Risk factors of lymph node metastasis in T1 esophageal squamous cell carcinoma

Background and Aim: To perform endoscopic mucosal resection (EMR) for T1 esophageal cancer, it is essential to estimate the lymph node status exactly. In order to evaluate the feasibility of EMR for esophageal cancers, we evaluated the clinicopathological features of T1 esophageal squamous carcinomas with an emphasis on the risk factors and distribution patterns of lymph node metastasis. Methods: From 1994 to 2006, a total of 200 patients with T1 esophageal carcinoma were treated surgically in our institution. Among them, clinicopathological features were evaluated for 197 consecutive patients with T1 squamous cell carcinoma. Results: The frequency of lymph node involvement was 6.25% (4/64) in mucosal cancers and 29.3% (39/133) in submucosal cancers (P < 0.001). In patients with M1 (n = 32) and M2 (n = 14) cancers, no lymph node metastasis was found. In multivariate analysis, size larger than 20 mm, endoscopically non‐flat type, and endo‐lymphatic invasion were significant independent risk factors for lymph node metastasis. The differentiation of tumor cell was not a risk factor for lymph node metastasis. Conclusions: We suggest that EMR may be attempted for flat superficial squamous esophageal cancers smaller than 20 mm. After EMR, careful histological examination is mandatory.     

Precise delineation of clinical target volume for crossing-segments thoracic esophageal squamous cell carcinoma based on the pattern of lymph node metastases

Background

This work aims to investigate lymph node metastases (LNM) pattern of crossing-segments thoracic esophageal squamous cell carcinoma (ESCC) and its significance in clinical target volume (CTV) delineation.

Methods

From January 2000 to December 2014, 3,587 patients with thoracic ESCC underwent surgery including esophagectomy and lymphadenectomy at Shandong Cancer Hospital and Institute. Information of tumor location based on preoperative endoscopic ultrasonography (EUS) and postoperative pathological results were retrospectively collected. The extent of the irradiation field was determined based on LNM pattern.

Results

Among the patients reviewed, 1,501 (41.8%) were crossing-segments thoracic ESCC patients. The rate of LNM were 12.1%, 15.2%, 8.0%, 3.0%, and 7.1% in neck, upper mediastinum, middle mediastinum, lower mediastinum, and abdominal cavity for patients with upper-middle thoracic ESCC, 10.3%, 8.2%, 11.0%, 4.8%, 8.2% for middle-upper thoracic ESCC, 4.8%, 4.8%, 24.1%, 6.3%, 22.8% for middle-lower thoracic ESCC and 3.9%, 3.1%, 22.8%, 11.9%, 25.8% for lower-middle thoracic ESCC, respectively. The top three sites of LNM were 105 (12.1%), 108 (6.1%), 101 (6.1%) for upper-middle thoracic ESCC, 108 (8.2%), 105 (7.5%), 106 (6.8%) for middle-upper thoracic ESCC, 1 (18.8%), 108 (17.9%), 107 (9.6%) for middle-lower thoracic ESCC, 1 (21.3%), 108 (16.1%), 107 (10.1%) for lower-middle thoracic ESCC.

Conclusions

Crossing-segments thoracic ESCC was remarkably common among patients. When delineating their CTV, tumor location should be taken into consideration seriously. For upper-middle and middle-upper thoracic ESCC, abdominal cavity may be free from irradiation. For middle-lower and lower-middle thoracic ESCC, besides irradiation of relative mediastinal, irradiation of abdominal cavity can’t be neglected.     

