Lower Thoracic Esophageal Squamous Cell Carcinoma Research Articles

Accurate location describe and management of lymph node recurrence after esophagectomy for thoracic esophageal squamous cell carcinoma：a retrospective cohort study.

Describe the accurate locations of lymph node recurrence LNR of Chinese patients with postoperative thoracic esophageal squamous cell carcinoma (ESCC) is essential for determining the need for further surveillance protocols and treatments. We aimed to evaluate the patterns of postoperative ESCC and its current risk stratification with LNR. This population-based cohort study included a retrospective review of the medical records and image material of patients with ESCC who underwent LNR after radical surgery between January 2013 and September 2022, with a median follow-up time of 5.71 years. Clinical features were extracted from these records, and survival analysis was performed. The primary endpoint was the accurate location and range of LNR according to the nomenclature of the Japanese Society for Esophageal Diseases. The second endpoints was to explore the related factors of recurrence range (RR) and overall survival (OS) . A total of 3268 lymph node regions were recurrence from 1129 patients, with a mean of 2.89 regions per patient. No.104, 106 and 107 was the most common recurrence of thoracic ESCC with an LNR rate higher than 15%. In upper thoracic ESCC, No.105 was a common recurrence site and abdominal lymph node recurrence was rare. In lower thoracic ESCC, retroperitoneal lymph node was a unique regions (15.4%). Anastomotic recurrence is an important recurrence pattern in patients with postoperative esophageal cancer, with an incidence of 24.5%. Rates of lymph node recurrence in range of lymph node dissection was low (13.9%). The median time of LRT was 20.0 (1.5-184.0) months. High range of recurrence was associated with significantly poorer OS in patients. Multiple linear regression analysis identified demonstrated N stage, tumor differentiation, adjuvant radiotherapy and total lymph nodes removed were association with recurrence range for patients. Supraclavicular and upper mediastinums lymph nodes were common recurrence site for ESCC patients , and careful initial staging and surveillance are needed. Thorough lymph node dissection may reduce the range of regional recurrence.

186. PROGNOSTIC ROLE OF NODAL SKIP METASTASIS IN THORACIC ESOPHAGEAL SQUAMOUS CELL CARCINOMA: A LARGE-SCALE MULTICENTER STUDY

Abstract Background Nodal skip metastasis (NSM) is found in esophageal squamous cell carcinoma (ESCC), however, its prognostic role is controversial. We aimed to investigate the prognostic value of NSM in thoracic ESCC patients. Methods NSM was categorized according to the N-groupings of JES staging system, which is tumor location dependent. Using the Kaplan–Meier method and Cox-regression analysis, we retrospectively analyzed the overall survival (OS) in 2325 ESCC patients after radical esophagectomy in three high-volume esophageal cancer centers. Predictive models were also constructed. Results The overall NSM rate was 20.0% (229/1141); NSM rate was 37.4%, 12.9%, and 22.2% in upper, middle and lower thoracic ESCC, respectively. Patients with NSM always had better prognosis than those without NSM. Furthermore, NSM was an independent prognostic factor for thoracic ESCC patients (HR = 0.633; 95% confidence interval [CI]: 0.499, 0.803; P < 0.001). By integrating the prognostic value of NSM and N stage, we proposed the New N staging system. The categories defined by the New N staging system were more homogeneous in terms of OS than those defined by the current N system. Moreover, the New N system was shown as an independent prognostic factor for thoracic ESCC patients as well (HR = 1.607; 95%CI: 1.520, 1.700; P < 0.001). Overall, the New N system had a slightly better homogeneity, discriminatory ability, and monotonicity of gradient than the N system. Conclusions Our study emphasized the prognostic power of NSM and developed a modified Node staging system to improve the efficiency of the current UICC/AJCC N staging system.

Impact of two‑field or three‑field lymphadenectomy on overall survival in middle and lower thoracic esophageal squamous cell carcinoma: A single‑center retrospective analysis.

Squamous cell carcinoma is the main subtype of esophageal cancer in East Asia. The effect of the number of lymph nodes (LNs) removed to treat middle and lower thoracic esophageal squamous cell carcinoma (ESCC) in China remains controversial. Therefore, the present study aimed to investigate the impact of the number of LNs removed during lymphadenectomy on the survival of patients with middle and lower thoracic ESCC. Data were obtained from the Sichuan Cancer Hospital and Institute Esophageal Cancer Case Management Database from January 2010 to April 2020. Either three-field systematic lymphadenectomy (3F group) or two-field systematic lymphadenectomy (2F group) was performed for ESCC cases with or without suspicious tumor-positive cervical LNs, respectively. Subgroups were designed for further analysis based on the quartile number of resected LNs. After 50.7 months of median follow-up, 1,659 patients who underwent esophagectomy were enrolled. The median overall survival (OS) of the 2F and 3F groups was 50.0 months and 58.5 months, respectively. The OS rates at 1, 3 and 5 years were 86, 57 and 47%, respectively, in the 2F group, and 83, 52 and 47%, respectively, in the 3F group (P=0.732). The average OS of the 3F B and D groups was 57.7 months and 30.2 months, respectively (P=0.006). In the 2F group, the OS between subgroups was not significantly different. In conclusion, resection of >15 LNs during two-field dissection in patients with ESCC undergoing esophagectomy did not affect their survival outcomes. In three-field lymphadenectomy, the extent of LNs removed could lead to different survival outcomes.

