Characteristics and clinical significance of lymph node metastases near the recurrent laryngeal nerve from thoracic esophageal carcinoma

Clinical value of station 4R node dissection in esophageal squamous cell carcinoma

BACKGROUND

Many controversies still exist concerning the optimal extent of lymphadenectomy during esophagectomy in esophageal squamous cell carcinoma (ESCC). The objective of this study was to explore the characteristics of 4R metastasis and evaluate the clinical value of 4R node dissection in ESCC.

METHODS

A total of 736 ESCC patients who underwent radical esophagectomy between 2005 and 2013 were retrospectively collected, among which 393 ones underwent 4R dissection. Propensity score matching (PSM) method was applied to reduce the effects of confounding variables between the 4R dissection and non-dissection groups to analyze overall survival.

RESULTS

Patients showed a low 4R metastasis rate of 5.1% (20/393) (5.2%, 5.8%, and 1.8% for upper, middle, and lower tumors, respectively). Correlation analyses identified that 4R metastasis was significantly associated with station 2R metastasis (p < 0.001) and pathologic tumor-node-metastasis (pTNM) stage (p < 0.001). All 4R metastases were observed in stages IIIB and IVA. Moreover, patients with station 4R dissection failed to achieve significantly improved overall survival compared with those without 4R dissection, regardless of tumor stage (overall: p = 0.696; stage 0-IIIA: p = 0.317; stage IIIB-IVA: p = 0.619).

CONCLUSION

4R metastasis is likely to be associated with more aggressive disease, and routine 4R node dissection might not be necessary for ESCC patients.

Transhiatal esophagectomy via mediastinoscopy versus sweet for T2 esophageal squamous cell carcinoma patients

BACKGROUND

The aim was to compare transhiatal esophagectomy via mediastinoscopy (TEM) with Sweet procedure for patients with T2 midpiece and distal esophageal squamous cell carcinoma (ESCC).

MATERIALS AND METHODS

By virtue of propensity score matching, 42 T2 ESCC patients who underwent TEM (n = 21) and Sweet procedure (n = 21) were included. Both the short-term and long-term outcomes of these patients were observed.

RESULTS

Compared with the Sweet procedure, the TEM procedure showed less operation time (133.8 ± 30.4 vs 171.2 ± 30.3 min, p = 0.038), reduced drainage volume in 24 h (83.8 ± 142.3 vs 665.2 ± 220.0 mL, p < 0.001), shorter reserving time of chest tube (26.2 ± 26.3 vs 82.8 ± 49.8 h, p < 0.001) and less dissected lymph nodes (12.4 ± 6.1 vs 17.0 ± 6.5, p = 0.041). The average survival period was 62.6 months for TEM group and 62.5 months for Sweet group (p = 0.753). The COX regression showed that the nodal staging could be regarded as an independent prognostic factor (p = 0.013), not the surgical method (p = 0. 754).

CONCLUSIONS

The TEM procedure could reduce operative trauma compared with the Sweet procedure. The long-term survival rate of TEM group was acceptable. The lymph node resection was a major disadvantage of TEM procedure. The TEM procedure might be an alternate choice for T2 midpiece and distal ESCC patients, especially for patients who cannot tolerate transthoracic esophagectomy.

Efficacy of sternocleidomastoid muscle flap in reducing anastomotic mediastinal/pleural cavity leak

BACKGROUND

Anastomotic mediastinal/pleural cavity leak (AMPCL) is a life-threatening postoperative complication after esophagectomy. The objective of this study was to find a safe and effective surgical method to reduce the incidence of AMPCL.

METHODS

A total of 223 patients who underwent surgery in Fujian Medical University Union Hospital from May 2020 to October 2021 were enrolled in this study. Data for preoperative and postoperative test indices, postoperative complications, perioperative treatment were collected. After using 1:1 propensity score matching (PSM) to match two cohort (caliper = 0.1), the relationship between various factors and the incidence of AMPCL were analyzed.

RESULTS

209 patients were included for further analysis in the end. There were 95 patients in the sternocleidomastoid muscle flap embedding group (intervention group) and 114 in the routine operation group (control group). There was a significant difference in mean age between two groups. Gender, age, body mass index, diabetes, American society of anesthesiologists score, preoperative neoadjuvant therapy, pathological stage were included in performing 1:1 PSM, and there were no significant differences between two groups. Median operative time was significantly less in intervention group. Anastomotic leak (AL) did not present significant difference between two groups (8 [8.6] vs. 13 [14.0], p = 0.247), however, the AMPCL in intervention group was significantly lower than control group (0 [0] vs. 6 [6.5], p = 0.029).

CONCLUSIONS

The sternocleidomastoid muscle flap embedding could significantly reduce the incidence of AMPCL. This additional procedure is safe, and effective without increase in the occurrence of postoperative complications and hospital expenses.

