Superficial esophageal carcinoma: a report of 12 cases

Prevalence and topography of lymph node metastases in early esophageal and gastric cancer. Ann Surg. 2014;259:96-101. [PMID: 24096772 DOI: 10.1097/sla.0000000000000239]

OBJECTIVE

To determine the prevalence and localization of lymph node metastases in patients with pT1 carcinoma of the esophagus, esophagogastric junction, and stomach.

BACKGROUND

Retrospective analysis and topographic description.

METHODS

We included 793 consecutive patients with pT1 carcinomas who underwent primary surgery for squamous cell carcinoma (SCC) of the esophagus, adenocarcinomas of the esophagogastric junction (AEG), or gastric cancer (GC). Clinical records and pathology reports were reviewed, and the prevalence and topography of lymph node metastases were identified.

RESULTS

The prevalence of lymph node metastases in SCC, AEG, and GC was 7%, 0%, and 5% for pT1a tumors and 24%, 18%, and 14% for pT1b tumors, respectively. Positive lymph node status was associated with worse overall survival (P<0.001). Not only infiltration of the submucosa (P=0.002) but also lymphatic vessel invasion (P<0.001), multifocal tumor growth (P=0.001), lower patient age (P=0.001), and poor tumor differentiation (P=0.05) were associated with nodal disease. These 5 parameters allowed the compilation of a nomogram to estimate the individual risk of lymph node metastases. In SCC, lymph node metastases were found from the neck to the celiac axis. In AEG, nodal disease was limited to the lower mediastinum and the D1 compartment. In GC, lymphatic spread exceeded the D1 compartment in 7% of node positive patients.

CONCLUSIONS

Risk estimation for lymph node metastases should not be based on depth of tumor infiltration alone but additional clinicopathological parameters should also be considered. The extent of lymphadenectomy in surgical procedures should respect the presented topography of lymph node metastases.

The Use of Neural Networks in Identifying Risk Factors for Lymph Node Metastasis and Recommending Management of T1b Esophageal Cancer

The objective of this study was to establish a prediction model of lymph node status in T1b esophageal carcinoma and define the best squamous and adenocarcinoma predictors. The literature lacks a satisfactory level of evidence of T1b esophageal cancer management. We performed an analysis pooling the effects of outcomes of 2098 patients enrolled into 37 retrospective studies using “neural networks” as data mining techniques. The percentages for lymph node, lymphatic (L1), and vascular (V1) invasion in Sm1 esophageal cancers were 24, 46, and 20 per cent, respectively. The same parameters apply to Sm2 with 34, 63, and 38 per cent as opposed to Sm3 with 51, 69, and 47 per cent. The respective number of patients with well, moderate, and poor histologic differentiation totaled 267, 752, and 582. The rank order of the predictors of lymph node positivity was, respectively: Grade III, (L1), (V1), Sm3 invasion, Sm2 invasion, and Sm1 invasion. Histologic-type squamous and adenocarcinoma (ADC/SCC) was not included in the model. The best predictors for SCC lymph node positivity were sm3 invasion and (V1). As concerns ADC, the most important predictor was (L1). Submucosal esophageal cancer should be managed with surgical resection. However, this is subject to the histologic type and presence of specific predictors that could well alter the perspective of multimodality management.

Risk of lymph node metastasis in submucosal esophageal cancer: a review of surgically resected patients

OBJECTIVES

Endoscopic local procedures are increasingly applied in patients with superficial esophageal cancer as an alternative to radical oncologic resection. The objective of this article is to determine the risk of nodal metastases in submucosal (sm) esophageal cancer, comparing the two predominating histologic tumor types, squamous cell cancer (SCC) and adenocarcinoma (ADC).

METHODS

A query of PubMed, MEDLINE, Embase and Cochrane Library (1980-2009) using predetermined search terms revealed 675 abstracts, of which 485 full-text articles were reviewed. A total of 105 articles met the selection criteria. A review of article references and consultation with experts revealed additional articles for inclusion. Studies that enrolled patients with submucosal esophageal cancer and provided adequate extractable data were included.

RESULTS

The pooled outcomes of 7645 patients with esophageal cancer involving the sm level of infiltration were included in the analysis. Overall, the percentage of lymph node metastasis in submucosal cancer was 37%. Lymph node (N), lymphatic (L) and vascular (V) invasion in sm1 esophageal cancers was 27, 46 and 22%, respectively. Within sm2 lesions, N, L and V invasion were involved in 38, 63 and 38% of patients, respectively. Finally, N, L and V involvement in patients with sm3 lesions was 54, 69 and 47%, respectively. The rates of lymph node metastasis for sm1 and sm2 were higher in SCC compared with ADC, whereas the lymph node metastasis for sm3 was comparable, with >50% involvement in both histologic subtypes. SCC revealed an overall more aggressive behavior compared with ADC (N+: 45 vs 26%; L+: 57 vs 37%; V+: 40 vs 18%).