363. THE MODALITY OF NEOADJUVANT VERSUS ADJUVANT CHEMORADIOTHERAPY FOR LOCALLY ADVANCED ESOPHAGEAL. CARCINOMA: A SINGLE CENTER, RANDOMIZED, CLINICAL TRIAL

Abstract Neoadjuvant chemoradiotherapy (nCRT) plus surgery is recommended as standard treatment for locally advanced esophageal squamous cell carcinoma (ESCC). However, studies have shown that surgery combined with adjuvant chemoradiotherapy (aCRT) can also provide survival benefits. The optimal modality of surgery combined chemoradiotherapy for esophageal cancer have not been determined yet. From March 2018 to January 2021, 203 patients with resectable middle and lower thoracic ESCC, were enrolled in this prospective study. Patients were randomized into two groups: nCRT plus minimally invasive esophagectomy (MIE), MIE plus aCRT. In nCRT group, the patients were treated with paclitaxel plus carboplatin for two cycles, with a total concurrent radiation dose of 40.0Gy. In aCRT group, the patients with pN (+) were treated with paclitaxel plus carboplatin for four cycles, with a total sequential radiation dose of 54.0Gy, The primary end points were 3-year OS and DFS on the analysis of an intention-to-treat basis. 74 patients received surgery in the nCRT group，99 patients received surgery in aCRT group. Among 74 patients in nCRT group, 62 patients (83.8%) underwent MIE, compared with 88 of 99 (88.9%) in aCRT group (P = 0.65). With median follow-up of 28.4 months for all the enrolled patients, no significant differences were found in the 3-year OS (77.2% vs 75.8% P = 0.82) and DFS (60.9% vs 60.6% P = 0.86) among nCRT and aCRT groups. Postoperative complications did not differ significantly between groups, except for arrhythmia, which occurred more frequently in nCRT group (31.1%) than in aCRT group (14.1%) (P = 0.07). Initial results of the trial showed that the treatment modality of nCRT followed by MIE has similar safety and survival benefit to that of MIE combined aCRT for locally advanced ESCC.

Development and validation of a nomogram for prediction of cervical lymph node metastasis in middle and lower thoracic esophageal squamous cell carcinoma

BackgroundEstimates of cervical lymph node (LN) metastasis in patients with middle and lower thoracic esophageal squamous cell carcinoma (ESCC) are important. A nomogram is a useful tool for individualized prediction.MethodsA total of 235 patients were enrolled in this study. Univariate and multivariate analyses were performed to screen for independent risk factors and construct a nomogram to predict the risk of cervical LN metastasis. The nomogram performance was assessed by discrimination, calibration, and clinical use.ResultsTotally, four independent predictors, including the maximum diameter of tumor, paraesophageal lymph node status, recurrent laryngeal nerve lymph node status, and the CT-reported cervical LN status, were enrolled in the nomogram. The AUC of the nomogram model in the training and validation dataset were 0.833 (95% CI 0.762–0.905), 0.808 (95% CI 0.696–0.920), respectively. The calibration curve demonstrated a strong consistency between nomogram and clinical findings in predicting cervical LN metastasis. Decision curve analysis demonstrated that the nomogram was clinically useful.ConclusionWe developed a nomogram that could be conveniently used to predict the individualized risk of cervical LN metastasis in patients with middle and lower thoracic ESCC.

Intraperitoneal perforation through lymph node metastases in a patient with esophageal squamous cell carcinoma during intensive chemotherapy: A case report with literature review.