A novel web-based dynamic nomogram for recurrent laryngeal nerve lymph node metastasis in esophageal squamous cell carcinoma

Background

Patients with esophageal squamous cell carcinoma (ESCC) are liable to develop recurrent laryngeal nerve (RLN) lymph node metastasis (LNM). We aimed to assess the predictive value of the long diameter (LD) and short diameter (SD) of RLN lymph node (LN) and construct a web-based dynamic nomogram for RLN LNM prediction.

Methods

We reviewed 186 ESCC patients who underwent RLN LN dissection from January 2016 to December 2018 in the Affiliated Hospital of North Sichuan Medical College. Risk factors for left and right RLN LNM were determined by univariate and multivariate analyses. A web-based dynamic nomogram was constructed by using logistic regression. The performance was assessed by the area under the curve (AUC) and Brier score. Models were internally validated by performing five-fold cross-validation.

Results

Patients who underwent left and right RLN LN dissection were categorized as left cohort (n = 132) and right cohort (n = 159), with RLN LNM rates of 15.9% (21/132) and 21.4% (34/159), respectively. The AUCs of the LD (SD) of RLN LN were 0.663 (0.688) in the left cohort and 0.696 (0.705) in the right cohort. The multivariate analysis showed that age, the SD of RLN LN, and clinical T stage were significant risk factors for left RLN LNM (all P < 0.05), while tumor location, the SD of RLN LN, and clinical T stage were significant risk factors for right RLN LNM (all P < 0.05). The dynamic nomograms showed reliable performance after five-fold cross-validation [(left (right), mean AUC: 0.814, range: 0.614–0.891 (0.775, range: 0.084–0.126); mean Brier score: 0.103, range: 0.084–0.126 (0.145, range: 0.105–0.206)], available at https://mpthtw.shinyapps.io/leftnomo/ and https://mpthtw.shinyapps.io/rightnomo/.

Conclusion

The LD and SD of RLN LN are inadequate to predict RLN LNM accurately, but online dynamic nomograms by combined risk factors show better prediction performance and convenient clinical application.

How to distinguish thoracic and cervical lymph nodes during minimally invasive esophagectomy

Purpose

In this article, we aimed to reconstruct the cervical–thoracic junction plane (CTJP) using a three‐dimensional (3D) reconstruction system. Thus, the CTJP can be judged during surgery to better distinguish cervical–thoracic lymph nodes.

Methods

We included patients in Fujian Medical University Union Hospital from December 2019 to March 2020. All patients underwent a thin‐slice and enhanced computed tomography scan of the chest with 3D reconstruction using the IQQA system (EDDA technology) to reconstruct the CTJP, brachiocephalic trunk, right common carotid artery, and right subclavian artery. The distance from the intersection of the right subclavian artery and the CTJP to the origin of the right subclavian artery (ORSA) was measured, and the relationship between this distance and the patient's sex, BMI and height was analyzed.

Results

Seventy‐three patients were enrolled, of whom 12 had ORSA above the CTJP, while 61 had ORSA below the plane. There was a significant difference in age between the two groups (p = 0.04), compared with height, weight and BMI (p > 0.05). In 61 patients with the ORSA below the CTJP, the average distance was 24.7 ± 7.6 mm. The difference between the distance and BMI (p = 0.02) was statistically significant, and it was increased with increasing BMI.

Conclusions

The relationship between the ORSA and CTJP can be clarified through 3D reconstruction. The cervical‐thoracic recurrent laryngeal nerve lymph nodes can be distinguished clearly in minimally invasive esophagectomy, contributing to the accurate N staging of middle‐thoracic esophageal cancer.

Preoperative Clinical Characteristics Predict Recurrent Laryngeal Nerve Lymph Node Metastasis and Overall Survival in Esophageal Squamous Cell Carcinoma: A Retrospective Study With External Validation

Background

Recurrent laryngeal nerve (RLN) lymph node metastasis (LNM) is not rare in patients with esophageal squamous cell carcinoma (ESCC). We aimed to develop and externally validate a preoperative nomogram using clinical characteristics to predict RLN LNM in patients with ESCC and evaluate its prognostic value.

Methods

A total of 430 patients with ESCC who underwent esophagectomy with lymphadenectomy of RLN LNs at two centers between May 2015 and June 2019 were reviewed and divided into training (center 1, n = 283) and external validation cohorts (center 2, n = 147). Independent risk factors for RLN LNM were determined by multivariate logistic regression, and a nomogram was developed. The performance of the nomogram was assessed in terms of discrimination, calibration, clinical usefulness, and prognostic value. The nomogram was internally validated by the bootstrap method and externally validated by the external validation cohort.

Results

Multivariate analysis indicated that clinical T stage (P <0.001), endoscopic tumor length (P = 0.003), bioptic tumor differentiation (P = 0.004), and preoperative carcinoembryonic antigen level (P = 0.001) were significantly associated with RLN LNM. The nomogram had good discrimination with the area under the curve of 0.770 and 0.832 after internal and external validations. The calibration curves and decision curve analysis confirmed the good calibration and clinical usefulness of this model. High-risk of RLN LNM predicted by the nomogram was associated with worse overall survival in the external validation cohort (P <0.001).