DISCUSSION

While endoscopic therapy may be adequate in selected patients with 'low-risk' sm1 ADC, submucosal SCC necessitates esophageal resection and systematic lymphadenectomy because of its aggressive nature and tendency for early metastasis.

Effect of tumour and chemoradiotherapy on oesophageal motility

BACKGROUND

The contribution of dysmotility to dysphagia in oesophageal cancer is unclear.

AIM

To examine oesophageal motility in patients with oesophageal carcinoma and to assess the effect of chemoradiotherapy on motility.

METHODS

Stationary manometry and 24-hour pH-metry were performed in 12 patients with oesophageal carcinoma and one week following completion of chemoradiotherapy using 5-fluorouracil (5-FU), cisplatin and 40Gy radiotherapy.

RESULTS

All patients had abnormal motility prior to treatment. Peristalsis was impaired in 11 patients with a mean (SD) of 25% (9) of waves normally propagated. Eight patients had 20% or more simultaneous waves. Following chemoradiotherapy, the percentage of waves normally propagated increased from 25% (9) to 521% (10) (p < 0.03) and normal peristalsis was restored in four patients. The percentage of simultaneous waves decreased from 38% (11) to 21.6% (10) (p = 0.129) while the percentage of dropped or increased waves decreased from 20% (11) to 8.3% (4) (p = 0.264).

CONCLUSIONS

Oesophageal motility is disturbed in oesophageal cancer. Dysphagia in oesophageal cancer may be partly explained by oesophageal dysmotility. This is improved by chemotherapy.

An extensive morphological and comparative study of clinically early and obvious squamous cell carcinoma of the esophagus

Squamous cell carcinoma of the esophagus appears mainly as an isolated tumor, frequently diagnosed in its latest stage. However, current advances in endoscopy, systematically used for high risk subjects, allow the detection of very early lesions such as epithelial dysplasia or in situ carcinoma. Twenty-eight squamous cell carcinomas were extensively studied: Group A contained 15 clinically "early cancers"; Group B 12 clinically obvious carcinomas and group C one clinically obvious bifocal carcinoma. All 15 "early cancers" were multicentric and composed of large fields of invasive, microinvasive or in situ carcinoma around which were found epithelial dysplasias of various degrees. Lymph node metastases at surgery were found in 26% of these cases. Obvious squamous cell carcinomas were contiguous with dysplastic areas in 16.6% and with in situ carcinomas in 33% of these cases. Half (50%) had lymph node metastases at surgery. There was no dysplasia or in situ carcinoma around the two main tumors of group C. A comparison between the different morphological features of the three groups leads us to question whether the solitary tumor of the esophagus really represents the final evolution of an early multifocal carcinoma.

Superficial esophageal carcinoma. Surgical treatment and the results

We report 92 patients treated with esophagectomy for superficial esophageal carcinoma (SEC; 9.1% of all resected esophageal cancers at our institution). The operative mortality rate was 5.4%. In 24 cases, cancer invasion was limited to the mucosa, and in 68 to the submucosa. Twenty-three patients in the former group had no lymph node involvement, whereas 24 patients (35.3%) of the latter group had lymph node metastases. The 5-year survival rate after surgery for patients with SEC limited to the mucosa was 83.5%, which was significantly better than that for carcinoma invading the submucosa (54.9%). No recurrent disease occurred in patients with lesions limited to the mucosa. In conclusion, an esophagectomy with wide lymphadenectomy is necessary to provide a better prognosis for SEC invading the submucosa, whereas a less extensive treatment may be considered for SEC limited to the mucosa.

Identification of synchronous esophageal tumors in patients with head and neck cancer

Patients with a primary head and neck neoplasm are at risk for additional malignancies of the upper aerodigestive tract, which may be asymptomatic. This phenomenon may reflect the regional carcinogenic influence of alcohol and tobacco abuse. A review of the recent literature documents the value of performing laryngoscopy, bronchoscopy, and esophagoscopy on all patients being staged for head and neck tumors to identify second synchronous cancers, the presence of which may significantly alter the treatment plan.

Superficially invasive squamous cell carcinoma of the esophagus. A study of seven cases in Memphis, Tennessee

Superficially invasive squamous cell carcinoma of the esophagus, defined as carcinoma with invasion limited to the mucosa or submucosa regardless of the presence of lymph node metastasis, is being increasingly recognized. We found 7 cases (13%) of this entity among 54 cases of esophageal squamous cancer resected between 1981 and 1984 in Memphis, Tennessee. Three patients presented with dysphagia, 1 with odynophagia, and 3 with nonesophageal symptoms. Barium esophagram demonstrated the tumor in 2 cases. Endoscopically, four lesions were identified as tumor and three were attributed to inflammation. Two tumors were nodules, three were plaques, one was polypoid, and one was grossly inapparent. Two patients died without evidence of disease. One patient with lymph node metastasis died of disease at 17 mo. Four patients have survived from 16 to 52 mo after resection without evidence of disease. Timely diagnosis of this early form of esophageal neoplasia provides the opportunity for curative resection.