Lymph Nodes In Esophageal Cancer Research Articles

The prognostic importance of the number of involved lymph nodes in esophageal cancer: Implications for revisions of the American Joint Committee on Cancer staging system

The prognostic importance of the number of involved lymph nodes in esophageal cancer: Implications for revisions of the American Joint Committee on Cancer staging system

The prognostic importance of the number of involved lymph nodes in esophageal cancer: Implications for revisions of the American Joint Committee on Cancer staging system

The American Joint Committee on Cancer (AJCC) staging system for esophageal cancer is controversial because it relies on arbitrary definitions of the anatomic location of lymph nodes to establish N and M status. It has been proposed that the number of involved lymph nodes may better predict survival. We reviewed our experience to determine the prognostic impact of the number of involved nodes and the extent of lymphadenectomy on the current staging system. Records of all patients who underwent resection of previously untreated adenocarcinoma and squamous cell carcinoma of the esophagus and gastroesophageal junction were reviewed. Overall survival according to the AJCC staging system and the number of involved lymph nodes was analyzed by the method of Kaplan and Meier and by recursive partitioning methods. Data were available on 336 patients operated on between January 1996 and September 2003. Recursive partitioning analysis using AJCC staging variables reproduced the AJCC staging system. When the number of involved lymph nodes is added, patients with more than 4 involved lymph nodes have survival similar to that of patients with M1 disease, and patients with no involved lymph nodes have the best prognosis. Recursive partitioning analysis identified 18 lymph nodes as the minimal number required for accurate staging. In patients who have 18 or more lymph nodes removed, survival is only predicted by the presence of nodal involvement and M1 disease. Our analysis suggests that revisions of the current AJCC staging system for esophageal cancer should include N staging based on the number of involved lymph nodes and minimal requirements for the extent of lymphadenectomy.

Fine-Needle Aspiration of Peritumoral Lymph Nodes in Esophageal Cancer with Endobronchial Ultrasound

Fine-Needle Aspiration of Peritumoral Lymph Nodes in Esophageal Cancer with Endobronchial Ultrasound

Oblique view of preoperative lymphoscintigraphy improves detection of sentinel lymph nodes in esophageal cancer

Because sentinel lymph nodes (SLNs) of esophageal cancer can be widely located between the neck and the upper abdomen, lymphoscintigraphy plays an important role in their detection, but some modifications are required to clearly visualize their locations. Recently, we applied the stereoscopic imaging method by adding the 10-degree oblique view to the conventional lymphoscintigraphy for SLNs, so that we could better determine SLN locations on the basis of depth information. In this report, we describe a case in which the oblique view of the lymphoscintigram contributed to improving the visualization of a mediastinal SLN of esophageal cancer. Evaluation of the patient's chest CT image validated the notion that gamma rays from SLN are less absorbed by the surrounding soft tissues and the sternum in acquisition from the oblique view than from the true anterior view. The additional oblique view of the lymphoscintigram is useful for evaluation of the SLNs of esophageal cancer.

Fine Needle Aspiration of Peritumoral Lymph Nodes in Esophageal Cancer with Endobronchial Ultrasound

Fine Needle Aspiration of Peritumoral Lymph Nodes in Esophageal Cancer with Endobronchial Ultrasound

