Original article
General thoracic
Survival in Patients With Esophageal Adenocarcinoma Undergoing Trimodality Therapy Is Independent of Regional Lymph Node Location

Presented at the Sixty-first Annual Meeting of the Southern Thoracic Surgical Association, Tucson, AZ, Nov 5–8, 2014.
https://doi.org/10.1016/j.athoracsur.2015.09.063Get rights and content

Background

The American Joint Committee on Cancer Cancer Staging Manual 7th Edition esophageal cancer staging was derived from outcomes of patients undergoing esophagectomy alone and eliminated nodal location from its schema. A limitation of this staging system is that it has not been validated in the setting of multimodality therapy for esophageal cancer. In addition, nodal location continues to influence treatment decisions. The aim of our study was to evaluate outcomes of patients with distal esophageal or gastroesophageal junction (GEJ) adenocarcinoma undergoing trimodality therapy and assess the effect of nodal location on survival.

Methods

This multiinstitutional retrospective study assessed patients with clinically node-positive (cN+) distal esophageal/GEJ adenocarcinoma treated with trimodality therapy between January 2002 and December 2011. Nodal stations were classified as paratracheal, subcarinal, celiac, lower esophageal, paraaortic, supraclavicular, or perigastric/perihepatic. Overall survival (OS) was estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify variables associated with OS.

Results

A total of 196 cN+ patients met the study criteria. The most prevalent metastatic nodal location was in the perigastric region, present in 141 patients (72%); paratracheal nodal involvement was present in 19 patients (10%). None of the nodal stations was significantly associated with OS on univariable analysis. Multivariable analysis identified age (hazard ratio [HR], 1.036; p = 0.001), male sex (HR, 2.39; p = 0.003), pathologic ypT3 (HR, 1.81; p = 0.048), and ypN3 (HR, 2.93; p = 0.003) as being significantly associated with survival.

Conclusions

The location of cN+ regional node disease in patients with distal esophageal or GEJ adenocarcinoma was not predictive of survival after trimodality therapy. Age, sex, pathologic tumor depth, and the number of involved nodes were independent predictors of survival. Patients with cN+ cancers should not be deprived of potentially curative surgical resection based solely on the location of regional nodal disease.

Section snippets

Patients and Methods

This was a multiinstitutional retrospective collaborative study from the Esophageal Cancer Study Group. Three institutions contributed data to the study: MD Anderson Cancer Center (n = 252), University of Rochester Medical Center (n = 30), and Virginia Mason Medical Center (n = 30). The study received approval by the Institutional Review Boards in all participating institutions, and a waiver of patient consent was obtained.

Based on the study’s inclusion criteria, we selected patients with

Results

The final study population consisted of 196 patients (176 men [90%]) with a median age of 61 years (range, 23 to 90 years) and a median body mass index of 27 kg/m2 (range, 18 to 68 kg/m2). Table 1 describes demographic characteristics. The location of 80% of the tumors was at the GEJ, and 72% (141 of 196) of patients presented with clinically involved lymph nodes located in the lesser sac (perigastric/perihepatic) location. However, 11% (22 of 196) of patients had metastatic lymph nodes that

Comment

Our study demonstrates that OS in patients with distal esophageal or GEJ adenocarcinoma treated with multimodality therapy depends on the pathologic depth of tumor invasion (ypT3) and the number of pathologically positive lymph nodes (ypN3) rather than on the specific location of the regional nodal metastases determined on the pretreatment clinical evaluation.

Multimodality therapy, more specifically preoperative chemotherapy or combined chemotherapy with radiotherapy, has become the standard

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