Evaluation of the Reliability of Clinical Staging of T2 N0 Esophageal Cancer: A Review of The Society of Thoracic Surgeons Database

Abstract

Background Clinical staging of esophageal cancer has improved with PET/CT and endoscopic ultrasound. Despite such progress, small single center studies have questioned the reliability of clinical staging of T2N0 esophageal cancer. This study broadly examines the adequacy of clinical staging of T2N0 disease using the Society of Thoracic Surgeons database. Methods We retrospectively studied 810 clinical stage T2N0 patients from 2002-2011. There were 58 excluded because of incomplete pathologic staging data. Clinical stage, pathologic stage, and preoperative characteristics were recorded. Logistic regression analysis was utilized to identify factors associated with upstaging at the time of surgery. Results Among 752 clinical stage T2N0 patients, 35.9 %(270) received induction therapy prior to surgery. Of 482 patients that went directly to surgery, 27.4%(132) were confirmed as pathologic T2N0, 25.9%(125) were downstaged(i.e. T0-1N0), while 46.7%(225) were upstaged at surgery (T3-4N0 or TanyN1-3). Exclusive tumor upstaging(i.e. pathological T3-4N0) accounted for 18.2%(41), while exclusive nodal upstaging(i.e. pathological T1-2N1-3) accounted for 44.5%(100). Combined tumor and nodal upstaging(i.e. pathological T3-4N1-3) accounted for 37.3%(84). Among patients who received induction therapy, 38.1%(103) were upstaged vs. 46.7%(225) without induction therapy(p=0.026). Comparing the induction therapy group and the primary surgical group, postoperative 30-day mortality(3.7% vs. 3.7%, p=1.0) and morbidity(46.3% vs. 45%, p=0.76) were similar. Conclusion Despite advances in staging techniques clinical staging of T2N0 esophageal cancer remains unreliable. Recognizing T2N0 as a threshold for induction therapy in esophageal cancer, many surgeons have opted to treat T2N0 disease with induction therapy, despite the fact that one quarter of these patients will be pathological T1N0. While this study demonstrated similar perioperative morbidity and mortality with and without induction therapy, further study is needed to examine the impact of upstaging on long-term survival.

Neoadjuvant treatment of locally advanced esophageal and junctional cancer: the evidence-base, current key questions and clinical trials

“…In addition, a multicenter European collaboration including 355 patients with cT2N0 disease and propensity matching showed no benefit to multimodal therapy compared with surgery alone (18). Consequently, at this point it is reasonable to conclude that there is no compelling evidence to support neoadjuvant therapy in this cohort, notwithstanding the limitations of even modern staging with EUS and CT-PET with understaging in approximately half of patients and overstaging in about one quarter of tumors in this group (37,38). RCTs powered on predicted node negative disease in adenocarcinoma and including surgery only arms would be of interest and should be developed.…”

Identification of Herb Pairs in Esophageal Cancer

“…The medical data stored in DBMS7.0 are renewed every 3 months [15]. As of December 31, 2014, a total of 20,889 medical records, 60 tumor types, 100,000 pathology records, 300,000 laboratory test results, 40,000 radiological examination results, 4,000 survival follow-up cases, and 41,000 cases used have been deposited in DBMS7.0 [16]. …”

Induction Therapy Does Not Improve Survival for Clinical Stage T2N0 Esophageal Cancer

“…2 Clinical staging modalities for this subset are known to be unreliable, with significant percentages of patients being under-staged or over staged. 3–7 Perhaps because clinical staging inaccuracies lead to a relatively high incidence of patients actually having nodal disease present at the time of surgical resection, induction therapy use in this setting has been increasing and was shown recently to exceed 50% for cases that were reported to the Society of Thoracic Surgeons General Thoracic Database in 2011. 3 However, induction therapy has not been definitively shown to improve outcomes in node-negative patients.…”

“…3–7 Perhaps because clinical staging inaccuracies lead to a relatively high incidence of patients actually having nodal disease present at the time of surgical resection, induction therapy use in this setting has been increasing and was shown recently to exceed 50% for cases that were reported to the Society of Thoracic Surgeons General Thoracic Database in 2011. 3 However, induction therapy has not been definitively shown to improve outcomes in node-negative patients. The purpose of this study was to use one of the largest nationwide cancer databases to test the hypothesis that induction therapy followed by surgical resection is associated with improved survival compared to initial treatment with surgical resection for patients with cT2N0 esophageal cancer.…”