Abstract
SummaryIntroductionThe prognostic value of histomorphologic regression in primary esophageal cancer has been previously established, however the impact of lymph node (LN) response on survival still remains unclear. The aim of this review was to assess the prognostic significance of LN regression or downstaging following neoadjuvant therapy for esophageal cancer.MethodsAn electronic search was performed to identify articles evaluating LN regression or downstaging after neoadjuvant therapy. Random effects meta-analyses were performed to assess the influence of regression in the LNs and nodal downstaging on overall survival. Histomorphologic tumor regression in LNs was defined by the absence of viable cells or degree of fibrosis on histopathologic examination. Downstaged LNs were defined as pN0 nodes by the tumor, node, and metastasis classification, which were positive prior to treatment neoadjuvant.ResultsEight articles were included, three of which assessed tumor regression (number of patients = 292) and five assessed downstaging (number of patients = 1368). Complete tumor regression (average rate of 29.1%) in the LNs was associated with improved survival, although not statistically significant (hazard ratio [HR] = 0.52, 95% confidence interval [CI] = 0.26–1.06; P = 0.17). LNs downstaging (average rate of 32.2%) was associated with improved survival compared to node positivity after neoadjuvant treatment (HR = 0.41, 95%CI = 0.22–0.77; P = 0.005).DiscussionThe findings of this meta-analysis have shown a survival benefit in patients with LN downstaging and are suggestive for considering LN downstaging to ypN0 as an additional prognostic marker in staging and in the comparative evaluation of differing neoadjuvant regimens in clinical trials. No statistically significant effect of histopathologic regression in the LNs on long-term survival was seen.
Highlights
The incidence of esophageal cancer is rapidly increasing, affecting > 450 000 people worldwide.[1]
The primary aim of this review is to evaluate the prognostic relevance of lymph node (LN) regression following neoadjuvant chemotherapy or chemoradiotherapy in patients treated for esophageal adenocarcinoma (AC) or squamous cell carcinoma (SCC) and to assess the prognostic relevance of LN downstaging in these patients
Publications were included in this review if they met each of the following criteria: 1. An esophageal resection with two- or three-field lymphadenectomy with curative intent was performed in patients with esophageal AC or SCC
Summary
The incidence of esophageal cancer is rapidly increasing, affecting > 450 000 people worldwide.[1] Surgical resection is the mainstay of curative treatment of resectable esophageal cancer.[2] the 5year survival rate of patients treated with surgery alone is only 15–24% due to the high incidence of locally advanced disease and distant metastases.[3,4,5] As a consequence, several studies have investigated the benefits of neoadjuvant regimens, which aim at downstaging the primary tumor and reducing micrometastatic disease. Patients without lymph node metastases have better overall survival regardless the tumor regression grade.[13,14,15,16] Controversial results were published by a randomized controlled trial comparing the prognostic impact of nodal response in surgery alone compared to neoadjuvant chemoradiotherapy followed by surgery.[17] Patients with persistent lymph node positivity following neoadjuvant treatment showed worse outcome compared to patients with positive nodes treated by surgery alone. The prognostic value of nodal response remains unclear
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