Barrett's esophagus and early esophageal cancer

EUS has been shown to be the most accurate radiologic method of staging tumors of the gastrointestinal tract. EUS staging (Table 1) is critical in early esophageal cancer because of the potential impact on therapy. T0 and T1 cancers that do not penetrate deeply into the submucosa can be endoscopically treated with curative intent by using either endoscopic mucosal resection (EMR) or mucosal ablation with photodynamic therapy or argon plasma coagulation. T1 tumors are readily seen as focal thickenings of the mucosa (first and second layers) that may extend into the submucosal layer but not into the muscle layer. The accuracy rate for staging esophageal cancers is lowest for T1 and T2 lesions. Hence, highfrequency catheter miniprobes have been used to improve the staging of early cancers.1 Probes can raise the EUS T-staging accuracy for early squamous cell esophageal cancers from 71% to 92% (71% to 86% for T1 mucosal cancer and 78% to 94% for T1 submucosal cancer).1 However, there are little published data on the EUS staging accuracy in patients with early adenocarcinoma in Barrett’s esophagus. Earlier studies with firstand second-generation standard radial echoendoscopes suggested a low staging accuracy.2,3 However, one later study reported high sensitivity (100%), specificity (94%), and negative predictive value (100%) of preoperative EUS for detection of submucosal invasion.4 Preliminary data from studies with both standard and high-frequency EUS suggest that the presence of layer 3 disruption suggests submucosal invasion, but its absence does not exclude it.5 Indeed, in a large (n = 130) retrospective series from the Mayo Clinic,3 the overall accuracy of EUS T-staging was only 61% (43% for T1 and 70% for T0) because of both overstaging and understaging. The T-staging accuracy was not improved significantly in the 16 patients who were also preoperatively staged with the 20-MHz probe. The risk of lymph node metastasis approaches 40% in deep T1 submucosal esophageal cancers. Hence, EUS N-staging is also important in selecting patients for possible endoscopic curative therapy of early esophageal cancer. When EUS N-staging is compared with results of meticulous operative dissection of lymph nodes, the overall accuracy for staging lymph nodes in esophageal cancer is about 87% to 88%.6 But most patients reported in studies of EUS and esophageal cancer staging have advanced disease. There are little published data on the accuracy of EUS for determining the presence or absence of lymph node involvement in patients with early adenocarcinoma. Mediastinal lymph nodes can be commonly found in patients with Barrett’s esophagus. In one series of patients who had preoperative EUS, the prevalence of malignant, benign, and indeterminate lymph nodes in patients with high-grade dysplasia who had surgery was 0%, 25%, and 12%, respectively.7 Limited data suggest that the EUS accuracy for detecting malignant lymphadenopathy or excluding it is high. One small published study showed that preoperative EUS detected the single instance of lymph node metastasis in 1 of 17 patients (this patient had a T3 N1 cancer) but inaccurately predicted the presence of N1 disease in 4 patients.4 Hence, the specificity of EUS was 81% and the sensitivity was 100%. Our prospective data from Johns Hopkins support these findings.7 In 27 patients who had Barrett’s esophagus with highgrade dysplasia or early adenocarcinoma who had preoperative EUS, prevalence of malignant lymphCurrent affiliation: Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Helical CT versus EUS with fine needle aspiration for celiac nodal assessment in patients with esophageal cancer

Background: Conventional CT is insensitive for detection of metastatic involvement of celiac lymph nodes in esophageal cancer. Helical CT has theoretical advantages over “slice” CT in this regard, but its performance has not yet been prospectively studied. Methods: Consecutive patients with untreated esophageal cancer were recruited after obtaining informed consent. Helical CT was performed on all patients and TNM staging was performed by a single radiologist. Subsequently, all patients underwent esophageal radial and, as needed, curvilinear array EUS with fine needle aspiration (FNA), for evaluation of celiac lymph nodes and TNM staging. Test performance characteristics with 95% confidence intervals were calculated, assuming EUS with FNA as the reference standard. Results: Forty-eight patients were recruited, of whom 37 (77%) were men. The mean (SD) age was 63.6 (10) years. Excluding 5 patients in whom a confirmatory FNA was not available (n = 43), helical CT identified celiac lymph nodes in 12 (28%) patients. The reference standard of EUS with FNA identified 15 (35%) patients with metastatic celiac lymph nodes, giving a sensitivity, specificity, and positive and negative predictive values for helical CT of 53% (95% CI [28%, 79%]), 86% (95% CI [73%, 99%]), 67% (95% CI [40%, 93%]), and 77% (95% CI [63%, 92%]), respectively, for assessing celiac lymph nodal involvement. The sensitivity and specificity of helical CT in detecting T4 disease were 25% (95% CI [3.8%, 46%]) and 94% (95% CI [85%, 100%]), respectively. There were 12 patients (25%; 95% CI [13%, 37%]) who were felt to have resectable disease by helical CT but had either metastatic involvement of celiac lymph nodes or T4 disease by EUS/FNA. Conclusions: Despite technological advances, helical CT still appears unreliable, mainly because of insensitivity, for the identification of inoperable T4 or metastatic involvement of celiac lymph node disease in esophageal cancer. (Gastrointest Endosc 2002;55:648-54.)

Wide-spread distribution of sentinel lymph nodes in esophageal cancer.

