Abstract
Lymph node status is the most important prognostic factor in esophageal cancer. Through improved detection of lymph node metastases, using the sentinel lymph node concept, accurate staging and more tailored therapy may be achieved. This review article outlines two principle ways in which the sentinel lymph node concept could dramatically influence current standard of care for patients with esophageal cancer. We discuss three limitations to universal acceptance of the technique, and propose next steps for increasing enthusiasm amongst physicians and surgeons including the development of a universal tracer, and improved contrast agents with novel dual-modality ‘visibility’.
Highlights
In the United Kingdom, the rate of death from esophageal cancer in men has increased by more than 65% since the 1970’s [1,2]
In 16 patients with esophageal cancer, Nishimura et al found that ferumoxtran-10 provided a combined accuracy of 96%, with 100% sensitivity and 95% specificity in locating the sentinel lymph node (SLN) [43]
Identification of the most important lymph nodes allows the pathologist to “ultra stage” these nodes with serial sectioning, immunohistochemistry, and/or reverse transcriptase polymerase chain reaction. This enables detection of micrometastatic disease, and identifies a patient subset that may benefit from adjuvant therapy
Summary
In the United Kingdom, the rate of death from esophageal cancer in men has increased by more than 65% since the 1970’s [1,2]. At the current time isolated tumor cells (ITCs), are still considered pN0 disease even though a New England Journal of Medicine paper, published in 2009, found that patients with favorable early-stage breast cancer and either micrometastases or ITCs in regional lymph nodes had a reduced 5-year rate of disease-free survival [28]. In 16 patients with esophageal cancer, Nishimura et al found that ferumoxtran-10 (an ultra-small 20 nm SPION) provided a combined accuracy of 96%, with 100% sensitivity and 95% specificity in locating the SLN [43] Taking this application one step further, Weissleder et al have shown that lymphotrophic SPIONs, injected systemically as exogenous contrast, can discriminate healthy versus tumor-burdened nodes by the degree of accumulation of particles in the nodes [44]. We are currently trialing a dual-modality tracer with both magnetic resonance imaging capability (using iron oxide) and radioactive properties (using 99mTc-antimony colloid) in a pig model
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