Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Annals of Surgical Oncology
Published in: Annals of Surgical Oncology 1/2018

01-01-2018 | Thoracic Oncology

Surgical Management of Early-Stage Esophageal Adenocarcinoma Based on Lymph Node Metastasis Risk

Authors: Andrew D. Newton, MD, Jarrod D. Predina, MD, MS, Leilei Xia, MBBS, Robert E. Roses, MD, Giorgos C. Karakousis, MD, Daniel T. Dempsey, MD, Noel N. Williams, MD, John C. Kucharczuk, MD, Sunil Singhal, MD

Published in: Annals of Surgical Oncology | Issue 1/2018

Login to get access

Abstract

Background

In early-stage esophageal adenocarcinoma (EAC), esophagectomy improves staging but also increases mortality compared with endoscopic resection. Our objective was to quantify esophagectomy mortality and lymph node metastasis (LNM) risk in early-stage EAC to improve surgical treatment allocation.

Methods

We identified National Cancer Database (2004–2014) patients with nonmetastatic, Tis, T1a, or T1b EAC who had primary surgical resection and microscopic examination of at least 15 lymph nodes. Univariate and multivariable logistic regression identified predictors of LNM. Cox regression identified predictors of death. The Kaplan–Meier method predicted overall survival (OS).

Results

In 782 patients, LNM rates were: all patients 13.8%, Tis 0%, T1a 3.6%, T1b 23.4%. Independent predictors of LNM were submucosal invasion, lymphovascular invasion (LVI), decreasing differentiation, and tumor size ≥ 2 cm (P < 0.05). For T1a tumors with poor differentiation or size ≥ 2 cm, LNM rates were 10.2 and 6.7%, respectively; 90-day mortality was 3.1%. The LNM rate in well differentiated T1b tumors < 2 cm was 4.2%; 90-day mortality was 6.0%. Estimated 5-year OS was 80.2% versus 64.4% (T1a vs. T1b). LNM increased risk of death for T1a (hazard ratio [HR] 8.52, 95% confidence interval [CI] 3.13–23.22, P < 0.001) and T1b tumors (HR 2.52, 95% CI 1.59–4.00, P < 0.001).

