Impact of Lymph-Node Metastatic Site in Patients with

Thoracic Esophageal CancerEdited by:Kunisaki C., Makino H., Kimura J.,Oshima T., Fujii S., Takagawa R., et al.

Presented for Journal Club by:Fuad Hassan BinGadeem

Aden,

8 Feb. 2010

Introduction:

Lymph Node Metastasis (LNM) is an independent prognostic factor for esophageal ca.

Lymph node dissection is one of the important treatment for this disease.

Introduction:

UICC/TNMUICC/TNM classification categorizes LNM according to the number of MLN irrespective to site.

By contrast 10th Ed. Japanese ClassificationJapanese Classification of Esophageal Cancer categorize according to both site and number of MLN.

Introduction: Several study reports suggest

the number of LNM had greater significance than the site of MLN.

However it remain unclear whether pts with intra-thoracic or extra-thoracic (cervical & abdominal) LNM achieve satisfactory outcomes after curative esophagectomy?

Patients and Methods: Retrospective Study April 1992- March 2002 Yokohama City University Japan (Dep. of Surgery GE. C. &

Dep. of GE. Surgery)

96 patients from 159 was selected. Confirmed esophageal SCC by endoscopic biopsy

specimen + Lymph node metastasis. Data source: Op. Path. Reports, outpatient data

base.

Preoperative Evaluation:

Findings: 96 Pts.: 32 tumor lower

TE, 54 middle TE, 10 CE.

15 Superficial type tumor, 42 well defined type tumor, 39 ill-defined type tumor.

Pre-Op.Evaluation

Barium-swallow

Endoscopy + Biopsy

CT-scan

Surgical Procedures:

Technique:

65 pts. 2-field esophagectomy (complete

dissection of mediastinal and abdominal

regional lymph nodes). 31 pts. 3-field esophagectomy (complete

dissection of mediastinal, abdominal and cervical regional lymph nodes).

Surgical Procedures:

Findings:

Of 96 pts. N1(ē regional LNM) 8 cervical

LNM, 76 thoracic LNM, 49 abdominal LNM. Depth of invasion: 15 T1, 32 T2, 47 T3, 2 T4. TNM Class.: 46 IIB, 50 III.

Neoadjuvant & Adjuvant Treatment

Neoadjuvant chemotherapy was not administered.

Adjuvant chemotherapy was administered to patients with tumors deeper than the muscularis propria (66 pts.) after informed consent.

Cisplatin (5mg/m² on days 1-5 & 8-12) +Fluorouracil (5-FU 500mg/m² on days 1-5 & 8-12).At least 4 course 1st 2 years.

Statistical Analysis:

SPSS v10.

Chi-square test

Student’s t-test mean+/- SD

Survival curve Kaplan-Meier method

Survival rates were calculated at intervals of one metastatic lymph node

Cox’s proportional hazards regression model to compare survival rate

Independent prognostic factors were assessed by the Cox’s proportional hazards regression model.

Results:

Number of MLN 3.54 +/- 3.89 (mean +/- SD) Number of dissected lymph node 40.4+/- 16.6

(mean +/- SD). Most significant difference in disease specific

survival was detected at threshold of value of 4 MLN.

5-year survival rates were 73.9%, 53.1% and 13.9% for pts without metastasis, ≤ 4 MLN, ≥5 or more MLN.

Significant difference between pts without metastasis, ≤ 4 MLN, ≥5 or more MLN.

Patient Character:

55 patients with extra-thoracic LNM or intrathoracic and extrathoracic LNM, 47 pts abdominal LNM and 6 cervical LNM.

5-year survival rates were 73.1%, 50.3%, and 23.5% for pts with extrathoracic, intrathoracic and both extra and intrathoracic LNM.

Patient Character:

Intrathoracic LNM in 41 pts (25.8%),extra-thoracic LNM in 20 pts (12.6%), & both intra thoracic & extrathoracic LNM in35 pts (22.0)Intrathoracic LNM was frequently observed in pts middle and upper thoracic esophageal cancer.Number of MLN was significantly greater in patients with both intrathoracic and extrathoracic LNM than in those with either extrathoracic or intrathoracic LNM alone.No difference between pts with intrathoracic LNM and those with extrathoracic LNM.

Number of MLN at each Tumor Site:

There was no significant difference in the Number of MLN between pts with intrathoracic metastasis and those with extra thoracic metastasis at each tumor siteSignificant difference in number of MLN between those with either intrathoracic metastasis or extrathoracic metastasis and those with both intrathoracic metastasis and extrathoracic metastasis among patients with middle thoracic and lower thoracic tumors.

Prognostic Factors for Disease-Specific Survival:

Univariate analysis showed that number of MLN significantly influence prognosis whereas the site of MLN was not a prognostic factor.

Multivariate analysis: number of LNM independently affected prognosis, whereas the site of LNM was not an independent prognostic factor.

Impact of Number and Site of LNM According to the Tumor Site:

There was no significant difference in survival time .

Favorable Survival Time for ≤ 4 MLN as compared those in pts with ≥5 or more MLN.

Impact of Site of LNM to Cervical and Abdominal Lymph Nodes

There were no significant difference between pts with abdominal LNM (5-year survival 34.5%,MST 35 months), and pts with the cervical lymph node metastasis (5-year survival 33.3%,MST 11 months).

Recurrence Pattern after 2-Field Lymph Node Dissection

Of 65 pts receiving 2-field lymph node dissection, recurrence was observed 38 pts.

Of 28 pts ē lower thoracic esophageal Ca LN recurrence 16 pts (2 cervical), hematogenous 14 pts, pleuritis carcinomatos 1 pts.

Of 35 pts ē middle thoracic esophageal Ca LN recurrence 15 pts (4 cervical), hematogenous 12 pts, pleuritis carcinomatos 1 pts.

Of 2 pts ē upper thoracic esophageal Ca 1 pt hematogenous recurrence.

Conclusion:

No relation of the anatomical distance to MLN from primary tumor.Lymph node metastasis spread multidirectionally in patients with thoracic esophageal cancerDistant lymph node metastasis was not a risk factor for poor survival.Surgical outcome depend on number not site of MLN after curative esophagectomy.Not possible to identify lymph-node metastasis accurately before surgery, systemic lymph node dissection is necessary for these patients.