Conclusion

A nomogram developed by preoperative clinical characteristics demonstrated a good performance to predict RLN LNM and prognosis for patients with ESCC.

Double-lumen tube versus bronchial blocker in lymphadenectomy along the left recurrent laryngeal nerve for esophageal cancer: a propensity-matched analysis

BACKGROUND

Lymph node (LN) dissection along left recurrent laryngeal nerve (RLN) is challenging in esophagectomy for esophageal cancer, and double-lumen endotracheal tube (DLT) impedes the exposure of this area. The aim of this study was to determine whether bronchial blockers (BB) could be a better choice for this procedure.

METHODS

The clinical characteristics of patients who received McKeown esophagectomy with radical lymph node dissection in Wuhan Tongji Hospital between August 2017 and July 2019 were retrospectively analyzed. The 1:1 propensity score match analysis was performed to compare the short-term effectiveness, the numbers of lymph nodes dissected, and the patterns of recurrence and survival between the two groups.

RESULTS

A total of 294 patients (192 and 102 in the DLT and BB group, respectively) were enrolled in the study. After matching, 204 patients (102 pairs) who underwent one-lung ventilation with DLT or BB displayed no significant variance in baseline characteristics. The BB group had higher number of LNs resected along left RLN (1.8 ± 2.3 vs. 2.5 ± 2.5, P = 0.001). For patients with metastatic left RLN LN, the BB group had longer medium survival time (15 vs. 32 months, P = 0.045), and tended to have longer medium recurrence-free survival time (6 vs. 15 months, P = 0.079), and lower rate of upper mediastinal and cervical LN recurrence (30.00% vs. 66.67%, P = 0.198). The postoperative complications were similar in both groups.

CONCLUSIONS

Compared with DLT, using BB in esophagectomy may allow more radical lymphadenectomy along left RLN.

Development of a prediction model for the risk of recurrent laryngeal nerve lymph node metastasis in thoracolaparoscopic esophagectomy with cervical anastomosis

Background

There are no effective preoperative diagnostic measures to predict the probability of left and right recurrent laryngeal nerve (RLN) lymph node (LN) metastasis using preoperative clinical data in patients undergoing thoracolaparoscopic esophagectomy with cervical anastomosis.

Methods

We retrospectively reviewed the clinical data of 1,660 consecutive patients with thoracic esophageal cancer who underwent esophagectomy with cervical anastomosis at the Department of Thoracic Surgery at the First Affiliated Hospital of Zhengzhou University between January 2015 and December 2020.

Results

A total of 299 and 343 patients who underwent left (Cohort 1) and right (Cohort 2) RLN LN dissection were included in the final analyses. The analyses were conducted within each cohort. Among the 299 patients in Cohort 1, left RLN LN involvement was found in 41 patients (13.7%). A multivariable analysis showed that age, tumor location, and short axis were significantly associated with RLN LN metastasis (all P<0.05). Among the 343 patients in Cohort 2, right RLN LN involvement was found in 65 patients (19.0%). A multivariable analysis showed that computed tomography (CT) appearance, tumor location, long axis, and short axis were significantly associated with RLN LN metastasis (all P<0.05). Based on the results of the multivariable analyses, we constructed nomograms that could estimate the probability of RLN LN metastasis. Finally, we stratified the 2 cohorts into risk subgroups using a recursive partitioning analysis (RPA). The risk of left and right RLN LN metastasis was found to be 9.3% and 7.5%, 27.3% and 21.4%, and 52.4% and 47.3% for the low-risk, intermediate-risk, and high-risk groups, respectively.

Conclusions

Our nomograms and RPAs appear to be suitable for the risk stratification of left and right RLN LN metastasis in patients undergoing thoracolaparoscopic esophagectomy with cervical anastomosis. This tool could be used to help clinicians to select more effective locoregional treatments, such as surgical protocols and radiation area selection.

The Impact of the Recurrent Laryngeal Nerve Injury on Prognosis After McKeown Esophagectomy for ESCC

Background

The objective of this study was to assess the impact of the recurrent laryngeal nerve injury (RLNI) after esophagectomy on prognosis.

Methods

Retrospectively collected data from 297 patients with esophageal squamous cell carcinoma (ESCC) who underwent McKeown esophagectomy at our department from April 2014 to May 2018, were analyzed.

Results

RLNI occurred in 31.9% of the patients. Left-side RLNI occurred 2.8 times more often than right-side RLNI. Among the cases in which assessment of the vocal cords was continued, 8.4% involved permanent injury. There were no significant differences among clinicopathological data between patients with RLNI and without. Compared with patients without RLNI, patients with RNLI have longer operation time, more number of bronchoscopy suctions, longer postoperation hospital stay, and higher incidence of postoperative complications. T stage, N stage, RLN lymph node metastasis were independent risk factors for the prognosis, but RLNI is not independent risk factors for long-term survival.