Intrapulmonary lymph node (stations 13 and 14) metastasis in peripheral non-small cell lung cancer

It remains unknown whether dissecting the intrapulmonary lymph nodes (stations 13 and 14) when resecting peripheral non-small cell lung cancer (NSCLC) is necessary for accurate tumor node metastasis (TNM) staging. This study investigated intrapulmonary lymph node dissection (stations 13 and 14) on the pathological staging of peripheral NSCLC and the metastatic pattern of the lymph nodes.This retrospective study included patients with primary peripheral NSCLC who underwent radical dissection between January 2013 and December 2015. The clinical data of patients and examination results of intrapulmonary stations 12, 13, and 14 lymph nodes were analyzed.Of 3019 resected lymph nodes in a total of 234 patients (12.9/patient), 263 (8.7%) had metastasis. Ninety-nine patients had lymph node metastasis (42.3%): 40 (17.1%) were N1, 11 (4.7%) were N2, 48 (20.5%) were both N1 and N2, and 135 (57.7%) had no N1 or N2 metastasis. Sixteen (6.8%) patients had metastasis of stations 13 and/or 14. Metastasis in N1 positive patients of stations 10, 11, 12, 13, and 14 were 2.7%, 10.5%, 9.8%, 10.4%, and 8.5%, respectively. Missed detection without station 13 and 14 dissection was up to 6.8% (16/234).Dissection of stations 13 and 14 could be helpful for the identification of lymph node metastasis and for the accurate TNM staging of primary NSCLC.     

Prognostic significance of perigastric lymph nodes metastases on survival in patients with thoracic esophageal cancer

Several publications have showed that the number of metastatic lymph node (LN) should be taken into consideration in nodal category of esophageal cancer, but seldom considered extent of involved regional LNs. The aim of this study is to evaluate the significance of the extent of regional LN metastasis on survival in patients with esophageal cancer. A total of 245 thoracic esophageal cancer patients underwent transthoracic esophagectomy with standard lymphadenectomy between January 2000 and December 2006 were included in the study. Data including demographic factors, pathologic findings, LN parameters and survival outcomes were collected. The survival experience was depicted using Kaplan‐Meier method. A multivariate Cox proportional hazard model was used to screen the significant prognostic factors. The univariate analysis to further explore the significant prognostic factor was done by log‐rank test. After a median follow‐up of 53.2 months, the 5‐year survival rate was 46.3% for the entire cohort. Cox model regression indicated that the LN status and perigastric nodal status, aside from residual tumor status, histological tumor type and depth of invasion, were the independent prognostic factors. Patients without LN metastasis had better 5‐year survival than those with positive nodes (64.2% vs. 18.9%, X²= 35.875, P < 0.001). However, For those patients with nodal involvement, there was no difference in 5‐year survival between patients with involved nodes <3 and ≥3 (27.8% vs. 0%, X²= 0.925, P= 0.336). When considering the location of LN metastasis, patients could be further stratified according to whether the perigastric nodes were involved or not (37.5% vs. 10.0%, X²= 4.295, P= 0.038). In conclusion, involved LN number had no prognostic implication in nodal involved patients based on our data. Whereas, perigastric nodal involvement should be used to refine the N category (N0, no nodal metastasis, N1, non‐perigastric node metastasis, N2, perigastric node metastasis) for the future esophageal cancer staging criteria.     

The number of lymph node metastases influences survival and International Union Against Cancer tumor–node–metastasis classification for esophageal squamous cell carcinoma

To study the influence of the number of metastatic lymph nodes (LNs) on survival and International Union Against Cancer tumor–node–metastasis (TNM) classification for esophageal carcinoma. The clinicopathological data on 1146 patients with esophageal squamous cell carcinoma who had undergone an esophagectomy were retrospectively studied. Survival was analyzed by the Kaplan–Meier method. By subclassifying the nodes (N) category according to the number of metastatic LNs as: N₀ for no LN metastases; N₁₍₁₎ for only one positive node; and N₁₍₂₎ for ≥2 positive nodes. TNM staging was refined as stage II_a (T_2‐3N₀M₀), stage II_b (T₁N₁M₀ and T₂N₁₍₁₎M₀), stage IIIa (T₂N₁₍₂₎M₀ and T₃N₁₍₁₎M₀), and stage III_b (T₃N₁₍₂₎M₀ and T₄N_anyM₀), and the survival was analyzed. LN metastases was found in 380 of 1146 (33.2%) treated esophageal cancer patients. In 4270 LNs harvested, metastases was detected in 807 (18.9%). The 5‐year survival rates of the patients with 0, 1, and ≥2 positive nodes were 59.8, 33.4, and 9.4%, respectively. There was statistically significant difference among these three groups. The 5‐year survival of the patients in stages T₂N₁M₀ and T₃N₁M₀ was significantly higher in the N₁₍₁₎ group than in the N₁₍₂₎ group (41.5 vs 24.1%, and 31.2 vs 6.8%, P < 0.001). The 5‐year survival rates of the patients in refined stage II_a, II_b, III_a, and III_b were 57.1, 42.2, 28.6, and 8.5%, with significant difference existing in each stage groups. The number of positive LNs significantly influenced survival of the patients with esophageal cancer. Three grade classification (0, 1, ≥2 positive nodes) could quite well demonstrate the effect of the number of LN metastases and the survival. The refined TNM classification based on the number of LN metastases could better reflect the prognosis of esophageal cancer. Our results offer a strong rationale for refining the International Union Against Cancer TNM classification for esophageal carcinoma.     

