Upper gastrointestinal tumors

Influence of the number of malignant regional lymph nodes detected by endoscopic ultrasonography on survival stratification in esophageal adenocarcinoma [1]

The current tumor-node-metastasis (TNM) staging for esophageal cancer looks at location of regional lymph nodes, but unlike staging of other gastrointestinal malignancies, it does not consider the number of lymph nodes. The inclusion of the number of lymph nodes to the current staging system may lead to more accurate staging.

Chen et al. [1] assessed whether the number of malignant-appearing regional lymph nodes seen on endoscopic ultrasound (EUS) correlates with patient survival. The secondary aim of the study was to see if a relationship exists between celiac node metastasis and tumor length and malignant periesophageal lymph nodes. This was an historical case series between 1994 and 2004, which identified 85 patients who had EUS to confirm the diagnosis of esophageal cancer. Malignant-appearing periesophageal lymph nodes were categorized as 0, 1 - 2, or > 2. Tumor length was divided into two groups based on endoscopic appearance, < 2.9 cm vs. > 3 cm. A total of 53 patients in this group had long-term follow up with documented mortality. EUS-TNM staging was T1 (19 %), T2 (26 %), T3 (42 %), T4 (13 %), N1 disease (69 %), and celiac lymph nodes (12 %). The study showed that involvement of an increased number of regional lymph nodes was associated with decreased survival. The median survivals were 66 months, 14.5 months, and 6.5 months for 0, 1 - 2, > 2-malignant lymph nodes, respectively. Celiac lymph node involvement was associated with worse survival and a higher likelihood of regional lymph node involvement. The study by Natsugoe et al. [2] included 313 patients, and showed that regional and metastatic lymph nodes correlated with a worse survival, but 94 % of patients had squamous-cell cancers. The study by Vazques-Sequeiros et al. [3] is the first to specifically look at esophageal adenocarcinoma. EUS criteria for identifying malignant lymph nodes had an accuracy of 75 %, and when combined with fine needle aspiration (FNA) this increased to 90 %. This study however is not without limitations, which include: retrospective nature; exact number of lymph nodes not always reported; FNA often not performed due to risk of tumor tracking; and not all lymph nodes had all criteria for nodal staging. Despite this, the study does have merit, and suggests that an increased number of regional lymph nodes correlates with patient survival in evaluating adenocarcinoma of the esophagus. It also suggests modifying the current staging system, and making the TNM staging similar to that of other gastrointestinal malignancies.

References

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