Sentinel lymph nodes are the first draining nodes that contain tumor cells. Identification of sentinel nodes may help to determine the suitable extent of lymphadenectoy. To assess the location of sentinel lymph nodes, a series of 41 patients with single and two metastatic lymph nodes who underwent esophagectomy and 3-field lymphadenectomy between 1991 and 1999 were investigated retrospectively. Only 29 (47.5%) of 61 metastatic nodes showed correspondence between the tumor site and the regional metastatic lymph nodes by routine histologic examination. In the patients with tumors in the upper and middle thoracic esophagus, metastatic lymph nodes were distributed in the cervix, mediastinum and abdomen. Although sentinel nodes were limited to the regional and adjusting compartments in 82%, nodes were found beyond the adjusting compartments in 18%. The sentinel nodes were broadly distributed depending on the location of the tumor in esophageal cancer.

Significance of immunohistochemically demonstrated micrometastases to lymph nodes in esophageal cancer with histologically negative nodes

Background: We examined the prevalence, patterns, and clinical significance of nodal micrometastases in patients with esophageal cancer. Methods: Cervical, mediastinal, and abdominal lymph nodes systematically removed from 37 patients without conventional histologic evidence of lymph node metastasis from esophageal squamous cell carcinoma were immunohistochemically examined to detect cells that were stained for cytokeratins by the monoclonal antibody cocktail AE1/AE3. Postoperative care and survival were compared in cases with and without such micrometastases. Results: Nodal micrometastases were found in 14 of 37 patients (38%). Among these patients, 9, 7, and 4 had micrometastases to abdominal, mediastinal, and cervical lymph nodes, respectively. Postoperative tumor recurrence was significantly more frequent in patients with micrometastases (50%) than in those without (9%, P =.008). Overall and relapse-free survival in the former group was significantly worse than in the latter group (P =.042 and P =.002, respectively). Nodal micrometastases had an independent prognostic importance for relapse-free survival as determined by multivariate analysis. Conclusions: Metastatic tumor cells are frequently present in lymph nodes, even in patients without histologic evidence of nodal metastasis from esophageal cancer. Nodal micrometastases indicates a poorer prognosis after a curative esophagectomy procedure in histologically node-negative cases. (Surgery 2000;127:40-6.)

Detection of micrometastases in histologically negative lymph nodes in esophageal cancer

Background. New molecular techniques may identify micrometastases in histologically negative lymph nodes and have an impact on the staging of esophageal cancer. We investigated the role of the reverse transcriptase–polymerase chain reaction (RT–PCR) assay to identify micrometastases in esophageal cancer. Methods. The RT–PCR assay to detect carcinoembryonic antigen (CEA) messenger ribonucleic acid (mRNA) was performed on lymph nodes from patients with esophageal cancer and benign esophageal disorders. The presence of CEA mRNA in lymph nodes was considered evidence of metastases. Results. Histopathologic study revealed metastases in 50 (41%) of 123 lymph nodes from 30 patients with esophageal cancer. All histologically positive lymph nodes contained CEA mRNA by RT–PCR. Of 73 histologically negative lymph nodes, 36 (49%) contained CEA mRNA, a significant increase compared with the histopathologic diagnosis ( p < 0.001). Lymph nodes in patients with benign disease contained no CEA mRNA. In 10 patients, histologic stage was N0. Five of them were also negative by RT–PCR, and all are alive with only one recurrence. In the remaining 5 patients, RT–PCR was positive for occult lymph node metastases; 2 have died of disease, and 1 is alive with recurrent disease. Conclusions. In patients with esophageal cancer, RT–PCR detects more lymph node metastases than does histopathology. Initial follow-up suggests a positive RT–PCR with negative histologic findings may have poor prognostic implications. Further studies will be needed to confirm any clinical implications.

Fluoresence of metastasized lymph nodes in esophageal cancer following the administration of intravenous eosin yellow using a laser beam

Fifteen patients with esophageal carcinoma received the photosensitizing dye Eosin Yellow (10 mg/kg) intravenously prior to surgery, and their para-esophageal lymph nodes were then examined for fluorescence using a laser beam at the time of operation. When the time interval between the injection of Eosin Yellow and the operation was 48 hours, 21 out of 22 (95.4 per cent) metastatic lymph nodes exhibited fluorescence and 25 out of 26 (96.2 per cent) non-metastatic lymph nodes did not exhibit fluorescence. This method proved to be invaluable for detecting metastatic lymph nodes macroscopically at the time of surgery for esophageal carcinoma.

Morphology and Treatment of Respiratory Tract Invasion due to Metastatic Mediastinal Lymph Nodes in Esophageal Cancer

Morphology and Treatment of Respiratory Tract Invasion due to Metastatic Mediastinal Lymph Nodes in Esophageal Cancer