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Surgical Management of Early-Stage Esophageal Adenocarcinoma Based on Lymph Node Metastasis Risk.
Ann Surg Oncol 2018; 25(1):318-325AS

Abstract

BACKGROUND

In early-stage esophageal adenocarcinoma (EAC), esophagectomy improves staging but also increases mortality compared with endoscopic resection. Our objective was to quantify esophagectomy mortality and lymph node metastasis (LNM) risk in early-stage EAC to improve surgical treatment allocation.

METHODS

We identified National Cancer Database (2004-2014) patients with nonmetastatic, Tis, T1a, or T1b EAC who had primary surgical resection and microscopic examination of at least 15 lymph nodes. Univariate and multivariable logistic regression identified predictors of LNM. Cox regression identified predictors of death. The Kaplan-Meier method predicted overall survival (OS).

RESULTS

In 782 patients, LNM rates were: all patients 13.8%, Tis 0%, T1a 3.6%, T1b 23.4%. Independent predictors of LNM were submucosal invasion, lymphovascular invasion (LVI), decreasing differentiation, and tumor size ≥ 2 cm (P < 0.05). For T1a tumors with poor differentiation or size ≥ 2 cm, LNM rates were 10.2 and 6.7%, respectively; 90-day mortality was 3.1%. The LNM rate in well differentiated T1b tumors < 2 cm was 4.2%; 90-day mortality was 6.0%. Estimated 5-year OS was 80.2% versus 64.4% (T1a vs. T1b). LNM increased risk of death for T1a (hazard ratio [HR] 8.52, 95% confidence interval [CI] 3.13-23.22, P < 0.001) and T1b tumors (HR 2.52, 95% CI 1.59-4.00, P < 0.001).

CONCLUSIONS

In T1a EAC with poor differentiation or size ≥ 2 cm, esophagectomy should be considered, whereas in T1b EAC with low-risk features (well-differentiated T1b EAC < 2 cm without LVI), endoscopic resection may be sufficient. Treatment guidelines for early-stage EAC should include all high-risk tumor features for LNM and stage-specific esophagectomy mortality.

Authors+Show Affiliations

Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA. Andrew.Newton@uphs.upenn.edu.Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA.Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA.Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA.Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA.Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA.Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA.Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA.Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

29147928

Citation

Newton, Andrew D., et al. "Surgical Management of Early-Stage Esophageal Adenocarcinoma Based On Lymph Node Metastasis Risk." Annals of Surgical Oncology, vol. 25, no. 1, 2018, pp. 318-325.
Newton AD, Predina JD, Xia L, et al. Surgical Management of Early-Stage Esophageal Adenocarcinoma Based on Lymph Node Metastasis Risk. Ann Surg Oncol. 2018;25(1):318-325.
Newton, A. D., Predina, J. D., Xia, L., Roses, R. E., Karakousis, G. C., Dempsey, D. T., ... Singhal, S. (2018). Surgical Management of Early-Stage Esophageal Adenocarcinoma Based on Lymph Node Metastasis Risk. Annals of Surgical Oncology, 25(1), pp. 318-325. doi:10.1245/s10434-017-6238-z.
Newton AD, et al. Surgical Management of Early-Stage Esophageal Adenocarcinoma Based On Lymph Node Metastasis Risk. Ann Surg Oncol. 2018;25(1):318-325. PubMed PMID: 29147928.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Surgical Management of Early-Stage Esophageal Adenocarcinoma Based on Lymph Node Metastasis Risk. AU - Newton,Andrew D, AU - Predina,Jarrod D, AU - Xia,Leilei, AU - Roses,Robert E, AU - Karakousis,Giorgos C, AU - Dempsey,Daniel T, AU - Williams,Noel N, AU - Kucharczuk,John C, AU - Singhal,Sunil, Y1 - 2017/11/16/ PY - 2017/05/18/received PY - 2017/11/18/pubmed PY - 2019/3/5/medline PY - 2017/11/18/entrez SP - 318 EP - 325 JF - Annals of surgical oncology JO - Ann. Surg. Oncol. VL - 25 IS - 1 N2 - BACKGROUND: In early-stage esophageal adenocarcinoma (EAC), esophagectomy improves staging but also increases mortality compared with endoscopic resection. Our objective was to quantify esophagectomy mortality and lymph node metastasis (LNM) risk in early-stage EAC to improve surgical treatment allocation. METHODS: We identified National Cancer Database (2004-2014) patients with nonmetastatic, Tis, T1a, or T1b EAC who had primary surgical resection and microscopic examination of at least 15 lymph nodes. Univariate and multivariable logistic regression identified predictors of LNM. Cox regression identified predictors of death. The Kaplan-Meier method predicted overall survival (OS). RESULTS: In 782 patients, LNM rates were: all patients 13.8%, Tis 0%, T1a 3.6%, T1b 23.4%. Independent predictors of LNM were submucosal invasion, lymphovascular invasion (LVI), decreasing differentiation, and tumor size ≥ 2 cm (P < 0.05). For T1a tumors with poor differentiation or size ≥ 2 cm, LNM rates were 10.2 and 6.7%, respectively; 90-day mortality was 3.1%. The LNM rate in well differentiated T1b tumors < 2 cm was 4.2%; 90-day mortality was 6.0%. Estimated 5-year OS was 80.2% versus 64.4% (T1a vs. T1b). LNM increased risk of death for T1a (hazard ratio [HR] 8.52, 95% confidence interval [CI] 3.13-23.22, P < 0.001) and T1b tumors (HR 2.52, 95% CI 1.59-4.00, P < 0.001). CONCLUSIONS: In T1a EAC with poor differentiation or size ≥ 2 cm, esophagectomy should be considered, whereas in T1b EAC with low-risk features (well-differentiated T1b EAC < 2 cm without LVI), endoscopic resection may be sufficient. Treatment guidelines for early-stage EAC should include all high-risk tumor features for LNM and stage-specific esophagectomy mortality. SN - 1534-4681 UR - https://www.unboundmedicine.com/medline/citation/29147928/Surgical_Management_of_Early_Stage_Esophageal_Adenocarcinoma_Based_on_Lymph_Node_Metastasis_Risk_ L2 - https://dx.doi.org/10.1245/s10434-017-6238-z DB - PRIME DP - Unbound Medicine ER -