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The N-Classification for Esophageal Cancer Staging: Should it be Based on Number, Distance, or Extent of the Lymph Node Metastasis?

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Abstract

Background

The recently published AJCC-TNM staging system for esophageal carcinoma made an obvious modification on N-classification based on the number of metastatic regional lymph nodes (LN). However, this classification might ignore the site at which these LNs occur, a factor that might be even more important in reflecting patients’ prognosis.

Methods

A retrospective study of 236 patients with carcinoma of thoracic esophagus who underwent esophagectomy between 1984 and 1989 with each at least six LNs removed was conducted, with a 10-year follow-up rate of 92.4%. The proposed scheme for N-classification according to the number (0, 1–2, 3–6, ≥7; N0–3), distance (0, 1, 2, 3 stations; S0–3), or extent (0, 1, and 2 fields; F0–2) of LN involvement was evaluated by univariate and multivariate survival analysis.

Results

The LN metastasis was identified in 112 patients, revealing a poorer 5-year survival in this patient group when compared to patients without node involvement. Cox regression analysis revealed that the number and distance of LN metastases and the number of metastasis fields were factors significantly influencing survival. When these factors were further analyzed by univariate log-rank test, no significant difference in survival existed between N2 and N3 patients, or among S1, S2, and S3 patients. When patients were grouped according to the extent of LN metastasis, significant differences in survival were observed overall and between each subgroup.

Conclusions

Refining the current N-classification for esophageal cancer according to the extent of LN metastasis, rather than by number alone, might be a better means of staging that could subgroup patients more effectively and result in different rates of survival.

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References

  1. Rice TW, Blackstone EH, Rybicki LA et al (2003) Refining esophageal cancer staging. J Thorac Cardiovasc Surg 25:1103–1113

    Article  Google Scholar 

  2. Dhar DK, Hattori S, Tonomoto Y et al (2007) Appraisal of a revised lymph node classification system for esophageal squamous cell cancer. Ann Thorac Surg 83:1265–1272

    Article  PubMed  Google Scholar 

  3. Edge SB, Byrd DR, Compton CC et al (2009) AJCC cancer staging manual, 7th edn. Springer, New York, pp 103–115

    Google Scholar 

  4. Rizk N, Venkatraman E, Park B et al (2006) The prognostic importance of the number of involved lymph nodes in esophageal cancer: implications for revisions of the American Joint Committee on Cancer staging system. J Thorac Cardiovasc Surg 132:1374–1381

    Article  PubMed  Google Scholar 

  5. Hofstetter W, Correa AM, Bekele N et al (2000) 7) Proposed modification of nodal status in AJCC esophageal cancer staging system. Ann Thorac Surg 84:365–375

    Article  Google Scholar 

  6. Altorki NK, Zhou XK, Stiles B et al (2008) Total number of resected lymph nodes predicts survival in esophageal cancer. Ann Surg 248:221–226

    Article  PubMed  Google Scholar 

  7. Hsu CP, Chen CY, Hsia JY et al (2001) Prediction of prognosis by the extent of lymph node involvement in squamous cell carcinoma of the thoracic esophagus. Eur J Cardiothorac Surg 19:10–13

    Article  PubMed  CAS  Google Scholar 

  8. Kunisaki C, Akiyama H, Nomura M et al (2005) Developing an appropriate staging system for esophageal carcinoma. J Am Coll Surg 201:884–890

    Article  PubMed  Google Scholar 

  9. Fu JH, Huang WZ, Huang ZF et al (2007) The impact of different N1 status on the prognosis of the thoracic esophageal squamous cell carcinoma. Chin J Thorac Cardiovasc Surg 23:28–30

    Google Scholar 

  10. Bogoevski D, Onken F, Koenig A et al (2008) Is it time for a new TNM classification in esophageal carcinoma? Ann Surg 247:633–641

    Article  PubMed  Google Scholar 

  11. Greenstein AJ, Litle VR, Swanson SJ et al (2008) Prognostic significance of the number of lymph node metastases in esophageal cancer. J Am Coll Surg 206:239–246

    Article  PubMed  Google Scholar 

  12. Mariette C, Piessen G, Briez N et al (2008) The number of metastatic lymph nodes and the ratio between metastatic and examined lymph nodes are independent prognostic factors in esophageal cancer regardless of neoadjuvant chemoradiation or lymphadenectomy extent. Ann Surg 247:365–371

    Article  PubMed  Google Scholar 

  13. Wilson M, Rosato EL, Chojnacki KA et al (2008) Prognostic significance of lymph node metastases and ratio in esophageal cancer. J Surg Res 146:11–15

    Article  PubMed  Google Scholar 

  14. Casson AG, Rusch VW, Ginsberg RJ et al (1994) Lymph node mapping of esophageal cancer. Ann Thorac Surg 58:1569–1570

    Article  PubMed  CAS  Google Scholar 

  15. Hosch SB, Stoecklein NH, Pichlmeier U et al (2001) Esophageal cancer: the mode of lymphatic tumor cell spread and its prognostic significance. J Clin Oncol 19:1970–1975

