Stenosis in Esophageal Cancer: A Poor Prognostic Indicator

Excerpt

Sugawara et al., in the recent article entitled, “The impact of pretreatment esophageal stenosis on survival in esophageal cancer patients,” examined a Japanese cohort of 496 consecutive patients within an 8-year period, of which 51 had esophageal stenosis.¹ Although not universal, the definition of stenosis is objectively and clearly defined as patients where a 5–6-mm diameter endoscope could not be passed through the tumor site of narrowing. The authors used multiple validated pretreatment prognostic tools: Onodera’s prognostic nutritional index, the Glasgow prognostic score (GPS), and the Charlson comorbidity index.^1,2 All patients were treated based on the algorithms established by the Japan Esophageal Society guidelines: for T1N1-3 or T2-4a (any N disease), neoadjuvant chemotherapy followed by surgery was performed.³ In general, patients were not stented. The operative methods included subtotal en bloc resection via cervico-thoraco-abdominal approach. For high risk, an abdominal cervical approach was used. For those who failed chemoradiation therapy, the McKeown esophagectomy was employed for salvage. Compared with those without stenosis, patients with stenosis tend to present at a later clinical stage, have a lower body mass index (BMI), higher pathological stage, achieve fewer R0 resections, and have greater recurrence than those who do not have stenosis. Esophageal stenosis was a predictor of decreased overall survival with a hazard ratio of 1.61 (95% confidence interval [CI] 1.07–2.42), although the effect is not as large as that of Stage III-IV and noncurative resection. Analyzing those with stenosis separately, multivariable analysis asserts that stenosis independent of staging portends poor prognosis in cancer-specific survival (CSS). For those undergoing surgery, stenosis demonstrated a significantly increased risk (hazard ratio [HR] = 1.67 95% CI 1.09–2.58) of lower CSS; however, the presence of pathological stage III–IV disease demonstrated greater effect with a hazard ratio of 5.75 (95% CI 3.13–10.57). Consistently, the authors show that stenosis, stage, and noncurative resection are strong predictors for poor prognosis. …