Effects of neoadjuvant chemotherapy on primary tumor and lymph node metastasis in esophageal squamous cell carcinoma: additive association with prognosis

SUMMARY.  Neoadjuvant chemotherapy (NACT) is widely used to treat esophageal squamous cell carcinoma with lymph node metastasis (ESCC). However, NACT frequently has differential effects on primary tumor (PT) and lymph node metastasis (LNM). The clinical significance of this phenomenon remains unclear. Reduction in tumor size of PT and LNM was evaluated separately in 47 node-positive ESCC patients undergoing NACT, followed by surgical resection. We analyzed the prognostic significance and various clinicopathological parameters. NACT resulted in an average reduction rate of 45.5% for PT and 36.6% for LNM; the correlation between these rates was weak but significant ( r ² = 0.122, P  = 0.016). The reduction rates in both PT and LNM were significant prognostic factors, with the maximal significance with cut-off at 30% size reduction for PT (3-year survival, 47.3 vs. 8.3%, P  = 0.0004) and 20% for LNM (51.3 vs . 7.1%, P  = 0.0013). When these cut-off values were used to define NACT response, 28 patients (59%) were deemed responders for both PT and LNM, while 7 (15%) were nonresponders for both, and the response was inconsistent in 12 patients (26%). Only both PT/LNM responders showed good survival rates, with the remaining categories showing poor survival (3-year survival 60.5 vs . 5.3% P  < 0.0001). Multivariate analysis identified neither the PT nor the LNM response alone as an independent prognostic factor; however the combined PT/LNM response was identified as an independent prognostic factor (hazard ratio [HR] 2.861, P  = 0.0255) in addition to the number of histological lymph node metastases (HR 2.551, P  = 0.0328). The response to NACT in LNM and PT correlates closely with postoperative survival. A good response in both enhances the postoperative prognosis.     

Clinicopathologic factors predicting lymph node metastasis in superficial esophageal squamous cell carcinoma

Abstract

Objective. Surgical resection is the treatment of choice for superficial esophageal squamous cell carcinoma (SESCC), but it is associated with high mortality and morbidity rates. Recently, endoscopic resection for SESCC has been indicated for patients with a low risk of lymph node metastasis (LNM). Therefore, to successfully treat SESCC with endoscopic resection, it is very important to identify patients with a low risk for LNM. The objective of this study was to investigate clinicopathologic factors that predict LNM in patients who underwent esophagectomy for SESCC. Methods. The study included 104 patients with SESCC from three university hospitals in Pusan, Korea. Clinicopathologic factors were evaluated to identify independent factors predicting LNM by univariate and multivariate analyses. Results. In univariate analysis, the depth of tumor invasion and lymphovascular invasion had significant influences on LNM (p = 0.001 and p < 0.001, respectively). Gross type, tumor size, and tumor differentiation were not predictive for LNM. In multivariate analysis, the depth of tumor invasion and lymphovascular invasion were signi?cantly associated with LNM in patients with SESCC (OR 9.04, p = 0.049; OR 11.61, p = 0.002, respectively). Conclusions. The depth of tumor invasion and lymphovascular invasion were independent predictors of LNM in patients with SESCC. Therefore, endoscopic resection could be performed in patients with SESCC that is limited to the mucosa, without lymphovascular invasion.     

