Junqiang Chen

The pattern and prevalence of lymphatic spread in thoracic oesophageal squamous cell carcinoma.

BACKGROUND Oesophageal squamous cell carcinoma (SCC) is a common type of cancer in China. The knowledge of its pattern of lymphatic metastasis would be of clinical value for surgical and radiation oncologists to treat this disease. MATERIAL AND METHODS A large series of 1850 thoracic oesophageal SCC was retrospectively analysed after extended oesophagectomy with three-field lymphadenectomy (3FL). Specimens were assessed for pattern of lymphatic spread. RESULT Of the 1850 patients, 1081 (58.4%) developed mediastinal, cervical and/or abdominal node metastases. The lymphatic metastasis rates were 35.6%, 22.2%, 26.5%, 6.1% and 26.5%, respectively, for the cervical, upper, middle, lower mediastinal nodes and abdominal nodes. The adjacent mediastinal node metastasis alone occurred in 5.5% of patients, and the multiple level or skip node spread accounted for 20.9% and 73.6% of patients with node metastases. Upward lymphatic spread developed in 46.4% of patients, both up- and downward in 33.2%, and the downward, 20.5%. For the upper oesophageal SCC, the most common node metastasis was in the cervical (49.5%) and followed by the upper mediastinal (28.7%), middle mediastinal (11.4%), abdominal (8.0%) and lower mediastinal (1.4%) nodes. For the middle oesophageal SCC, the highest incidence of node spread was also in the cervical (35.0%) and similar rates in the middle mediastinal (29.8%), abdominal (27.2%) and upper mediastinal (22.4%) nodes, but the least in the lower mediastinal (6.0%) node. For the lower oesophageal SCC, more node metastasis occurred in the abdominal (51.7%), and followed by the middle mediastinal (25.6%), cervical (17.2%), lower mediastinal (13.9%) and upper mediastinal (10.0%). However, the lymphatic metastasis rates of the upper, middle and lower thoracic oesophageal SCC were similar. The unfavourable factors for lymphatic metastasis were long oesophageal lesion (p<0.000), late T stage (p<0.000) and poor differentiation of tumour cells (p<0.000). CONCLUSION The prevalence was: (1) lymphatic spread prone to the upward in the upper oesophageal SCC, downward in the lower one and both up- and downward in the middle one with in favour of the upward and (2) multiple level and skip node metastases were very often seen. The unfavourable factors for node spread were long oesophageal lesion, late T stage and poor differentiation of tumour cells.

Postoperative Radiotherapy Improved Survival of Poor Prognostic Squamous Cell Carcinoma Esophagus

BACKGROUND The purpose of this study was identify prognostic factors and to investigate the association between postoperative radiotherapy and overall survival of thoracic esophageal squamous cell carcinoma patients. METHODS From January 1993 to March 2007, 1,715 patients underwent extended esophagectomy with three-field lymph node dissection with or without postoperative radiotherapy and were eligible for analysis. Patients were grouped to surgery only (n = 1,277) and surgery plus postoperative radiotherapy (n = 438). Radiation dose was 50 Gy in 25 fractions. RESULTS The overall survival rates at 1, 3, 5, and 10 years were 86.6%, 61.3%, 49.4%, and 36.1%, respectively. Univariate and multivariate analyses showed that age 60 years or more, male sex, tumor more than 5 cm long, poorly differentiated histology, T4 tumor, presence of a vascular cancer thrombus in the surgical specimen, lymph node positivity, 3 or more positive lymph nodes, and disease stage II or higher were negative prognostic factors for overall survival. Postoperative radiation therapy improved overall survival for patients with poor disease-related prognostic factors: positive nodal disease, 3 or more positive lymph nodes, stage III/IV, and large or deeply invading tumor. Postoperative radiation had no survival benefit for patients who did not have the poor disease-related prognostic factors. CONCLUSIONS Postoperative radiotherapy is indicated for patients with poor disease-related prognostic factors.

Number and location of positive nodes, postoperative radiotherapy, and survival after esophagectomy with three-field lymph node dissection for thoracic esophageal squamous cell carcinoma