IntroductionEsophageal fistula after treatment is a critical and fatal complication of esophageal cancer. A fistula forming from lower thoracic esophageal cancer to the peritoneum through lymph node metastases following chemotherapy has not been reported. We report a case of peritonitis due to lymph node perforation through the tumor ulcer after induction of biweekly docetaxel, cisplatin, and 5FU combined chemotherapy (Bi-DCF) for advanced esophageal squamous cell carcinoma (ESCC).Presentation of caseA 48-year-old woman was referred to us with a diagnosis of lower thoracic ESCC and thoracoabdominal aortic aneurysm. Esophagogastroduodenoscopy showed a circumferential type 3 tumor with stenosis in the lower thoracic esophagus. Contrast-enhanced computed tomography (CT) showed a thoracoabdominal aortic aneurysm and wall thickening of the lower thoracic esophagus that was suspicious of esophageal cancer. Lymph node metastases dumpling from around the tumor to abdominal cavity were also observed. The initial diagnosis was ESCC T3 N3 M1 (para-aortic lymph nodes and liver) Stage IVB. She was started on Bi-DCF (docetaxel 35 mg/m2 days 1/15, cisplatin 40 mg/m2 days 1/15, 5FU 400 mg/m2 days 1–5, 15–19) as the first-line regimen. The third day after starting chemotherapy, she felt strong abdominal pain, and internal necrosis of lymph nodes around the primary lesion and free air in the abdominal cavity were found. Peritonitis was diagnosed due to a fistula formed from the lower thoracic ESCC to the peritoneum through lymph node metastases. She underwent emergency laparoscopic drainage, omental filling, and jejunostomy. Postoperatively, her general condition and inflammatory findings improved within 10 days, and she could continue intensive chemotherapy as scheduled.DiscussionBecause of the risk of perforation and fistula in regimens that are expected to cause tumor shrinkage, careful observation may be required after starting chemotherapy.ConclusionWe report the first case of peritonitis caused by perforation through lymph node metastasis of thoracic esophageal cancer.

Postoperative solitary liver metastasis from esophageal squamous cell carcinoma achieving a clinical complete response to chemotherapy with cisplatin and 5-fluorouracil followed by stereotactic body radiotherapy: A case report.

Treatment strategies for distant organ metastasis have changed markedly since the concept of oligometastasis was introduced. The perception that distant organ metastasis is a systemic disease and not eligible for local therapy is now a thing of the past. Therefore, the present report details a case of postoperative solitary liver metastasis from esophageal squamous cell carcinoma (ESCC), which achieved a clinical complete response to chemotherapy with cisplatin and 5-fluorouracil (5-FU) followed by stereotactic body radiotherapy (SBRT). A 76-year-old male patient underwent esophagectomy for lower thoracic ESCC. At 7 months after surgery, abdominal CT revealed a solitary hypovascular mass, 28 mm in size, in segment 7 of the liver. After three courses of chemotherapy with cisplatin and 5-FU, abdominal CT revealed that the liver mass had shrunk to 7 mm in size. SBRT was then administered with a 6 MV X-ray beam generated by a linear accelerator. A total dose of 50 Gy was given in 5 fractions of 10 Gy to the liver mass. At 1 month after SBRT, abdominal CT revealed that the liver mass had disappeared. The patient received no further adjuvant chemotherapy and had no recurrence at 18 months after diagnosis of liver metastasis and 13 months after SBRT.

Mapping of Cervical and Upper Mediastinal Lymph Node Recurrence for Guiding Clinical Target Delineation of Postoperative Radiotherapy in Thoracic Esophageal Squamous Cell Carcinoma.

BackgroundThe lower neck and upper mediastinum are the major regions for postoperative radiotherapy (PORT) in thoracic esophageal squamous cell carcinoma (TESCC). However, there is no uniform standard regarding the delineation of nodal clinical target volume (CTVnd). This study aimed to map the recurrent lymph nodes in the cervical and upper mediastinal regions and explore a reasonable CTVnd for PORT in TESCC.MethodsWe retrospectively reviewed patients in our hospital with first cervical and/or upper mediastinal lymph node recurrence (LNR) after upfront esophagectomy. All of these recurrent lymph nodes were plotted on template computed tomography (CT) images with reference to surrounding structures. The recurrence frequency at different stations was investigated and the anatomic distribution of recurrent lymph nodes was analyzed.ResultsA total of 119 patients with 215 recurrent lymph nodes were identified. There were 47 (39.5%) patients with cervical LNR and 102 (85.7%) patients with upper mediastinal LNR. The high-risk regions were station 101L/R, station 104L/R, station 106recL/R, station 105 and station 106pre for upper TESCC and station 104L/R, station 106recL/R, station 105, station 106pre and station 106tbL for middle and lower TESCCs. LNR in the external group of station 104L/R was not common, and LNR was not found in the narrow spaces where the trachea was in close contact with the innominate artery, aortic arch and mediastinal pleura. LNR below the level of the cephalic margin of the superior vena cava was also not common for upper TESCC.ConclusionsThe CTVnd of PORT in the cervical and upper mediastinal regions should cover station 101L/R, station 104L/R, station 106recL/R, station 105 and station 106pre for upper TESCC and station 104L/R, station 106recL/R, station 105, station 106pre and station 106tbL for middle and lower TESCCs. Based on our results, we proposed a useful atlas for guiding the delineation of CTVnd in TESCC.

