Evaluation of the reliability of clinical staging of T2 N0 esophageal cancer: a review of the Society of Thoracic Surgeons database

Abstract

Background: Clinical staging of esophageal cancer has improved with positron-emission tomography/computed tomography and endoscopic ultrasound imaging. Despite such progress, small single-center studies have questioned the reliability of clinical staging of T2 N0 esophageal cancer. This study broadly examines the adequacy of clinical staging of T2 N0 disease using The Society of Thoracic Surgeons database.

Methods: We retrospectively studied 810 clinical stage T2 N0 patients from 2002 to 2011, with 58 excluded because of incomplete pathologic staging data. Clinical stage, pathologic stage, and preoperative characteristics were recorded. Logistic regression analysis was used to identify factors associated with upstaging at the time of surgical intervention.

Results: Among 752 clinical stage T2 N0 patients, 270 (35.9%) received induction therapy before the operation. Of 482 patients who went directly to surgical intervention, 132 (27.4%) were confirmed as pathologic T2 N0, 125 (25.9%) were downstaged (ie, T0-1 N0), and 225 (46.7%) were upstaged at the operation (T3-4 N0 or Tany N1-3). Exclusive tumor upstaging (ie, pathologic T3-4 N0) accounted for 41 patients (18.2%), whereas exclusive nodal upstaging (ie, pathological T1-2 N1-3) accounted for 100 (44.5%). Combined tumor and nodal upstaging (ie, pathological T3-4 N1-3) accounted for 84 patients (37.3%). Among patients who received induction therapy, 103 (38.1%) were upstaged vs 225 (46.7%) without induction therapy (p = 0.026). Comparing the induction therapy group and the primary surgical group, postoperative 30-day mortality (3.7% vs 3.7%, p > 0.99) and morbidity (46.3% vs 45%, p = 0.76) were similar.

Conclusions: Despite advances in staging techniques, clinical staging of T2 N0 esophageal cancer remains unreliable. Recognizing T2 N0 as a threshold for induction therapy in esophageal cancer, many surgeons have opted to treat T2 N0 disease with induction therapy, even though one-quarter of these patients will be pathologic T1 N0. Although this study demonstrated similar perioperative morbidity and mortality with and without induction therapy, further study is needed to examine the effect of upstaging on long-term survival.

Keywords: 7; ASA; American Society of Anesthesiologists; CI; CROSS; CT; Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study; EMR; EUS; FN; FNA; FP; G1; G2; G3; G4; GTSDB; General Thoracic Surgery Database; Gx; NPV; Negative predictive value; OR; PET; PPV; Pathologic staging; Positron emission tomography; SD; STS; Society of Thoracic Surgeons; TN; TP; True positive; c; clinical staging; computed tomography; confidence interval; esophageal mucosal resection; esophageal ultrasound; false negative; false positive; fine needle aspiration; grade moderately differentiated; grade poorly differentiated; grade undetermined; grade undifferentiated; grade well differentiated; odds ratio; p; positive predictive value; standard deviation; true negative.

Figure 1

Incidence of Clinical T2N0 Diagnosis and Rate of Induction Therapy Given to Patients with cT2N0 Esophageal Cancer