食管癌术后纵隔淋巴结转移两种疗法疗效比较

目的对食管癌术后纵隔淋巴结转移患者,比较三维调强适形放疗与常规放疗的疗效。方法分析2003年1月~2008年12月间安徽省立医院肿瘤放疗科收治的102例食管癌术后纵隔淋巴结转移患者,按不同标准对其分类入组并统计生存时间,对所得数据进行Log-Rank单因素分析。结果 102例患者中,调强放疗组局控率为87.2%,常规放疗组局控率为74.5%,局控率差异P〈0.05,放疗结束后13个月,两组生存率分别为46.0%、47%,P〈0.05。结论对食管癌术后纵隔淋巴结转移患者：三维调强适形放疗肿瘤局控率高于常规放疗,三维调强适形放疗远期生存率与常规放疗无差异。     

胸段食管鳞癌淋巴结转移规律及淋巴结清扫方式探讨

目的探讨胸段食管鳞癌淋巴结转移规律及术中淋巴结清扫方式。方法 480例行根治术的胸段食管鳞癌患者,标记各部位清扫淋巴结分别送检,进行临床病理资料分析。结果本组386例患者有淋巴结转移。全组清扫淋巴结5 424枚,平均每例清扫11.3枚,689枚淋巴结有转移。22例患者出现跳跃性淋巴结转移,其中胸上段3例、中段9例、下段1例。胸上段食管鳞癌颈部淋巴结转移率47.6%,高于胸中段（10.5%）和胸下段（1.3%）,P均〈0.05。胸下段食管鳞癌向腹腔淋巴结转移率为33.1%,高于胸中段（19.4%）和胸上段（3.8%）,P均〈0.05。胸中段食管鳞癌有上纵隔淋巴结（23.5%）及下纵隔淋巴结（29%）和腹腔淋巴结（19.4%）的双向转移趋势,隆突下淋巴结转移多见,转移率54.2%。结论 胸上段食管癌淋巴结转移以颈段食管旁、锁骨上、上中纵隔转移多见,胸中段食管癌淋巴结转移具有明显的上下双向转移和跳跃性转移特点,胸下段食管癌淋巴结转移以腹部、中下纵隔转移多见。胸上段食管癌行颈、胸、腹三野淋巴结清扫,重点清扫颈段食管旁及锁骨上、下界包括隆突下淋巴结;胸下段食管癌可行胸、腹两野淋巴结清扫,重点清扫隆突下、下胸段食管旁、胃左动脉旁淋巴结;胸中段食管癌淋巴结清扫方式应根据具体情况设定。     

Early appendiceal adenocarcinoma. A review of the literature with special reference to optimal surgical procedures

Received: October 23, 2000 / Accepted: February 2, 2001     

Prognostic significance of the endoscopic ultrasound defined lymph node metastasis count in esophageal cancer

The key prognostic factor which predicts outcome after esophagectomy for cancer is the number of malignant lymph node metastases, but data regarding the accuracy of endoscopic ultrasound (EUS) in determining and predicting the metastatic lymph node count preoperatively are limited. The aim of this study was to assess the prognostic significance of EUS defined lymph node metastasis count (eLNMC) in patients diagnosed with esophageal cancer. Two hundred and sixty‐seven consecutive patients (median age 63 years, 187 months) underwent specialist EUS followed by stage directed multidisciplinary treatment (183 esophagectomy [64 neoadjuvant chemotherapy, 19 neoadjuvant chemoradiotherapy], 79 definitive chemoradiotherapy, and 5 palliative therapy). The eLNMC was subdivided into four groups (0, 1, 2 to 4, >4) and the primary measure of outcome was survival. Survival was related to EUS tumor (T) stage (P < 0.0001), EUS node (N) stage (P < 0.0001), EUS tumor length (p < 0.0001), and eLNMC (P < 0.0001). Multivariable analysis revealed EUS tumor length (hazard ratio [HR] 1.071, 95% CI 1.008–1.138, P= 0.027) and eLNMC (HR 1.302, 95% CI 1.133–1.496, P= 0.0001) to be significantly and independently associated with survival. Median and 2‐year survival for patients with 0, 1, 2–4, and >4 lymph node metastases were: 44 months and 71%, 36 months and 59%, 24 months and 50%, and 17 months and 32%, respectively. The total number of EUS defined lymph node metastases was an important and significant prognostic indicator.     