Pattern of Recurrence in 428 Patients With Thoracic Esophageal Squamous Cell Carcinoma After Radical Surgery and Its Implication in Postoperative Radiotherapeutic Clinical Target Volume.

PurposeThis study aimed to analyze the recurrence patterns of thoracic esophageal squamous cell carcinoma (ESCC) after radical surgery, and to understand its implication in the clinical target volume (CTV) design of postoperative radiotherapy (PORT) in patients with ESCC.Methods and materialsA total of 428 recurrent ESCC patients after radical surgery between 2014 and 2018 were included in this study. Recurrence patterns, especially anastomotic and regional lymph node recurrence (LNR), were analyzed. A T-shaped CTV were proposed for PORT and were evaluated whether it could cover most of regional LNR.ResultsThese patients all experienced anastomotic and/or regional LNR. Among the 428 patients, 27 cases (6.3%) had anastomotic recurrence only, and184 cases (43.0%) had LNR only. Those sites with an LNR rate higher than 15% in upper thoracic ESCC were as follows: No.101, No.104R, No.104L, No.106recR, No.106recL, No.106pre, No.106tb, No.107, and No. 109. Those with middle thoracic ESCC were as follows: No.104R, No.104L, 106recR, No.106recL, No.106pre, No.106tb, and No.107. Lastly, individuals with lower thoracic ESCC were as follows: No.104L, 106recR, No.106recL, No. 106pre, No. 106tb, No.107, and abdominal No. 3. The proportion of LNR not included in the proposed T-shaped CTV was 12.5% (1/8), 4.7% (6/128), and 10.4% (5/48) in the upper, middle, and lower thoracic segments, respectively.ConclusionsLNR was the most common type of local-regional recurrence in patients after radical surgery. Supraclavicular, superior and middle mediastinal lymph nodes had the highest recurrence rate, the rate of LNR which was outside T-shaped PORT CTV we proposed was less than 15%.

Prognostic Role of Nodal Skip Metastasis in Thoracic Esophageal Squamous Cell Carcinoma: A Large-Scale Multicenter Study.

Nodal-skip metastasis (NSM) is found in esophageal squamous cell carcinoma (ESCC), but its prognostic role is controversial. This study aimed to investigate the prognostic value of NSM for thoracic ESCC patients. Categorization of NSM was according to the N groupings of Japan Esophagus Society (JES) staging system, which is dependent on tumor location. Using the Kaplan-Meier method and Cox-regression analysis, this study retrospectively analyzed the overall survival (OS) for 2325 ESCC patients after radical esophagectomy at three high-volume esophageal cancer centers. Predictive models also were constructed. The overall NSM rate was 20% (229/1141): 37.4% in the in upper, 12.9% in the middle, and 22.2% in the lower thoracic ESCC. The patients with NSM always had a better prognosis than those without NSM. Furthermore, NSM was an independent prognostic factor for thoracic ESCC patients (hazard ratio [HR], 0.633; 95% confidence interval [CI], 0.499-0.803; P < 0.001). By integrating the prognostic values of NSM and N stage, the authors proposed the new N staging system. The categories defined by the new N staging system were more homogeneous in terms of OS than those defined by the current N system. Moreover, the new N system was shown to be an independent prognostic factor also for thoracic ESCC patients (HR, 1.607; 95% CI, 1.520-1.700; P < 0.001). Overall, the new N system had slightly better homogeneity, discriminatory ability, and monotonicity of gradient than the current N system. This study emphasized the prognostic power of NSM and developed a modified node-staging system to improve the efficiency of the current International Union for Cancer Control (UICC)/American Joint Committee on Cancer (AJCC) N staging system.

Para-aortic lymph node metastasis in lower Thoracic Esophageal Squamous Cell Carcinoma after Radical Esophagectomy: a CT-based atlas and its clinical implications for Adjuvant Radiotherapy.