PURPOSE To analyze influences of the number and location of positive lymph nodes and postoperative radiotherapy on survival for patients with thoracic esophageal squamous cell carcinoma (TE-SCC) treated with radical esophagectomy with three-field lymphadenectomy. METHODS AND MATERIALS A total of 945 patients underwent radical esophagectomy plus three-field lymph node dissection for node-positive TE-SCC at Fujian Provincial Tumor Hospital between January 1993 and March 2007. Five hundred ninety patients received surgery only (S group), and 355 patients received surgery, followed 3 to 4 weeks later by postoperative radiotherapy (S+R group) to a median total dose of 50 Gy in 25 fractions. We assessed potential associations among patient-, tumor-, and treatment-related factors and overall survival. RESULTS Five-year overall survival rates were 32.8% for the entire group, 29.6% for the S group, and 38.0% for the S+R group (p = 0.001 for S vs. S+R). Treatment with postoperative radiotherapy was particularly beneficial for patients with ≥3 positive nodes and for those with metastasis in the upper (supraclavicular and upper mediastinal) region or both the upper and lower (mediastinal and abdominal) regions (p < 0.05). Postoperative radiotherapy was also associated with lower recurrence rates in the supraclavicular and upper and middle mediastinal regions (p < 0.05). Sex, primary tumor length, number of positive nodes, pathological T category, and postoperative radiotherapy were all independent predictors of survival. CONCLUSIONS Postoperative radiotherapy was associated with better survival for patients with node-positive TE-SCC, particularly those with three or more positive nodes and positive nodes in the supraclavicular and superior mediastinal regions.

Postoperative radiation therapy with or without concurrent chemotherapy for node-positive thoracic esophageal squamous cell carcinoma

PURPOSE To retrospectively compare the efficacy of radiation therapy (RT) and chemotherapy plus RT (CRT) for the postoperative treatment of node-positive thoracic esophageal squamous cell carcinoma (TESCC) and to determine the incidence and severity of toxic reactions. METHODS AND MATERIALS We retrospectively reviewed data from 304 patients who had undergone esophagectomy with 3-field lymph node dissection for TESCC and were determined by postoperative pathology to have lymph node metastasis without distant hematogenous metastasis. Of these patients, 164 underwent postoperative chemotherapy (cisplatin 80 mg/m(2), average days 1-3, plus paclitaxel 135 mg/m(2), day 1; 21-day cycle) plus RT (50 Gy), and 140 underwent postoperative RT alone. RESULTS The 5-year overall survival rates for the CRT and RT groups were 47.4% and 38.6%, respectively (P=.030). The distant metastasis rate, the mixed (regional lymph node and distant) metastasis rate, and the overall recurrence rate were significantly lower in the CRT group than in the RT group (P<.05). However, mild and severe early toxic reactions, including neutropenia, radiation esophagitis, and gastrointestinal reaction, were significantly more common in the CRT group than in the RT group (P<.05). No significant differences in incidence of late toxic reactions were found between the 2 groups. CONCLUSIONS Our results show that in node-positive TESCC patients, postoperative CRT is significantly more effective than RT alone at increasing the overall survival and decreasing the rates of distant metastasis, mixed metastasis, and overall recurrence. Severe early toxic reactions were more common with CRT than with RT alone, but patients could tolerate CRT.

The pattern of cervical lymph node metastasis in thoracic esophageal squamous cell carcinoma may affect the target decision for definitive radiotherapy

BACKGROUND Metastasis to lymph nodes is a key determinant of thoracic esophageal squamous cell carcinoma (TE-SCC) prognosis. We sought to identify factors linked with cervical lymph node metastasis, which could be used to inform the decision of surgical and definitive radiotherapy. METHODS We retrospectively reviewed records from 1715 patients who had had radical esophagectomy with three-field lymphadenectomy between January 1993 and March 2007 in our hospital. All patients included in the study had pathologically confirmed TE-SCC and no clinical evidence of cervical metastasis. RESULTS Cervical node metastases were found in 547 patients (31.9%); rates of cervical-node positivity were 44.2% for those with upper-thoracic tumors, 31.5% for mid-thoracic tumors, and 14.4% for lower-thoracic tumors. Univariate analysis showed that cervical node metastasis was associated with tumor site, differentiation, and length, pathologic T status, and pN status (P<0.05); however, only tumor site and pN status retained significance in multivariate analysis (P<0.05). Positive cervical nodes were most often found in the paraesophageal region (72.3%), followed by supraclavicular (24.4%); involvement of deep cervical (2.4%) or retropharyngeal nodes (0.9%) was rare (P<0.0001). Positive cervical nodes were most often associated with upper TE-SCCs (60.1%), followed by middle TE-SCCs (31.2%) and lower TE-SCCs (10.6%). CONCLUSIONS Upper TE-SCC with multiple involved nodes at any site was associated with a high rate of cervical node metastasis. These findings provide critical information for clinical decision-making regarding the extent of nodal dissection or the size of radiation fields in definitive radiotherapy.

