Significant understaging is seen in clinically staged T2N0 esophageal cancer patients undergoing esophagectomy

Abstract

This study aimed to determine the impact of preoperative staging on the treatment of clinical T2N0 (cT2N0) esophageal cancer patients undergoing esophagectomy. We reviewed a retrospective cohort of 27 patients treated at a single institution between 1999 and 2011. Clinical staging was performed with computed tomography, positron emission tomography, and endoscopic ultrasound. Patients were separated into two groups: neoadjuvant therapy followed by surgery (NEOSURG) and surgery alone (SURG). There were 11 patients (41%) in the NEOSURG group and 16 patients (59%) in the SURG group. In the NEOSURG group, three of 11 patients (27%) had a pathological complete response and eight (73%) were partial or nonresponders after neoadjuvant therapy. In the SURG group, nine of 16 patients (56%) were understaged, 6 (38%) were overstaged, and 1 (6%) was correctly staged. In the entire cohort, despite being clinically node negative, 14 of 27 patients (52%) had node-positive disease (5/11 [45%] in the NEOSURG group, and 9/16 [56%] in the SURG group). Overall survival rate was not statistically significant between the two groups (P = 0.96). Many cT2N0 patients are clinically understaged and show no preoperative evidence of node-positive disease. Consequently, neoadjuvant therapy may have a beneficial role in treatment.

Clinical T2N0 Esophageal Cancer: Identifying Pretreatment Characteristics Associated With Pathologic Upstaging and the Potential Role for Induction Therapy

“…While previous institutional reviews have shown that even though a majority of their patients were receiving both EUS and PET/CT staging, pathologic upstaging after esophagectomy still persisted among 50–60% of cT2N0 patients. [2,3,15] For patients that may have only received one staging modality, the proportions of stage migration may be even higher. Another limitation is the inability to account for all selection biases and factors among patients that receive either induction therapy for cT2N0 esophageal cancer or adjuvant therapy for upstaged upfront cT2N0 esophagectomy patients.…”

Lymph Node Harvest During Esophagectomy Is Not Influenced by Use of Neoadjuvant Therapy or Clinical Disease Stage

“…In this study, we have had a consistent cadre of three experienced general surgeons and two experienced thoracic surgeons who utilized a standard technique across the study period, which should minimize variation. It should also be understood that preoperative staging can be inaccurate, despite the use of current technologies, 21 which is another important limitation in this study. We have used clinical staging as a baseline reference against which to judge the response to neoadjuvant treatment.…”

Stage‐directed individualized therapy in esophageal cancer

“…One of the concerns of treating patients with T2N0 esophageal cancer is that clinical staging is often inaccurate and the presence of occult nodal disease is missed. Despite advances in staging techniques, understaging rates between 25% and 68% have been reported for patients with cT2N0 esophageal cancer undergoing surgery only …”

“…Owing to the risk of nodal disease and concerns regarding the reliability of current clinical staging techniques, a multimodality treatment approach is recommended by some studies in cT2N0 esophageal cancer patients . However, so far most studies have failed to prove a survival benefit for a multimodality treatment approach compared with a surgery‐alone approach for early‐stage esophageal tumors .…”