Development and validation of a nomogram for preoperative prediction of lymph node metastasis in pathological T1 esophageal squamous cell carcinoma

Endoscopic resection is increasingly used to treat patients with pathological T1 (pT1) esophageal squamous cell carcinoma (ESCC) because of its small surgical trauma. However, reports of the risk factors for lymph node metastasis (LNM) have been controversial. Therefore, we aim to build a nomogram to individually predict the risk of LNM in pT1 ESCC patients, to make an optimal balance between surgical trauma and surgical income.One hundred seventy patients with pT1 esophageal cancer in our hospital were analyzed retrospectively. Logistic proportional hazards models were conducted to find out the risk factor associated with LNM independently, and those were imported into R library “RMS” for analysis. A nomogram is generated based on the contribution weights of variables. Finally, decision analysis and clinical impact curve were used to determine the optimal decision point.Twenty-five (14.7%) of the 170 patients with pT1 ESCC exhibited LNM. Multivariable logistic regression analysis showed that smoking, carcinoembryonic antigen, vascular tumor thromboembolus, and tumor differentiation degree were independent risk factors for LNM. The nomogram had relatively high accuracy (C index of 0.869, 95% confidence interval: 0.794–0.914, P < .0001). The decision curve analysis provided the most significant clinical benefit for the entire included population, with scores falling just above the total score of 85 in the nomogram.Smoking, carcinoembryonic antigen, vascular tumor thromboembolus, and tumor differentiation degree may predict the risk of LNM in tumor 1 ESCC. The risk of LNM can be predicted by the nomogram.     

Radiofrequency ablation for pulmonary metastases from esophageal squamous cell carcinoma

Radiofrequency ablation (RFA) is increasingly being used for the treatment of intrathoracic malignancies. Although RFA has been found to be promising in the treatment of lung metastases from some types of neoplasms, little is known concerning its clinical significance in the treatment of pulmonary metastasis from esophageal squamous cell carcinoma (ESCC). This retrospective study evaluated the feasibility, safety, and effectiveness of computed tomography‐guided RFA for pulmonary metastasis from ESCC. A series of 10 ESCC patients with 17 pulmonary tumors were included. Correct placement of the ablation device into the target tumor proved to be feasible in all tumors (100%). The mean visual analog scale score, with values that ranged from 0 (no pain) to 10 (worst pain possible), was 1. This suggested that this procedure was well tolerated. No procedure‐related deaths occurred. A pneumothorax needing drainage was a major complication in two patients. Local control of ablated tumor lasting for at least 1 year was achieved in 10 (83%) of 12 assessable tumors. Although locoregional recurrences developed in two tumors, these lesions could be recontrolled by repeat treatment with RFA. Three patients died of recurrent disease. The predicted 1‐ and 2‐year overall survival rates after lung RFA were 77.8% and 62.2%, respectively. Percutaneous computed tomography‐guided RFA yielded relatively high levels of local control in patients with pulmonary metastases from ESCC and was associated with an acceptable level of complications. It was concluded that a prospective study will be necessary to evaluate the effectiveness of a combination of systemic therapy and RFA for ESCC lung metastases.     