Conclusion

RLNI is a serious complication that will affect the short-term prognosis of patients and reduce the quality of life of patients. It should be avoided as much as possible during surgery, but it may not have negative impact on the long-term survival.

The value of enhanced CT scanning for predicting lymph node metastasis along the right recurrent laryngeal nerve in esophageal squamous cell carcinoma

Background

The right recurrent laryngeal nerve (RRLN) is the region most prone to lymph node metastasis in esophageal squamous cell carcinoma (ESCC). Nodal involvement may be underestimated by traditional imaging prediction criteria, such as a short axis diameter of 10 mm. The purpose of this study was to determine a more accurate imaging criterion to guide clinical treatment strategy selection.

Methods

The clinical data of 307 patients with thoracic ESCC who underwent surgery at Shanghai Chest Hospital between January 2018 and December 2018 were retrospectively analyzed. Utilizing 1-mm layer thickness enhanced computed tomography (CT), the RRLN lymph node short diameter (LNSD) size was measured. Univariate and multivariate analyses were performed to determine the risk factors for lymph node metastasis along the RRLN.

Results

In our study, RRLN lymph node metastasis occurred in 60 (19.5%) patients and general lymph node metastasis occurred in 150 (48.9%) patients. Of the resected lymph nodes along the RRLN, 14.5% (121/832) were positive. Multivariate analysis identified LNSD [odds ratio (OR), 1.236] as an independent risk factor for RRLN lymph node metastasis. In CT evaluation, a short diameter of 6.5 mm in the RRLN lymph nodes is a critical predictor of metastasis at this site (sensitivity =50%, specificity =83.4%) and a larger short diameter was associated with a higher risk of metastasis (P<0.001).

Conclusions

A 6.5 mm cutoff in LNSD can be applied to clinically predict lymph node metastasis in the RRLN region for patients with ESCC.

Five genes as a novel signature for predicting the prognosis of patients with laryngeal cancer

In this study, we purpose to investigate a novel five-gene signature for predicting the prognosis of patients with laryngeal cancer. The laryngeal cancer datasets were obtained from The Cancer Genome Atlas (TCGA). Both univariate and multivariate Cox regression analysis was applied to screening for prognostic differential expressed genes (DEGs), and a novel gene signature was obtained. The performance of this Cox regression model was tested by receiver operating characteristic (ROC) curves and area under the curve (AUC). Further survival analysis for each of the five genes was carried out through the Kaplan-Meier curve and Log-rank test. Totally, 622 DEGs were screened from the TCGA datasets in this study. We construct a five-gene signature through Cox survival analysis. Patients were divided into low- and high-risk groups depending on the median risk score, and a significant difference of the 5-year overall survival was found between these two groups (P < .05). ROC curves verified that this five-gene signature had good performance to predict the prognosis of laryngeal cancer (AUC = 0.862, P < .05). In conclusion, the five-gene signature consist of EMP1, HOXB9, DPY19L2P1, MMP1, and KLHDC7B might be applied as an independent prognosis predictor of laryngeal cancer.

Tumor length-to-height ratio as a predictor of recurrent laryngeal nerve lymph node metastasis in patients with thoracic esophageal squamous cell carcinoma

BACKGROUND

The metastasis of laryngeal nerve lymph node is mostly found in the upper-and middle esophageal cancer, the ratio of esophageal length from the upper incisors to the position where the esophageal tumor began to appear as proven via endoscopy to the height (LH) is likely to affect the possibility of detection of recurrent laryngeal nerve(RLN) lymph node (LN) metastasis. The purpose of this study was to evaluate the predictive value of LH for RLN LN metastasis.

METHODS

One hundred and eighty-eight patients (mean age: 64.89 years; range: 46-84 years) calculated LH before esophagectomy and LN dissection were retrospective analyzed. The clinicopathological data of the patients, LH calculations were compared with the RLN LN histopathologic results to investigate the effect of LH on the diagnosis of RLN LN metastasis.

RESULTS

The LH correlated with that of the RLN LN metastasis in receiver-operating-characteristic (ROC) analysis. Our ROC analyses demonstrated the optimal cut-off value was 16.66 for LH with an area under the curve value of 0.69. Compared with the Height (H) and L, ROC curve for LH have better performance in predicting the RLN LN metastasis.

CONCLUSIONS

LH is a useful predictive tool in the evaluation of RLN LN metastasis for esophageal cancer. The present findings support the result that LH can be an indicator of RLN LN dissection.

Novel technique for lymphadenectomy along left recurrent laryngeal nerve during thoracoscopic esophagectomy

BACKGROUND

In esophageal squamous carcinoma, lymphadenectomy along the left recurrent laryngeal nerve (RLN) is recommended owing to its highly metastatic potential. However, this procedure is difficult due to limited working space in the left upper mediastinum, and increases postoperative complications.

AIM

To present a novel method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the semi-prone position.