Background: Our previous work showed that para-aortic lymph node (PALN) metastasis was the major failure pattern in lower thoracic esophageal squamous cell carcinoma (LTESCC) patients who presented abdominal LN failure after curative surgery. We thereby aim to generate a computerized tomography (CT)-based documentation of PALNs and to propose a clinical target volume (CTV) for this region.Methods: Sixty-five patients were enrolled. The epicentre of each PALN was drawn onto an axial CT image of a standard patient with reference to the surrounding anatomical landmarks. A CTV for PALN was generated based on the final result of node distribution, and was evaluated for dosimetric performance in three simulated patients.Results: All the studied 248 LNs were below the level of 1.0 cm above the celiac artery (CA), and 94.76% were above the bottom of vertebra L3. Horizontally, 93.33% of the LNs in the celiac level were located within an expansion of 1.5 cm on the CA, and 94.12% of the LNs in the superior mesenteric artery (SMA) level were within 1.5 cm on the left side of the SMA. Below the SMA, all the LNs were behind the left renal vein, left to the right border of the inferior vena cava, and 98.51% of the LNs were medial to the lateral surface of the left psoas major. The proposed CTV could cover 92.74% of the LNs and was dosimetrically feasible.Conclusions: The proposed CTV is the first one to focus on the high-risk area of abdominal failure in LTESCC patients after surgery and can serve as a reference in the adjuvant radiotherapy for LTESCC patients.

Effect and Toxicity of Bilateral Supraclavicular Lymph Node Irradiation on Stage III Lower Thoracic Esophageal Cancer After Radical Surgery

Surgery is the most important treatment for patients with lower thoracic esophageal squamous cell carcinoma (LTEC). Treatment failures, especially loco-regional recurrence involving mediastinal, abdominal, and supraclavicular lymph nodes area, are common after radical esophagectomy. Post-operative radiotherapy (PORT) has been demonstrated to benefit patients with stage III disease. However, whether bilateral supraclavicular lymph node radiotherapy should be included in the clinical target volume (CTV) remains unclear for those patients with lower thoracic esophageal cancer. So, we aim to explore whether PORT including the bilateral supraclavicular region can reduce the recurrence of supraclavicular lymph node, prolong overall survival and control distant metastasis in patients with stage III LTEC. We retrospectively analyzed 79 patients with stage III LTEC who had undergone radical surgery and PORT between 2010 and 2014. Among these patients, 51 patients received PORT which CTV excluding the bilateral supraclavicular lymph node region (Group A), and the remaining 28 patients received PORT which CTV including the supraclavicular region (Group B). Clinical outcomes (including local control, survival time, side-effects and prognostic factors) were analyzed with SPSS 25.0. Follow-up to August 2016, the 1-, 2-, and 3-year supraclavicular lymph nodes metastasis rates were 15.7%, 41.2%, 45.1% in Group A, 10.7%, 10.7%, 10.7% in Group B. The median overall survival (OS) of Group A and Group B were 25 and 24.5 months respectively. Univariate and multivariate analysis indicated that radiotherapy to the supraclavicular region decreased supraclavicular lymph node recurrence (p = 0.007/0.016, respectively) but did not prolong OS (p = 0.273/0.324) or control distant metastasis (p = 0.760/0.804). Our data also indicated that PORT including the supraclavicular region was not associated with the increase of radiotherapy-related complications (all p > 0.05). PORT including the bilateral supraclavicular region can reduce the recurrence of supraclavicular lymph node in patients with stage III LTEC without increase of treatment-related toxicities. However, PORT including bilateral supraclavicular region failed to prolong OS or control distant metastasis. Further prospective studies are warranted.

Pattern of subcarinal lymph node metastasis and dissection strategy for thoracic esophageal cancer.

BackgroundThis study aimed to assess the role of subcarinal lymph nodes in lymph node metastasis in thoracic esophageal squamous cell carcinoma (ESCC) and to investigate the adequate range of lymph node dissection during esophagectomy.MethodsThis study included 782 thoracic ESCC patients who underwent esophagectomy between July 2008 and December 2010. The metastatic rate of subcarinal lymph nodes and their influencing factors were investigated. The outcome of subcarinal lymph node dissection was assessed using the efficacy index (the incidence of metastasis to a lymph node station (%) multiplied by the 5-year survival rate (%) of patients with metastasis to that lymph node station and divided by 100). Additionally, postoperative complications were compared between the subcarinal lymph node resection and reservation groups.ResultsThe metastatic rates of subcarinal lymph nodes in the upper, middle, and lower thoracic ESCC were 8.3% (4/48), 19.1% (79/414), and 16.2% (23/142), respectively (χ2=3.669, P>0.05) and in T1, T2, T3, and T4 tumors were 0% (0/71), 4% (4/100), 22.2% (85/383), and 34% (17/50), respectively (χ2=42.859, P<0.05). Tumor invasion and size were significantly correlated with metastasis. For upper thoracic ESCC with positive subcarinal lymph nodes, metastasis tendency was mainly to the lower mediastinum. In middle third esophageal cancer, after subcarinal lymph nodes were involved, metastasis to the lower mediastinal lymph nodes increased by nearly 50%, and bidirectional metastasis increased by nearly three times compared with that before involvement. For lower third cancer with positive subcarinal lymph nodes, metastasis tendency was mainly to the upper mediastinum. The postoperative complication rates in the resection and reservation groups were as follows: overall, 19% and 14.6%, respectively (P>0.05), and pulmonary, 10.3% and 7.3%, respectively (P>0.05). The efficacy indexes of lymph node dissection at the upper, middle, and lower third esophagus were 0%, 7.6%, and 27.5%, respectively.ConclusionsDissection of subcarinal lymph nodes, which does not increase postoperative complications, should be performed routinely in lower thoracic ESCC after submucosal invasion of tumor; meanwhile, tumors larger than 3cm should also result in subcarinal lymph node dissection in patients with a tumor located in the upper esophagus and T1-T2 ESCC.