    PubMed  CAS  Google Scholar 

  16. Zhang HL, Chen LQ, Liu RL et al (2010) The number of lymph node metastases influences survival and international union against cancer tumor-node-metastasis classification for esophageal squamous cell carcinoma. Dis Esophagus 23:53–58

    Article  PubMed  CAS  Google Scholar 

  17. Fujita H, Kakegawa T, Yamana H et al (1995) Mortality and morbidity rates, postoperative course, quality of life, and prognosis after extended radical lymphadenectomy for esophageal cancer. Comparison of three-field lymphadenectomy with two-field lymphadenectomy. Ann Surg 222:654–662

    Article  PubMed  CAS  Google Scholar 

  18. DeMeester TR (1997) Esophageal carcinoma: current controversies. Semin Surg Oncol 13:217–233

    Article  PubMed  CAS  Google Scholar 

  19. Tachibana M, Yoshimura H, Kinugasa S et al (2001) Clinicopathologic factors correlated with number of metastatic lymph nodes in oesophageal cancer. Dig Liver Dis 33:534–538

    Article  PubMed  CAS  Google Scholar 

  20. Xu Y, Guo Z (2000) The number of lymph node with metastases influences survival in patients with cancer of the thoracic esophagus. Zhonghua Zhong Liu Za Zhi 22:244–246 (Chinese)

    PubMed  CAS  Google Scholar 

  21. An FS, Huang JQ, Chen SH (2003) Analysis of lymph node metastases of 217 cases of thoracic esophageal carcinoma and its impact on prognosis. Ai Zheng 22:974–977 (Chinese)

    PubMed  Google Scholar 

  22. Fang WT, Chen WH (2008) Current trends in extended lymph node dissection for thoracic esophageal carcinoma: evidence and experience. China Oncol 18:345–349 (Chinese)

    Google Scholar 

  23. Shimada H, Okazumi S, Matsubara H et al (2006) Impact of the number and extent of positive lymph nodes in 200 patients with thoracic esophageal squamous cell carcinoma after three-field lymph node dissection. World J Surg 30:1441–1449

    Article  PubMed  Google Scholar 

  24. Japanese Society for Esophageal Disease (2008) Japanese classification of esophageal cancer, 10th edn. Kanehara Co. Ltd, Tokyo

    Google Scholar 

  25. Hu Y, Hu C, Zhang H et al (2010) How does the number of resected lymph nodes influence TNM staging and prognosis for esophageal carcinoma? Ann Surg Oncol 17:784–790

    Article  PubMed  Google Scholar 

  26. Dutkowski P, Hommel G, Bottger T et al (2002) How many lymph nodes are needed for an accurate pN classification in esophageal cancer? Evidence for a new threshold value. Hepatogastroenterology 49:176–180

    PubMed  Google Scholar 

  27. Adachi W, Koike S, Nimura Y et al (1996) Clinicopathologic characteristics and postoperative outcome in Japanese and Chinese patients with thoracic esophageal cancer. World J Surg 20:332–336

    Article  PubMed  CAS  Google Scholar 

  28. Tachibana M, Kinugasa S, Yoshimura H et al (2005) Clinical outcomes of extended esophagectomy with three-field lymph node dissection for esophageal squamous cell carcinoma. Am J Surg 189:98–109

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The authors are grateful to their participants, and they acknowledge the support of the National Natural Science Foundation of China under NSFC grant 30770982.

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Authors and Affiliations

  1. Department of Thoracic Surgery, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, Sichuan, 610041, China

    Qi-Rong Xu, Xue-Peng Zhuge & Long-Qi Chen

  2. Department of Thoracic Surgery, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050000, China

    He-Lin Zhang

  3. Department of Thoracic Surgery, Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, China

    Yu-Min Ping

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  1. Qi-Rong Xu
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  2. Xue-Peng Zhuge
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  3. He-Lin Zhang
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  4. Yu-Min Ping
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  5. Long-Qi Chen
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Corresponding authors

Correspondence to He-Lin Zhang or Long-Qi Chen.

Additional information

This article was read at International Surgical Week ISW 2009 Adelaide, September 6–10, 2009 and the abstract was published in World J Surg (2009) 33:S1–S268. doi: 10.1007/s00268-009-0165-5.

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Xu, QR., Zhuge, XP., Zhang, HL. et al. The N-Classification for Esophageal Cancer Staging: Should it be Based on Number, Distance, or Extent of the Lymph Node Metastasis?. World J Surg 35, 1303–1310 (2011). https://doi.org/10.1007/s00268-011-1015-9

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  • DOI: https://doi.org/10.1007/s00268-011-1015-9

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