METHODS

The fundamental concept of this novel method is to exfoliate a bilateral pedicled nerve flap, which is a two-dimensional membrane, which includes the left RLN, lymph nodes (LNs) along the left RLN, and tracheoesophageal vessels, by suspending the esophagus to the dorsal side and pushing the trachea to the ventral side (named “bilateral exposure method”). Then, the hollow-out method is performed to transform the two-dimensional membrane to a three-dimensional structure, in which the left RLN and tracheoesophageal vessels are easily distinguished and preserved during lymphadenectomy along the left RLN. This novel method was retrospectively evaluated in 116 consecutive patients with esophageal squamous carcinoma from August 2016 to February 2018.

RESULTS

There were 58 patients in each group. No significant difference was found between the two groups in terms of age, gender, postoperative pneumonia, anastomotic fistula, and postoperative hospitalization. However, the number of dissected LNs along the left RLN in this novel method was significantly higher than that in the conventional method (4.17 ± 0.359 vs 2.93 ± 0.463, P = 0.0447). Moreover, the operative time and the rate of postoperative hoarseness in the novel method were significantly lower than those in the conventional method (306.0 ± 6.774 vs 335.2 ± 7.750, P = 0.0054; 4/58 vs 12/58, P = 0.0312).

CONCLUSION

This novel method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the semi-prone position is much safer and more effective.

The clinical significance of the intraoperative pathological examination of bilateral recurrent laryngeal nerve lymph nodes using frozen sections in cervical field lymph node dissection of thoracic esophageal squamous cell carcinoma

Background

The aim of this study was to evaluate intraoperative pathological examination of the left and right recurrent laryngeal nerve lymph nodes (LNs) using frozen section as a predictor of cervical LN metastasis.

Methods

Retrospectively collected data from 69 patients with esophageal squamous cell carcinoma who had undergone intraoperative pathological examination of the left and right recurrent laryngeal nerve LNs using frozen sections and three-field LN dissection in the Fujian Medical University Union Hospital from December 2015 to April 2018, was used to explore the relationship between recurrent laryngeal nerve LN metastasis and cervical LN metastasis and to determine whether cervical-field LN dissection should be performed in patients with thoracic esophageal cancer.

Results

In the entire cohort, 15.9% (11/69) of patients had metastasis in the cervical LNs. We detected 1,195 cervical LN, with an average of 17.3 LN dissections per patient; 28 (2.3%) cases had LN metastasis. Patients with recurrent laryngeal nerve LN metastasis tended to have a high incidence of cervical LN metastasis (P=0.017). Multivariate analysis showed that left recurrent laryngeal nerve LN metastasis was the only independent risk factor for cervical LN metastasis (P=0.02). The incidence of postoperative pulmonary infection was 18.8% (13/69), chylothorax was 2.9% (2/69), anastomotic leakage was 2.9% (2/69), and hoarseness was 8.7% (6/69) for the entire cohort. There was no significant increase in complications compared with patients with 2-field LN dissection in our hospital during the same period. Additional studies are necessary to establish postoperative locoregional recurrence rates and long-term survival.

Conclusions

Intraoperative pathological examination of left recurrent laryngeal nerve LN using frozen sections has some prognostic value in predicting cervical LN metastasis and it can be an indicator for the selection of cervical-field dissection in thoracic esophageal carcinoma.

A nomogram prediction model for recurrent laryngeal nerve lymph node metastasis in thoracic oesophageal squamous cell carcinoma

Background

The metastasis rate to the recurrent laryngeal nerve lymph node (RLN LN) is high, but resection of it is challenging and increases complications. This study explored the risk factors for the RLN LN metastasis in thoracic oesophageal squamous cell carcinoma and developed a novel scoring system to predict it.

Methods

We retrospectively analysed the clinicopathological data of 265 patients between 2015 and 2018. Univariate and multivariate analyses were performed to screen for risk factors and establish a logistic regression model to predict the risk of RLN LN metastasis. A nomogram was constructed accordingly. Further analyses were conducted regarding right and left RLN LN metastasis alone.

Results

(I) The metastatic rates of the left and right RLN LN were 15.1% and 20.4%, respectively. (II) Multivariate logistic regression analysis showed that the short axis diameter of the left RLN LN, short axis diameter of the right RLN LN, maximum diameter of the tumor, tumor location, subcarinal lymph node status and paraoesophageal lymph node status were all independent risk factors for RLN LN metastasis. (III) Multivariate logistic regression analysis showed that the short axis diameter of right RLN LN, tumor location and subcarinal lymph node status were independent risk factors for right RLN LN metastasis. (IV) Multivariate logistic regression analysis showed that short axis diameter of left RLN LN was an independent risk factor for left RLN LN metastasis.

Conclusions

The metastatic rates of the left and right RLN LNs were high and can be predicted according to these nomograms.

