Early esophageal cancer: pattern of lymphatic spread and prognostic factors for long-term survival after surgical resection

Abstract

Objective: The objective of this study was to assess the prevalence and pattern of lymphatic spread in patients with early squamous cell and adenocarcinoma and identify prognostic factors for long-term survival after resection and lymphadenectomy.

Summary background data: Limited endoscopic approaches without lymphadenectomy are increasingly applied in patients with early esophageal cancer.

Material and methods: A total of 290 patients with early esophageal cancer (157 adenocarcinoma, 133 squamous cell cancer) had surgical resection with systematic lymphadenectomy. Specimens were assessed for prevalence and pattern of lymphatic spread. Prognostic factors were determined by multivariate analysis.

Results: None of the 70 patients with adenocarcinoma limited to themucosa had lymphatic spread, as compared with 2 of 26 with mucosal squamous cell cancer. Lymphatic spread was more common in patients with submucosal squamous cell cancer as compared with submucosal adenocarcinoma (36.4% versus 20.7%). Although lymph node metastases were usually limited to locoregional lymph node stations in early adenocarcinoma, distant lymphatic spread was frequent in early squamous cell cancer. On multivariate analysis, only histologic tumor type and the presence of lymph node metastases were independent predictors of long-term survival. Five-year survival rate was 83.4% for early adenocarcinoma versus 62.9% for early squamous cell cancer and 48.2% versus 79.5% for patients with/without lymphatic spread.

Discussion: Prevalence and pattern of lymphatic spread as well as long-term prognosis differ markedly between early esophageal squamous cell and adenocarcinoma. Limited resection techniques and individualized lymphadenectomy strategies appear applicable in patients with early adenocarcinoma.

FIGURE 1. Topographic distribution of lymph node metastases shown as the number of patients with positive nodes at the specified regions in relation to the total number of patients in the group. (A) Patients with early adenocarcinoma (all but 2 located below the level of the tracheal bifurcation). (B) Early esophageal squamous cell cancer located below the level of the tracheal bifurcation. (C) Early esophageal squamous cell cancer located at or above the level of the tracheal bifurcation. In patients with lymph node metastases at more than one location, all locations are shown.

FIGURE 2. Overall survival rate of resected early esophageal cancer in relation to the presence of lymph node metastases (pN0 vs pN+) (P < 0.01).

FIGURE 3. Overall survival rate of resected early esophageal cancer in relation to histologic tumor type (adenocarcinoma vs squamous cell cancer) (P < 0.01).