Conclusions

In T1a EAC with poor differentiation or size ≥ 2 cm, esophagectomy should be considered, whereas in T1b EAC with low-risk features (well-differentiated T1b EAC < 2 cm without LVI), endoscopic resection may be sufficient. Treatment guidelines for early-stage EAC should include all high-risk tumor features for LNM and stage-specific esophagectomy mortality.
Literature
1.
Edgren G, Adami HO, Weiderpass E, Nyren O. A global assessment of the oesophageal adenocarcinoma epidemic. Gut. 2013;62(10):1406–14.CrossRefPubMed
2.
Lagergren J, Lagergren P. Recent developments in esophageal adenocarcinoma. CA Cancer J Clin. 2013;63(4):232–48.CrossRefPubMed
3.
Hur C, Miller M, Kong CY, Dowling EC, Nattinger KJ, Dunn M, Feuer EJ. Trends in esophageal adenocarcinoma incidence and mortality. Cancer. 2013;119(6):1149–58.CrossRefPubMed
4.
Ngamruengphong S, Wolfsen HC, Wallace MB. Survival of patients with superficial esophageal adenocarcinoma after endoscopic treatment vs surgery. Clin Gastroenterol Hepatol. 2013;11(11):1424–29. e1422; quiz e1481.
5.
6.
Pech O, May A, Manner H, et al. Long-term efficacy and safety of endoscopic resection for patients with mucosal adenocarcinoma of the esophagus. Gastroenterology. 2014;146(3):652–60. e651.
7.
Rentz J, Bull D, Harpole D, et al. Transthoracic versus transhiatal esophagectomy: a prospective study of 945 patients. J Thorac Cardiovasc Surg. 2003;125(5):1114–20.CrossRefPubMed
8.
Bailey SH, Bull DA, Harpole DH, et al. Outcomes after esophagectomy: a ten-year prospective cohort. Ann Thorac Surg. 2003;75(1):217–22; discussion 222.CrossRefPubMed
9.
Ra J, Paulson EC, Kucharczuk J, et al. Postoperative mortality after esophagectomy for cancer: development of a preoperative risk prediction model. Ann Surg Oncol. 2008;15(6):1577–84.CrossRefPubMed
10.
Wright CD, Kucharczuk JC, O’Brien SM, Grab JD, Allen MS. Predictors of major morbidity and mortality after esophagectomy for esophageal cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database risk adjustment model. J Thorac Cardiovasc Surg. 2009;137(3):587–95; discussion 596.CrossRefPubMed
11.
Connors RC, Reuben BC, Neumayer LA, Bull DA. Comparing outcomes after transthoracic and transhiatal esophagectomy: a 5-year prospective cohort of 17,395 patients. J Am Coll Surg. 2007;205(6):735–40.CrossRefPubMed
12.
Jamieson GG, Mathew G, Ludemann R, Wayman J, Myers JC, Devitt PG. Postoperative mortality following oesophagectomy and problems in reporting its rate. Br J Surg. 2004;91(8):943–47.CrossRefPubMed
13.
Rice TW, Rusch VW, Apperson-Hansen C, et al. Worldwide esophageal cancer collaboration. Dis Esophagus. 2009;22(1):1–8.CrossRefPubMed
14.
Pech O, Gunter E, Dusemund F, Origer J, Lorenz D, Ell C. Accuracy of endoscopic ultrasound in preoperative staging of esophageal cancer: results from a referral center for early esophageal cancer. Endoscopy. 2010;42(6):456–61.CrossRefPubMed
15.
Shin S, Kim HK, Choi YS, Kim K, Shim YM. Clinical stage T1-T2N0M0 oesophageal cancer: accuracy of clinical staging and predictive factors for lymph node metastasis. Eur J Cardiothorac Surg. 2014;46(2):274–79; discussion 279.CrossRefPubMed
16.
Bergeron EJ, Lin J, Chang AC, Orringer MB, Reddy RM. Endoscopic ultrasound is inadequate to determine which T1/T2 esophageal tumors are candidates for endoluminal therapies. J Thorac Cardiovasc Surg. 2014;147(2):765-71; discussion 771–73CrossRefPubMed
17.
Bilimoria KY, Stewart AK, Winchester DP, Ko CY. The National Cancer Data Base: a powerful initiative to improve cancer care in the United States. Ann Surg Oncol. 2008;15(3):683–90.CrossRefPubMedPubMedCentral
18.
Lorenz D, Origer J, Pauthner M, et al. Prognostic risk factors of early esophageal adenocarcinomas. Ann Surg. 2014;259(3):469–76.CrossRefPubMed
19.
Pennathur A, Farkas A, Krasinskas AM, et al. Esophagectomy for T1 esophageal cancer: outcomes in 100 patients and implications for endoscopic therapy. Ann Thorac Surg. 2009;87(4):1048–54; discussion 1054–5.CrossRefPubMedPubMedCentral
20.