Anatomy of lymphatic drainage of the esophagus and lymph node metastasis of thoracic esophageal cancer

The lymphatic drainage of the inner layers (mucosa and submucosa) and the outer layers (muscularispropria and adventitia) of the thoracic esophagus is different. Longitudinal lymphatic vessels and long drainage territory in the submucosa and lamina propria should be the bases for bidirectional drainage and direct drainage to thoracic duct and extramural lymph nodes (LN). The submucosal vessels for direct extramural drainage are usually thick while lymphatic communication between the submucosa and intermuscular area is usually not clearly found, which does not facilitate transversal drainage to paraesophageal LN from submucosa. The right paratracheal lymphatic chain (PLC) is well developed while the left PLC is poorly developed. Direct drainage to the right recurrent laryngeal nerve LN and subcarinal LN from submucosa has been verified. Clinical data show that lymph node metastasis (LNM) is frequently present in the lower neck, upper mediastinum, and perigastric area, even for early-stage thoracic esophageal cancer (EC). The lymph node metastasis rate (LNMR) varies mainly according to the tumor location and depth of tumor invasion. However, there are some crucial LN for extramural relay which have a high LNMR, such as cervical paraesophageal LN, recurrent laryngeal nerve LN, subcarinal LN, LN along the left gastric artery, lesser curvature LN, and paracardial LN. Metastasis of thoracic paraesophageal LN seems to be a sign of more advanced EC. This review gives us a better understanding about the LNM and provides more information for treatments of thoracic EC.

Esophageal cancer lymph node metastasis-associated gene signature optimizes overall survival prediction of esophageal cancer

Esophageal cancer (EC) is characteristic of early regional lymph node metastasis (LNM) and most patients with metastasis have a poor prognosis. However, the current diagnostic techniques do not enable precise differentiation of EC LNM, prognostic stratification, and individual survival estimation. To identify potential molecular biomarkers for EC patients with LNM, we explored differently expressed genes in The Cancer Genome Atlas database between 77 non-LNM cases and 88 LNM cases by limma package R. Then, according to univariate and multivariate Cox regression analyses, we constructed an 8-messenger RNA (mRNA) prognostic signature model, which could predict the outcome in a more exact way. The area under the curve of the risk score is significantly higher than other clinical information, indicating that the 8-mRNA-based risk score is a good indicator for prognosis. Then, combined with other individual risk factors, such as age, sex, T stage, M stage, etc, we could precisely calculate the individual 1-, 3-, and 5-year survival rates. The Gene Set Enrichment Analysis, Gene Ontology, and Kyoto Encyclopedia of Genes and Genomes analysis indicate that the risk model is mainly associated with cancer-related pathways, such as cell division, cellular meiosis, and cell cycle regulation. In summary, the 8-mRNA-based risk score model that we developed successfully predicts the survival of EC. It is independent of clinical information and performing better than other clinical information for prognosis.

Cervical or thoracic anastomosis for patients with cervicothoracic esophageal squamous cell carcinoma

Background

For cervical and higher-level esophageal tumors, the choice of cervical anastomosis or thoracic anastomosis is still controversial. The goal of this study was to explore the optimal surgical approach for cervicothoracic esophageal squamous tumors.

Methods

We retrospectively analyzed 3,802 consecutive patients with esophageal squamous cell tumors in Nanjing Drum Tower Hospital from Jan 2001 to Jan 2017. Twenty-six patients with cervical anastomosis and twenty-eight patients with thoracic anastomosis were evaluated.

Results

The cervical anastomosis group exhibited a greater number of resected lymph nodes (36.5±7.3 vs. 19.9±5.7, P<0.001). In addition, the cervical anastomosis group exhibited a higher recurrence rate (71.4% vs. 41.7%, P=0.047) and increased locoregional recurrence (P=0.040). Overall survival was not significantly different between groups (P=0.331). Moreover, multivariate Cox regression analysis revealed that postoperative locoregional recurrence is an independent risk factor for survival (P=0.031, 95% CI: 1.114-8.952).

Conclusions

Thoracic anastomosis led to satisfactory results in patients with cervicothoracic esophageal squamous tumors.

Optimized lymph node dissection range during progression of lower thoracic esophageal squamous cell carcinoma in the latest therapeutic surgical strategy: A retrospective analysis

The distribution of lymph node metastases, including recurrences, remains elusive in lower thoracic esophageal squamous cell carcinoma (LtESCC). The present study was a retrospective investigation into the optimized lymph node dissection range during LtESCC. Esophagectomies were performed on 163 patients with ESCC between 2009 and 2016, among whom 41 patients with LtESCC were examined. The rates of pathological and potential (including recurrences) metastases to lymph nodes and the prognosis (median, 34 months) were determined. Preoperative Docetaxel, Cisplatin and 5-fluorouracil chemotherapy was administered in >60% of cStage II/III LtESCC. During stage progression, abdominal lymph node metastasis rapidly becomes aggressive in LtESCC and lymph node metastases to the para-aortic area were more dominant than cervical and recurrent laryngeal nerve (RLN) areas. There were few control failures of regional lymph node metastases in LtESCC with surgery, if 1 unique case with cStage III who had metastases and recurrences of multiple lymph nodes during the clinical course was excluded. Defective lymph node dissection around the RLN did not worsen LtESCC prognosis with no RLN palsy. In the context of the potent preoperative chemotherapy and esophagectomy, lymph node dissection of cervical, para-aortic and RLN areas are putatively not mandatory to all LtESCC patients.