Implication of clinical target delineation for T1b/T2 thoracic esophageal squamous cell carcinoma based on the pattern of lymph node metastases.

Aim: This study aimed to explore different patterns of lymph node metastases (LNM) in T1b and T2 thoracic esophageal squamous cell carcinoma (ESCC), and to further clarify its significance in radiotherapy target delineation. Materials & methods: Data of 1960 patients with T1b and T2 thoracic ESCC treated at different cancer centers were retrospectively analyzed. All patients underwent esophagectomy and lymphadenectomy. χ2 test and multivariate analysis were applied for analyzing clinicopathological factors related to LNM. Results: Age, location, tumor length, T stage and pathological grade were significantly associated with LNM (p < 0.01). For T1b ESCC, LNM rates in all sites were below 15%. For T2 upper thoracic ESCC, LNM rates were over 15% in upper mediastinal (15.8%). For T2 middle thoracic ESCC, LNM rates were middle mediastinal (17.2%) and abdominal (15.5%). For T2 lower thoracic ESCC, LNM rates were lower mediastinal (24.9%) and abdominal (22.5%). Subgroup analysis of T2 middle thoracic ESCC demonstrated that for patients older than 60years, tumor length <4cm and tumors were well differentiated. The LNM rates for abdominal were 11.9, 12.7 and 9.9%. Conclusion: Given the different patterns of LNM between T1b and T2 thoracic ESCC, target delineation should be adjusted accordingly.

Mapping patterns of metastatic lymph nodes for postoperative radiotherapy in thoracic esophageal squamous cell carcinoma: a recommendation for clinical target volume definition

BackgroundThe clinical target volume (CTV) for postoperative radiotherapy for thoracic esophageal squamous cell carcinoma (TESCC) needs to be defined. The study aim was to map metastatic lymph nodes (LNMs) in a computed tomography (CT)-based atlas and delineate the postoperative radiotherapy target area.MethodsSixty-nine TESCC patients with first recurrent regional LNMs after esophagectomy were included. The LNM epicenters were registered onto corresponding anatomic axial CT images of a standard patient in the treatment position, with reference to the surrounding vascular and bony structures. The LNM sites were based on lymph node map of esophageal cancer, AJCC 8th. The lymph metastasis risk for different segments of thoracic esophagus was assessed.ResultsOne hundred and seventy-nine LNMs were mapped onto standard axial CT images. The upper-middle mediastinum region (station 1 to 8 M) contained 97% of metastases in the upper segment of thoracic esophagus, 90% in the middle segment, and 66% in the lower one. Advanced pathological stage (≥IIIB) might be a predictive factor for upper abdominal region (UAR) relapse in lower TESCC. Lower cervical para-tracheal LNMs were within a 4.3-cm bilaterally expanded area from the midline of the body and a 2.2-cm expanded area from the anterior of vertebral body, from the superior border of the C7, to the inferior border of the first thoracic vertebra.ConclusionA modified target from the upper border of C7 to the lower border of caudal margin of the inferior pulmonary vein level could cover the high-risk area of TESCC underwent postoperative radiotherapy. UAR seems to be an elective irradiation target for lower TESCC at pathological IIIB stage and higher.

Prognostic Evaluation of Nodal Skip Metastasis for Thoracic Esophageal Squamous Cell Carcinoma

Nodal skip metastasis (NSM) is a prognostic factor in certain malignant tumors, but the clinical and prognostic implications of NSM in esophageal squamous cell carcinoma (ESCC) are still unclear. The study aimed to assess its risk factors and prognostic value in thoracic ESCC. A retrospective study was conducted in patients with thoracic ESCC who underwent esophagectomy from March 2009 to March 2012 in the Department of Thoracic Surgery, West China Hospital, Sichuan University. The prognostic implications and risk factors of NSM were assessed in our study. The incidence of NSM in the entire cohort was 37.9%. Tumor location (P= .016), pT stage (P= .029), and pN stage (P < .001) were identified to be independent risk factors for NSM. The overall survival (OS) was similar between patients with and without NSM. The OS had no significant difference between pN1 patients with and without NSM, whereas the OS was significantly worse in pN2 patients with NSM than those without NSM (P= .001). The OS was similar between patients with NSM level 1 and NSM level 2, but the OS was significantly better in patients with NSM level 1 than NSM level 2 among patients with lower thoracic ESCC (P= .013). The effect of NSM on prognosis of thoracic ESCC may be mainly reflected in patients with pN2 stage. The prognostic value of NSM level for thoracic ESCC may be mainly reflected in patients with lower thoracic tumor.

