The prognostic importance of pathologically involved celiac node metastases in node-positive patients with carcinoma of the distal esophagus or gastroesophageal junction: a surgical series from the Mayo Clinic

Abstract

The management of esophageal cancer with involvement of celiac lymph nodes is controversial. The purpose of this retrospective study was to evaluate the clinical importance of metastases to celiac lymph nodes in patients with carcinoma of the distal esophagus or gastroesophageal junction (GEJ) who undergo surgical treatment with curative intent. We reviewed the medical records of 310 patients who underwent definitive esophagectomy at the Mayo Clinic, Rochester, Minnesota, between 1976 and 1999 for carcinoma of the distal esophagus or GEJ. The disease location was distal esophagus in 163 and GEJ in 147. Fifty-two patients (17%) were found to have celiac node involvement. The survival of these patients was compared with that of 97 N0 patients and 161 N1 patients without celiac node involvement. Squamous cell carcinoma and adenocarcinomas were found in 24% and 76%, respectively. Ivor Lewis esophagectomy was the most common surgical procedure (76%), followed by transhiatal resection (14%) and modified Ivor Lewis procedure (5%). The median number of nodes resected was 15 (range, 2-45). The median survival of the entire group was 18.8 months. The median survival was 48 months (range, 1.6 months-22 years) for N0 patients and 15.9 months (range, 0.03 months-14.4 years) for N1 patients without celiac node disease (P < 0.001). The median survival was 11.7 months (range, 2.2 months-15.7 years) for celiac node-positive patients, and this difference was statistically significant when compared with survival in N0 patients (P= 0.001) but not when compared with that in N1 patients without celiac node disease (P= 0.57). Survival at 3 and 5 years was 61% and 45% for N0 patients, 21% and 9% for N1 patients without celiac node disease, and 18% and 11% for patients with celiac node disease, respectively. At 10 years, 7% of patients with celiac node involvement in their resected specimen were alive. By multivariate analysis, patients with 4 or more positive lymph nodes had the worst prognosis (risk ratio [RR], 2.63; 95% confidence interval [CI], 1.98-3.48), regardless of their location. We concluded that celiac node metastases were not an adverse prognostic indicator in patients with celiac node involvement compared with N1 patients without celiac node disease. Overall, the number of positive nodes, not their location, correlated best with survival. Although median survival was poor, a small number of patients with resected celiac node disease had long-term survival. Patients with undetected celiac node disease at the time of surgical resection who were subsequently found to have celiac node involvement appeared to have a prognosis similar to that of patients with stage III disease. Therefore, treatment with curative intent should be considered for fit patients with celiac node disease.

Gastric cardiac carcinomas involving the esophagus are more adequately staged as gastric cancers by the 7th edition of the American Joint Commission on Cancer Staging System

“…9 Total gastrectomy with en-bloc resection of advanced gastric cardiac carcinomas involving the esophagus along with the surrounding lymph nodes in the celiac axis region has been advocated to improve patient survival. 21,23 We found herein that the AJCC 7th system was not as good for prognostic stratification of patients with gastric cardiac carcinomas involving the esophagus when they were grouped as esophageal cancers, compared with when staged as gastric cancers. 8 These results will certainly fuel the ongoing controversy debate about the pathogenesis, origin, and classification of gastroesophageal junction cancers and gastric cardiac carcinomas involving the esophagus.…”

“…This rate was similar to that reported in Japanese patients 22 and slightly better than that described in a similar study from Taiwan, in which no long-term survival was observed in patients with celiac nodal diseases. 2 Recently, Schomas et al 23 systematically investigated the prognostic significance of celiac axis nodal involvement in patients with gastroesophageal junction cancer and found that the survival rates of those with celiac nodal metastasis were comparable with those of pN1, and similar to patients with stage pIII disease. However, over 52% of their patients had cancers within the distal esophagus above the gastroesophageal junction; therefore, their data may not be comparable with ours.…”

Does recurrent laryngeal nerve lymph node metastasis really affect the prognosis in node-positive patients with squamous cell carcinoma of the middle thoracic esophagus?

“…Our report showed that the survival rate decreased with an increasing number of metastatic nodes, and that the optimal cutoff value was between 1–6 and ≥ 7 metastatic nodes. On the other hand, there was little evidence supporting that the site of metastatic nodes influenced the prognosis of esophageal carcinoma [14,22,23]. For example, celiac node metastasis, which was regarded as M1 disease in the past, did not mean poor prognosis in node-positive patients with esophageal cancer [22,23].…”

“…On the other hand, there was little evidence supporting that the site of metastatic nodes influenced the prognosis of esophageal carcinoma [14,22,23]. For example, celiac node metastasis, which was regarded as M1 disease in the past, did not mean poor prognosis in node-positive patients with esophageal cancer [22,23]. It was found that for middle and lower thoracic esophageal carcinoma, survival of patients with celiac node metastasis did not differ from those with left gastric node metastasis [23].…”

Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group

“…To take into account these risks and the inconclusive clinical studies, neoadjuvant treatment and the following surgery should currently only be carried out for patients in good general condition with advanced but resectable, non-metastatic EC (>cT2 and/or Npos and M0). It should be noted that lymph node metastases at the coeliac trunk (formally M1a) should be treated as regional lymph node metastases [16][17][18][19]. If necessary, staging laparoscopy should be performed to confirm the diagnosis or rule out a peritoneal carcinosis.…”