Salvage lymphadenectomy for cervical lymph node recurrence after esophagectomy for squamous cell carcinoma of the thoracic esophagus

Prognosis of patients with recurrent esophageal cancer is usually unsatisfactory. We have successfully treated five patients with cervical node recurrence after esophagectomy with multimodal treatment including salvage lymphadenectomy. In order to clarify the efficacy of salvage surgery for cervical node recurrence, we have reviewed the clinical course and prognosis of these patients. From August 2004 to December 2007, 30 patients with 33 recurrent sites were treated in the Department of Surgery, Iizuka Hospital. Among these patients, there were five patients with recurrence limited within the cervical nodes. Salvage cervical lymphadenectomy was performed for all five patients. Curative resection was achieved in four patients and reduction surgery followed by planned chemoradiotherapy was performed in another patient. All stations including the suspicious node were dissected and a partial sternotomy was added for one patient whose recurrent tumor was located in the right recurrent nerve node. There was no mortality and one minor complication (subcutaneous hemorrhage) was observed. Median duration of hospital stay was 7 days. Adjuvant chemotherapy was performed for all patients. Median follow‐up period was 54 months and all patients are alive without relapse of the disease. Salvage cervical lymphadenectomy is a safe and effective treatment for patients with cervical node recurrence after esophagectomy.     

Study of abnormal chromosome regions in esophageal squamous cell carcinoma by comparative genomic hybridization: relationship of lymph node metastasis and distant metastasis to selected abnormal regions

Squamous cell carcinoma of the esophagus (ESCC) has a poor prognosis among digestive tract cancers. Lymph node metastasis and distant metastasis are the major factors determining its prognosis. We used comparative genomic hybridization (CGH) to evaluate primary tumor lymph nodes and metastatic areas from ESCC patients in order to determine the relationship between abnormal chromosome regions and outcome. Tumor tissues and lymph nodes were collected from 51 patients with ESCC, and abnormal chromosome regions were detected by CGH. We searched for regions that were significantly more common in patients with lymph nodes metastases (n≥ 6) or distant metastases, and correlated those chromosomal changes with survival. Regions showing amplification in more than 65% of esophageal squamous cell cancers were as follows: 17q12 (90.2%), 17q21 (86.3%), 3q29 (82.4%), 3q28 (78.4%), 8q24.2 (76.5%), 22q12 (76.5%), 3q27 (74.5%), 8q24.3 (74.5%), 1q22 (70.6%), 5p15.3 (70.6%), 22q13 (70.6%), 3q26.3, 8q23, 8q24.1, 9q34, 11q13, 17p12, 17q25, 20q12, 20q13.1 (68.6%), 1q32, 1q42, and 20q13.2 (66.7%). Regions showing deletion in more than 50% of the tumors were as follows: Yp11.3 (62.7%), 3p26 (56.9%), Yq12 (54.9%), 13q21 (52.9%), 4q32 (51.0%), and 13q22 (51.0%). When Fisher's test was used to assess associations of these regions with metastases to lymph nodes, amplification at 2q12–14 (P= 0.012), 3q24–26 (P= 0.005), and 7q21–31 (P= 0.026) were significant. Survival was worse for patients with amplification at all 3 regions. In patients with distant organ metastases, amplification at 7p13–21 was significant (P= 0.008), and survival was worse. Chromosomal amplifications in ESCC at 2q12–14, 3q24–26, and 7q21–31 were associated with lymph node metastasis, while amplification at 7p13–21 was related to distant metastasis. Amplification at these regions correlated with worse survival. Genes involved in the phenotype of ESCC may exist in these regions. Identification of these genes is a theme for future investigation.     

Expression and prognostic relevance of p21WAF1 in stage III esophageal squamous cell carcinoma

The prognostic effect of p21^WAF1 expression on esophageal squamous cell carcinoma patients is controversial. Further clarifying the effect of this protein is beneficial for optimizing the patient outcomes. In the current study, we investigated the expression of p21^WAF1 protein in 189 specimens of stage III ESCC by immunohistochemistry. As shown by the Kaplan–Meier curve, the overall survival rate of the positive‐expression group was significantly higher than that of the negative‐expression group (P < 0.05). No significant correlation was observed between p21^WAF1 expression and clinicopathological parameters in terms of gender, age, tumor location, tumor grade, pathological stage, and number of regional lymph node metastases (P > 0.05). We concluded that p21^WAF1 played an intricate role in the tumorigenesis and development of ESCC. p21^WAF1 could serve as a positive prognostic predictor for stage III ESCC patients.     