Davison JM, Landau MS, Luketich JD, et al. A model based on pathologic features of superficial esophageal adenocarcinoma complements clinical node staging in determining risk of metastasis to lymph nodes. Clin Gastroenterol Hepatol. 2016;14(3):369–77. e363.
21.
Leers JM, DeMeester SR, Oezcelik A, et al. The prevalence of lymph node metastases in patients with T1 esophageal adenocarcinoma a retrospective review of esophagectomy specimens. Ann Surg. 2011;253(2):271–78.CrossRefPubMed
22.
Holscher AH, Bollschweiler E, Schroder W, Metzger R, Gutschow C, Drebber U. Prognostic impact of upper, middle, and lower third mucosal or submucosal infiltration in early esophageal cancer. Ann Surg. 2011;254(5):802–07; discussion 807–8.CrossRefPubMed
23.
Lee L, Ronellenfitsch U, Hofstetter WL, et al. Predicting lymph node metastases in early esophageal adenocarcinoma using a simple scoring system. J Am Coll Surg. 2013;217(2):191–99.CrossRefPubMed
24.
Altorki NK, Lee PC, Liss Y, et al. Multifocal neoplasia and nodal metastases in T1 esophageal carcinoma: implications for endoscopic treatment. Ann Surg. 2008;247(3):434–39.CrossRefPubMed
25.
Gamboa AM, Kim S, Force SD, et al. Treatment allocation in patients with early-stage esophageal adenocarcinoma: prevalence and predictors of lymph node involvement. Cancer. 2016;122(14):2150–57.CrossRefPubMed
26.
Ishihara R, Oyama T, Abe S, et al. Risk of metastasis in adenocarcinoma of the esophagus: a multicenter retrospective study in a Japanese population. J Gastroenterol. 2016;52(7):800–08.CrossRefPubMed
27.
Liu L, Hofstetter WL, Rashid A, et al. Significance of the depth of tumor invasion and lymph node metastasis in superficially invasive (T1) esophageal adenocarcinoma. Am J Surg Pathol. 2005;29(8):1079–85.PubMed
28.
Pouw RE, Heldoorn N, Alvarez Herrero L, et al. Do we still need EUS in the workup of patients with early esophageal neoplasia? A retrospective analysis of 131 cases. Gastrointest Endosc. 2011;73(4):662–68.CrossRefPubMed
29.
Worrell SG, Boys JA, Chandrasoma P, et al. Inter-observer variability in the interpretation of endoscopic mucosal resection specimens of esophageal adenocarcinoma: interpretation of ER specimens. J Gastrointest Surg. 2016;20(1):140–44; discussion 144–5.CrossRefPubMed
30.
Mohiuddin K, Dorer R, El Lakis MA, Hahn H, Speicher J, Hubka M, Low DE. Outcomes of surgical resection of T1bN0 esophageal cancer and assessment of endoscopic mucosal resection for identifying low-risk cancers appropriate for endoscopic therapy. Ann Surg Oncol. 2016;23(8):2673–78.CrossRefPubMed
Metadata
Title
Surgical Management of Early-Stage Esophageal Adenocarcinoma Based on Lymph Node Metastasis Risk
Authors
Andrew D. Newton, MD
Jarrod D. Predina, MD, MS
Leilei Xia, MBBS
Robert E. Roses, MD
Giorgos C. Karakousis, MD
Daniel T. Dempsey, MD
Noel N. Williams, MD
John C. Kucharczuk, MD
Sunil Singhal, MD
Publication date
01-01-2018
Publisher
Springer International Publishing
Published in
Annals of Surgical Oncology / Issue 1/2018
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-017-6238-z

Other articles of this Issue 1/2018

Annals of Surgical Oncology 1/2018 Go to the issue

Colorectal Cancer

Locally Advanced Colorectal Cancer: True Peritoneal Tumor Penetration is Associated with Peritoneal Metastases

Bone and Soft Tissue Sarcomas

Long-Term Survival According to Histology and Radiologic Response to Preoperative Chemotherapy in 126 Patients Undergoing Resection of Non-GIST Sarcoma Liver Metastases

Pancreatic Tumors

The Role of Venous and Arterial Resection in Pancreatic Cancer Surgery

Gastrointestinal Oncology

Vitamin Status and the Development of Postoperative Cognitive Decline in Elderly Surgical Oncologic Patients

Hepatobiliary Tumors

Adjuvant Chemoradiotherapy is Associated with Improved Survival for Patients with Resected Gallbladder Carcinoma: A Systematic Review and Meta-analysis

Gastrointestinal Oncology

Induced Bias Due to Crossover Within Randomized Controlled Trials in Surgical Oncology: A Meta-regression Analysis of Minimally Invasive versus Open Surgery for the Treatment of Gastrointestinal Cancer