Prevalence and Risk Factors for Malignant Nodal Involvement in Early Esophago-Gastric Adenocarcinoma: Results From the Multicenter Retrospective Congress Study (endosCopic resectiON, esophaGectomy or Gastrectomy for Early Esophagogastric Cancers)

Abstract

Objective: The aim of this study was to quantify lymph node metastasis (LNM) risk and outcomes following treatment of early esophago-gastric (EG) adenocarcinoma.

Background: The standard of care for early T1N0 EG cancer is endoscopic resection (ER). Radical surgical resection is recommended for patients perceived to be at risk of LNM. Current models to select organ-preserving versus surgical treatment are inconsistent.

Methods: CONGRESS is a UK-based multicenter retrospective cohort study. Patients diagnosed with clinical or pathological T1N0 EG adenocarcinoma from 2015 to 2022 were included. Outcomes and rates of LNM were assessed. Cox regression was performed to assess the impact of prognostic and treatment factors on overall survival.

Results: A total of 1601 patients from 26 centers were included, with median follow-up 32 months (IQR 14-53). 1285/1612 (80.3%) underwent ER, 497/1601 (31.0%) underwent surgery. Overall rate of LNM was 13.5%. On ER staging, tumour depth (T1bsm2-3 17.6% vs T1a 7.1%), lymphovascular invasion (17.2% vs 12.6%), or signet cells (28.6% vs 13.0%) were associated with LNM. In multivariable regression analysis, these were not significantly associated with LNM rates or survival. Adjusting for demographic and tumour variables, surgery after ER was associated with significant survival benefit, HR 0.33 (0.15-0.77), P =0.010.

Conclusions: This large multicenter data set suggests that early EG adenocarcinoma is associated with significant risk of LNM. These data are representative of current real clinical practice with ER-based staging, and suggests previously held beliefs regarding reliability of predictive factors for LNM may need to be reconsidered. Further research to identify patients who may benefit from organ-preserving versus surgical treatment is urgently required.

FIGURE 1

Flowchart of patients meeting inclusion criteria and treatment pathway. ER indicates endoscopic resection.

FIGURE 2

Flowchart illustrating differences between ER and final (surgical) pathology for patients undergoing initial ER followed by surgery. Individual plots for T stage, worst tumor differentiation grade, and LVI. Patients with initial R1 ER margins excluded from this analysis.

FIGURE 3

Observed nodal metastasis risk in patients undergoing surgery after endoscopic resection. Rates of nodal metastasis in surgical specimen, stratified by T stage, differentiation, and lymphovascular invasion seen on endoscopic resection specimen. Percentages with absolute numbers in parentheses. Numbers do not equate to total surgical volume as patients not included here if any missing histological data or initial pathology showed dysplasia only.