Efficacy comparison of transcervical video-assisted mediastinoscopic lymphadenectomy combined with left transthoracic esophagectomy versus right transthoracic esophagectomy for esophageal cancer treatment

Background

This study aimed to propose a new surgical strategy, i.e., the transcervical video-assisted mediastinoscopic lymphadenectomy (VAMLA) with esophagectomy via the left transthoracic approach for patients with esophageal cancer (EC), and to compare the outcomes with those of esophagectomy via the right thoracic approach.

Methods

From December 2014 to March 2016, 49 cases were enrolled in this non-randomized concurrent control study. Twenty-eight patients with EC who underwent transcervical VAMLA with esophagectomy via the left transthoracic approach were assigned into the study group, while 21 EC patients undergoing esophagectomy via the right transthoracic approach during the same period were enrolled into the control group. Operative outcomes including operative time, the numbers of removed lymph nodes, intraoperative blood loss, the length of hospital stay, and postoperative complications in both groups were evaluated and compared.

Results

There were no significant differences in the baseline profiles between the two groups, and all patients in the two groups successfully underwent the surgery. There was a significant difference between transcervical VAMLA with esophagectomy via the left thoracic approach and esophagectomy via the right thoracic approach with regard to the number of all dissected lymph nodes [(29.0 ± 8.7) vs. (17.8 ± 8.1), p < 0.05], dissected superior mediastinal lymph nodes [(11.2 ± 5.0) vs. (3.7 ± 2.9), p < 0.05], and dissected in the recurrent laryngeal nerve lymph nodes [(5.6 ± 3.5) vs. (2.3 ± 2.1), p < 0.05]. No significant differences were observed in the operative time, intraoperative blood loss, length of postoperative hospital stay, number of dissected abdominal lymph nodes, postoperative pulmonary complications (pneumonia and atelectasis), anastomotic fistula, chylothorax, and vocal cord paralysis (p > 0.05).

Conclusion

Transcervical VAMLA combined with esophagectomy via the left thoracic approach appears technically feasible and safe and shows advantages in the number of dissected superior mediastinal lymph nodes, suggesting that it may serve as a new treatment option for patients with esophageal carcinoma.

High Gpx1 expression predicts poor survival in laryngeal squamous cell carcinoma

OBJECTIVE

Several studies have demonstrated that abnormal glutathione peroxidases 1 (Gpx1) expression can influence the biological behavior of malignant cells. However, the roles of Gpx1 in laryngeal squamous cell carcinoma (LSCC) remain unknown. The purpose of this study is to analyze the Gpx1 expression and prognostic significance in LSCC patients.

METHODS

Gpx1 mRNA levels in laryngeal tissues were determined by qRT-PCR. Meanwhile, We examined the expression levels of Gpx1 protein in 140 primary tumor tissues and 28 cases of normal tissues by immunohistochemistry (IHC) analysis on tissue microarrays (TMA).

RESULTS

Our results revealed that the frequency of high Gpx1 was significantly higher in cancer tissue compared to normal surgical margins; Gpx1 expression correlated with clinical features and overall survival (OS). Gpx1 overexpression was significantly associated with lymph node metastasis (P=0.023) and TNM stage (P=0.008); Kaplan-Meier survival curves revealed that patients with high Gpx1 expression had worse prognoses than patients with low Gpx1 expression; By multivariate analysis, we revealed that high Gpx1 expression level (HR 2.101, 95%CI 1.011-4.367; P=0.047) was an independent prognostic factor of survival in LSCC patients.

CONCLUSION

We speculate that Gpx1 can be applied to predict the prognosis in LSCC patients.

An original technique for lymph node dissection along the left recurrent laryngeal nerve after stripping the residual esophagus during video-assisted thorocoscopic surgery of esophagus

BACKGROUND

A clear operative view of the middle and lower mediastinum is possible in prone position during video-assisted thorocoscopic surgery of esophagus (VATS-E), but the working space in the upper mediastinum is limited and lymph node dissection along the left recurrent laryngeal nerve (RLN) is difficult in this position.

METHODS

Esophagectomy and lymph node dissection are performed for pneumothorax by maintaining CO₂ insufflation in the prone position. Working space in the left upper mediastinal area for lymph node dissection around RLN is limited in this position. To create space, the residual esophagus is stripped in the reverse direction and retracted toward the neck after the stomach tube is removed through the nose. Lymph node dissection is performed after stripping the residual esophagus.

RESULTS

We could obtain a clear operative field in the upper left mediastinum by stripping the residual esophagus in the prone position, enabling safe and straightforward lymph node dissection along the left RLN. The rate of permanent RLN paralysis was 1.2%.