Effects of lymph node metastasis of thoracic esophageal squamous cell carcinoma on design of radiotherapy target volume.

Objective:To analyze the correlation between lymph node metastasis of thoracic esophageal squamous cell carcinoma (ESCC) and clinical and pathological factors, and to provide a reference for the outline of clinical target volume.Methods:The pathological characteristics of 1034 thoracic ESCC patients after surgery were described, and the correlations between clinical and pathological factors and lymph node metastasis were studied by univariate and Logistic multivariate analyses.Results:Lymph node metastasis was significantly correlated with tumor length, invasion depth and differentiation degree (P<0.01), but not gender, age, tumor site or pathological type (P>0.05). Logistic multivariate analysis showed that tumor length, invasion depth and differentiation degree were independent risk factors for thoracic ESCC. The lymph node metastasis rates of mid-thoracic ESCC in the middle mediastinum, lower-thoracic ESCC in the lower mediastinum and abdominal cavity were 18.5%, 35.3% and 19.7% respectively in the T1-T2 stage. In the T3-T4 stage, the lymph node metastasis rates of mid-thoracic ESCC in the middle mediastinum and abdominal cavity were 39.6% and 17.4% respectively, and those of lower-thoracic ESCC in middle and lower mediastina and abdominal cavity were 21.1%, 43.4% and 29.8% respectively. Highly/moderately differentiated mid-thoracic ESCC in the middle mediastinum, lower-thoracic ESCC in middle and lower mediastina and abdominal cavity had the lymph node metastasis rates of 34.7%, 15.1%, 33.5% and 23.7% respectively. Lowly differentiated mid-thoracic ESCC in the middle mediastinum and abdominal cavity had the lymph node metastasis rates of 46.9% a 29.6% respectively, and those of lower-thoracic ESCC in middle and lower mediastina and abdominal cavity were 25.5%, 49.1% and 27.3% respectively.Conclusion:During the outline of radiotherapy target volume for thoracic ESCC, tumor length, invasion depth and differentiation degree should be comprehensively considered to selectively irradiate the regions prone to lymph node metastasis.

Recommendation for the definition of postoperative radiotherapy target volume based on a pooled analysis of patterns of failure after radical surgery among patients with thoracic esophageal squamous cell carcinoma

BackgroundElective use of radiation therapy to treat regionally involved lymph nodes (LNs) after radical surgery for esophageal squamous cell carcinoma (ESCC) is controversial. We studied metastasis patterns through a pooled analysis of published results to guide post-operative radiotherapy (PORT) target designation.MethodsWe searched the MEDLINE database for literature published from May 1977 to March 2018, and found 14 relevant original studies that included 2738 patients with thoracic ESCC. We calculated probabilities of recurrence and metastasis in local (including anastomoses and tumor bed), LNs and distal areas.ResultsRecurrence rates were 1.88% for local, 13.18% for distal, and 22.16% for LNs. Within LNs, recurrence rates were cervical/supraclavicular: 37.69%, upper mediastinal: 44.30%, middle mediastinal: 21.81%, lower mediastinal: 2.57%, abdominal paraaortic: 25% and upper abdominal: 9.56%. Whereas cervical/supraclavicular and upper mediastinal LNs had the highest recurrence rates, abdominal LNs also had high recurrence rates in patients with lower thoracic ESCC.ConclusionsPORT volume should include the cervical/supraclavicular and upper mediastinal LNs for all thoracic ESCC, and abdominal paraaortic LNs for lower thoracic ESCC. Anastomoses and tumor beds should not be included in the PORT volume if they are not adjacent to the PORT-LN regions. Upper abdominal LNs might not necessarily be included in the PORT volume for thoracic ESCC.

