localization of BRCA2 and suppression of LIMD1, causing abnormal cell division in EC cells.