Prognostic factors in patients with thoracic esophageal carcinoma staged pT 1-4a N 0 M 0 undergone esophagectomy with three-field lymphadenectomy

BACKGROUND To analyze prognostic factors in patients with thoracic esophageal carcinoma staged pT1-4aN0M0 and undergone esophagectomy with 3-field lymphadenectomy and to evaluate the effect of postoperative radiotherapy. METHODS From January 1993 to March 2007, 770 patients with stage pT1-4aN0M0 underwent 3-field lymphadenectomy at Fujian Province Cancer Hospital, China were enrolled for analysis. The study consisted of 770 patients with stage pT1-4aN0M0 who underwent 3-field lymphadenectomy at Fujian Province Cancer Hospital, China. A total of 687 had received surgery only, and 83 patients had undergone surgery followed by postoperative radiotherapy. Radiation dose was 50 Gy in 25 fractions. RESULTS The overall survival rates at 1, 3, 5, and 10 years were 92.9%, 80.8%, 71.7% and 57.4%, respectively. Univariate analysis showed that age and T staging were two independent factors on prognoses. Five-year survival in cases younger and older than 60 were 76.5% vs. 63.3% (P=0.001), while those of pT1, pT2, pT3 and pT4a were 83.8%, 78.8%, 67.8% and 54.1%, respectively (P=0.000). Five-year survival in group of simple surgery was 71.3%, compared with 74.5% in group of surgery plus postoperative radiotherapy (P=0.763), while stratified analysis indicated that postoperative radiotherapy was able to boost the survival of patients in pT4a which were 72.4% vs. 33.8% (P=0.036) and to lower relapse rate of tumor bed in patients with pT4a (P=0.005). Multivariate analysis showed that age and T staging were two independent factors on prognoses. CONCLUSIONS Patients with high T staging and at an age more than 60 turned out bad prognoses, neither could postoperative radiotherapy improve their survival.

A new clinical staging system for esophageal cancer to predict survival after definitive chemoradiation or radiotherapy

This study is to evaluate the prognostic value of a new clinical staging system for esophageal cancer to predict survival after (chemo)radiotherapy. This retrospective study enrolled 444 patients with esophageal squamous cell carcinoma who underwent definitive intensity-modulated radiotherapy with or without chemotherapy between January 2008 and May 2014. A clinical staging system based on the gross tumor volume and maximum diameter of metastatic lymph nodes was developed and the prognostic value of this staging system was compared with that of the 8th edition of American Joint Committee on Cancer TNM staging system. The 3-year survival rate in the whole group was 44.5%. Multivariate analysis showed that gross tumor volume and maximum diameter of metastatic lymph nodes were independent prognostic factors. According to the proposed clinical staging system, the 3-year survival curves of each T, N, and TNM stage were well segregated. On the other hand, 3-year survival rates based on the 8th edition of cTNM staging system were similar between cT3 and cT4, cN1 and cN2, cN2, and cN3, III and IVa stages.The proposed clinical staging system appears to be a simple and accurate predictor of outcome in patients with esophageal squamous cell carcinoma who underwent definitive (chemo) intensity-modulated radiotherapy.

Patterns and rates of abdominal lymphatic metastasis following esophageal carcinoma

Aim To determine the rate of abdominal lymph node metastasis after radical surgery for esophageal cancer and define the radiotherapy target area. Methods Of the 1593 patients who underwent R0 radical esophagectomy for thoracic esophageal squamous cell carcinoma (TE-SCC), 148 developed abdominal lymph node (LN) metastases within three years of surgery. During that time interval, patients were examined by various imaging methods (enhanced computer tomography, magnetic resonance imaging, and positron emission tomography–CT) at set time points. The emerging recurrence pattern, preferred sites for abdominal metastasis, and correlation with added clinical factors were carefully recorded, to permit for delineation of a target area for radiotherapy. Results We found postoperative metastatic abdominal LNs in 9.3% of the patients treated for esophageal cancer. Lesions in the upper, middle, and lower esophageal segments metastasized to abdominal LNs at 2.3%, 7.8%, and 26.6% (P < 0.0001), respectively. Of all cases, 4.8% had fewer than two affected LNs, while 20.1% had more than three metastatic LNs (P< 0.0001). The metastasis rates of negative and positive celiac LNs were 4.6% and 22.7%, respectively. Abdominal LN metastasis rates for the following LNs: 16a2 and 16a1 of para-aortic, celiac artery, posterior surface of the pancreatic head and common hepatic artery were 64.9%, 41.2%, 37.8%, 32.4%, and 20.9%, respectively. The overall rate of metastasis to these groups of LNs was 91.9%. Conclusion This study determined that stations 16a1 and 16a2 of the para-aortic, truncus coeliacus, posterior surface of the pancreatic head, and arteria hepatica communis lymph nodes were the preferred sites for abdominal LN metastasis, thus defining target areas for postoperative radiotherapy.