CONCLUSIONS

Lymph node dissection along the left RLN after esophageal stripping is possible in the prone position during VATS-E.

Left thoracotomy for middle or lower thoracic esophageal carcinoma: still Sweet enough?

BACKGROUND

Esophagectomy via left thoracotomy (the Sweet procedure) has long been the conventional route for resection of esophageal carcinoma, especially in China. However, this procedure is being increasingly critiqued, mainly regarding the lymphadenectomy. The objective of this study was to compare the Sweet procedure with the right upper mediastinal lymph node resection (MS) and Ivor-Lewis (IL) procedure in the treatment of middle or lower thoracic esophageal squamous cell carcinoma (OSCC-MLT) in terms of lymphadenectomy, postoperative complications, and long-term survival.

METHODS

A total of 336 OSCC-MLT patients underwent radical intent surgery (188 with MS and 148 with IL procedure) between January 2007 and September 2013 in our hospital. After propensity score matching, 129 patients from each procedure were included. The efficacy of lymph node dissection at each station was estimated by the index of estimated benefit from lymph node dissection (IEBLD).

RESULTS

IEBLD is relatively high in stations 2L, 2R, 8, 16 and 17. The metastasis rates and ratios were similar between the MS and IL procedures at each station. The MS procedure significantly outperformed the IL procedure with a shorter operating time (212 vs. 317 min), shorter in-hospital stay (10.7 vs. 15.3 days), and fewer postoperative complications (30.2% vs. 43.4%). However, the 5-year survival rates were not significantly different between the two procedures (46.9% vs. 44.0%).

CONCLUSIONS

The MS procedure of esophagectomy is not inferior to the IL procedure in efficiency, moreover the MS procedure is safer.

Three-field lymph node dissection in treating the esophageal cancer

There are many controversies in lymphadenectomy for thoracic esophageal cancer, and whether 3-field lymphadenectomy or 2-field lymphadenectomy is better have still been in doubt. The aim of this article is to review the role of the lymph node dissection by introducing the merits and demerits in 3-field lymphadenectomy, and the development in lymphadenectomy's selection, treatment and diagnosis. All the literatures related to esophageal lymphadenectomy and minimally invasive surgery (MIE) were searched in PubMed database and the cross references were added and reviewed to complete the reference list. Several researches elucidated that better overall survival (OS) in patients with esophageal cancer after 3-field lymphadenectomy had been reported worldwide, and 3-field lymphadenectomy is more suitable for treating esophageal cancer with cervical and/or upper mediastinal lymph nodes metastasis than 2-field lymphadenectomy regardless of the tumor's histology and location. Many approaches based on the characteristics of esophageal cancer lymph node metastasis are taken to improve the accuracy of 3-field lymphadenectomy and decrease the postoperative morbidity and mortality, while every approach needs further studies to demonstrate its feasibility. The benefits of the recently rapid-developed techniques performed in treating esophageal cancer: the MIE and the robotic-assisted thoracoscopic esophagectomy are illuminated as well, and both of them are technically safe and feasible for esophageal cancer, whereas further evaluations are still necessary.

Clinical Significance of miR-149 in the Survival of Patients with Laryngeal Squamous Cell Carcinoma

MicroRNAs (miRNAs) play critical roles in the progression of laryngeal cancer (LC). In this study, we aimed to investigate whether miR-149 is associated with the prognosis of patients with LC. A total of 97 laryngeal squamous cell carcinoma patients who underwent tumor resection were included in our follow-up study. In vitro studies was performed in cancer cell line Hep-2 to explore the antitumor role of miR-149 in LC. We found that the expression of miR-149 was significantly lower in tumor tissues, compared with vocal cord polyp tissues (P < 0.05). Kaplan-Meier analysis revealed that miR-149 expression status is significantly associated with survival duration (log rank test, P < 0.05), and multivariate Cox regression analysis revealed that patients with low miR-149 expression had shorter survival times compared with patients with high miR-149 expression. In vitro studies revealed that the exogenous expression of miRNA-149 inhibits the proliferation of human Hep-2 cells and induces cell apoptosis. Our study suggests that miR-149 expression in laryngeal squamous cell carcinoma tissues is critically associated with the prognosis of patients, and the ectopic expression of miR-149 in Hep-2 cells inhibits proliferation and cell cycle progression.

Lymphatic spreading and lymphadenectomy for esophageal carcinoma

Esophageal carcinoma (EC) is a highly lethal malignancy with a poor prognosis. One of the most important prognostic factors in EC is lymph node status. Therefore, lymphadenectomy has been recognized as a key that influences the outcome of surgical treatment for EC. However, the lymphatic drainage system of the esophagus, including an abundant lymph-capillary network in the lamina propria and muscularis mucosa, is very complex with cervical, mediastinal and celiac node spreading. The extent of lymphadenectomy for EC has always been controversial because of the very complex pattern of lymph node spreading. In this article, published literature regarding lymphatic spreading was reviewed and the current lymphadenectomy trends for EC are discussed.