PS02.203: CHARACTERISTICS AND RISK FACTORS OF LYMPH NODE METASTASIS IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA PATIENTS WITH PREOPERATIVE COMPUTED TOMOGRAPHY-NEGATIVE LYMPH NODES

Abstract Background Characteristics and risk factors of lymph node metastasis (LNM) in esophageal squamous cell carcinoma (ESCC) patients with preoperative computed tomography (CT)-negative lymph nodes are not well elucidated. This study aimed to identify the characteristics and risk factors of LNM in ESCC patients with preoperative CT-negative lymph nodes. Methods We conducted a retrospective analysis of consecutive ESCC patients who had preoperative CT-negative lymph nodes and received esophagectomies between August 2013 and July 2016. Lymph node with a short-axis diameter ≦10 mm on preoperative CT image was considered as CT-negative lymph node. Eligible patients included those: aged 18∼80, without neoadjuvant therapy, without other malignant tumor history, without distant metastasis, without multiple esophageal lesions, tumor locating in the thoracic esophagus, receiving McKeown esophagectomy, undergoing R0 resection, having number of lymph nodes resection≧15, pathological staging as T1a-4aN0–3. Univariate and multivariate logistic regression analyses were used to identify risk factors of LNM. Results Among 243 ESCC patients identified, 137 had LNM (56.4%). The median number of lymph nodes dissected and LNM were 24 (range 15–79) and 2 (range 1–14), respectively. The rates of LNM of the upper, middle and lower thoracic ESCC were 50.0%, 59.3% and 55.1%, respectively. The rates of LNM with the maximal short-axis diameter of lymph node on preoperative CT of ≦5 mm, 6 mm, 7 mm, 8 mm, 9 mm and 10 mm were 57.4%, 42.9%, 47.4%, 31.8%, 73.9% and 70.8%, respectively (P = 0.034). Univariate analysis showed that age (P = 0.041), maximal short-axis diameter of lymph node on CT (P = 0.034), cervical lymph node dissection (P = 0.031), lymphovascular invasion (P &lt; 0.001) and perineural invasion (P = 0.017) were associated with LNM. Multivariate analysis revealed that cervical lymph node dissection (P = 0.018), lymphovascular invasion (P = 0.007) and perineural invasion (P = 0.025) were independent risk factors of LNM. Conclusion Our study showed that the rates of LNM were also high in ESCC patients with preoperative CT-negative lymph nodes. Standard lymph node dissection is necessary for these patients. Cervical lymph node dissection, lymphovascular invasion and perineural invasion are independent risk factors of LNM in ESCC patients with preoperative CT-negative lymph nodes. Disclosure All authors have declared no conflicts of interest.

PS01.236: MEDIASTINOSCOPIC SALVAGE ESOPHAGECTOMY FOR RECURRENT ESOPHAGEAL CANCER AFTER DEFINITIVE CHEMORADIOTHERAPY IN A PREVIOUSLY PNEUMONECTOMIZED PATIENT

Abstract Background Mediastinoscopic esophagectomy is a minimally invasive surgery for thoracic esophageal cancer avoiding one-lung ventilation or transthoracic procedure. Methods We performed for the first time in the literature, salvage esophagectomy with combination of mediastinoscopic cervical approach and laparoscopic/mediastinoscopic transhiatal approach for recurrent thoracic esophageal squamous cell carcinoma (ESCC) after definitive chemoradiotherapy (dCRT) in a patient who had previously undergone a left pneumonectomy for primary lung cancer. Results A 66-year-old man was diagnosed as local recurrence of lower ESCC (cT3N0M0 cStage II) at 9 years after dCRT. His medical history included left-sided pneumonectomy for lung adenocarcinoma 9 years previously. Then the patient was diagnosed as lower thoracic ESCC (cT3N1M0 cStage III) at 2 months after pneumonectomy. He received dCRT consisting of CDDP/5-FU infusion and irradiation (60 Gy) and achieved complete response. No evidence of tumor recurrence was observed at endoscopic surveillance up until 6 years after dCRT. For this present surgery, a cervical wound was made and the intramediastinal procedure was performed under pneumomediastinum. After mobilization of upper/middle thoracic esophagus, the esophageal wall was safely separated from the remaining part and the stump of the left main bronchus. Dense adhesions between the esophagus and fibrotic tissue at the site of previous left mediastinal pleural resection was divided using a sealing device. In the abdomen, 5 ports were inserted to perform abdominal and transhiatal procedures under CO2 insufflation. After mobilization of the stomach, fibrotic scar tissue around the lower esophagus was divided using a sealing device and the peri-esophageal space dissected from cervical and transhiatal approach were connected to completely mobilize the thoracic esophagus. The esophagectomy was uneventfully carried out followed by reconstruction with gastric conduit via retrosternal rout. Pathological findings demonstrated a moderately differentiated ESCC (pT3-AD pN1 M0 pStage III), indicating that R0 resection was successfully performed. The patient has been closely observed as an outpatient and was alive and healthy at 3 months after the operation without tumor recurrence. Conclusion Mediastinoscopic esophagectomy is a safe and curative treatment strategy for esophageal cancer patients who had a previous pneumonectomy, even in salvage surgery for recurrent cancer after dCRT. Disclosure All authors have declared no conflicts of interest.