Tumor cell dissociation score highly correlates with lymph node metastasis in superficial esophageal carcinoma

BACKGROUND: It is still not clear which parameters are important for predicting the metastatic potential of superficial esophageal squamous cell carcinoma (SESCC). The purpose of the present paper was thus to investigate tumor cell dissociation (TCD) in SESCC as a predictive factor of lymph node metastasis. METHODS: Thirty-three SESCC were classified into four groups based on the depth of tumor invasion. Carcinomas not invading as far as the muscularis mucosa were classified as group A; carcinomas invading to the muscularis mucosa or less than one-third of the upper submucosa were classified as group B; those invading to the middle layer of the submucosa were classified as group C; and those invading one-third of the lower submucosa were classified as group D. The TCD score was calculated by dividing the length of the TCD region by the maximal longitudinal length of the area of invasion into or beyond the lamina propria, and multiplying by 100. E-cadherin expression of the carcinomas was investigated in the TCD area and the successive area of mucosal invasive carcinoma (SAM). RESULTS: The incidence of lymph node metastasis was 0% in group A, 10% in group B, 36.4% in group C and 57.1% in group D. The mean TCD scores (+/-SEM) of SESCC with lymph node metastasis were higher than that without (85.3 +/- 5.7, 16.3 +/- 3.9, respectively; P < 0.001). In group C, the TCD score of cases with lymph node metastases was higher than in those without lymph node metastasis (P < 0.001). E-cadherin expression was significantly reduced in the area of TCD compared with the SAM located over the TCD area (P < 0.001). CONCLUSIONS: The TCD score is an important predictive marker for lymph node metastasis in SESCC. Clinical evaluation of TCD scores in endoscopic mucosal resection (EMR) specimens would enable accurate prediction of lymph node metastasis and extend the indication of EMR treatment for SESCC.     

The significance of abdominal para‐aortic lymph node metastasis in patients with lower thoracic esophageal cancer

Para‐aortic lymph node (PALN) recurrence is often seen in patients with lower thoracic esophageal cancer treated by esophagectomy with extended lymph node dissection. However, the clinicopathological characteristics of patients with PALN metastasis and the significance of PALN dissection are unknown. A total of 283 patients with lower thoracic esophageal cancer underwent esophagectomy with lymphadenectomy at our hospital between April 1984 and March 2007. Among these 283 patients, 60 patients were enrolled in this retrospective study according to following criteria: (i) clinical T2 to T4 tumor, (ii) no clinical PALN metastasis, and (iii) received PALN dissection. PALN dissection was indicated by a tumor depth of at least T2 and no severe complications. The clinicopathological data, recurrence pattern, and overall survival were compared between patients with PALN and without PALN metastasis. The mean length of surgery was 587 min and the mean blood loss was 1383 mL. The morbidity was 33.3% and mortality was 5% in this series. Sixteen patients (26.7%) had PALN metastasis; these showed significantly more lymph node metastases (15.8 ± 13.2 vs. 3.0 ± 3.2, P < 0.0001) and significantly worse survival rates (53.3% vs. 79.9% at 1 year, 6.7% vs. 62.0% at 3 years, P < 0.0001) than patients without PALN metastasis. The incidence of lymph node recurrence (P < 0.0001) and hematogenous recurrence (P= 0.0487) was also higher in patients with PALN metastasis than in patients without PALN metastasis. Among the 16 patients with PALN metastasis, a univariate analysis revealed total number of metastatic nodes < 8 (P= 0.0325) to be a significant prognostic factor. A multivariate logistic regression analysis of the regional lymph nodes identified the invasion of the lower mediastinal nodes (hazard ratio = 6.120) and retroperitoneal nodes (hazard ratio = 15.167) to be significantly correlated with PALN metastasis. PALN metastasis is suggested to be related to the systemic spread of lymphatic metastasis even in lower thoracic esophageal cancer. PALN dissection for pathological PALN(+) patients should not be performed. It remains to be determined in future prospective studies whether patients without pathological PALN metastasis, but showing PALN micrometastasis, could achieve improved survival with PALN dissection.