Original article
General thoracic
Proposed Modification of Nodal Status in AJCC Esophageal Cancer Staging System

Presented at the Fifty-third Annual Meeting of the Southern Thoracic Surgical Association, Tucson, AZ, Nov 8–11, 2006.
https://doi.org/10.1016/j.athoracsur.2007.01.067Get rights and content

Background

The current American Joint Committee on Cancer (AJCC) esophageal cancer staging for nodal status is difficult to interpret and is based solely on lymph node location relative to the primary tumor’s esophageal location. Recent reports suggest that the number of lymph nodes involved is also an important factor. We reviewed our esophageal experience to propose an improved nodal staging system.

Methods

In all, 1,027 patients with resected esophageal cancer from 1970 to 2005 were reviewed. Lymph nodes stations were assigned according to AJCC criteria. Overall survival was assessed by Kaplan-Meier analysis. The impact of location, number of involved lymph nodes, and use of preoperative chemotherapy or radiation therapy, or both, was assessed.

Results

Nonregional nodal involvement (n = 17) was associated with decreased survival compared with regional (n = 441) or celiac nodal (n = 73) involvement (3-year: 0% versus 24% and 23%; p < 0.001). The number of involved lymph nodes was strongly associated with survival (3-year: 0 nodes = 63%, 1 to 3 nodes = 31%, more than 3 nodes = 13%; p < 0.001), and multivariable Cox proportional-hazards analysis suggested that the location and number of involved lymph nodes were independent predictors of survival (p < 0.001). We propose a modified nodal staging system that designates celiac nodes as regional and includes number of involved nodes: pN0, no nodes (3 years = 63%, n = 496); pN1-regional, 1 to 3 nodes (3 years = 32%, n = 292); pN2-regional, more than 3 nodes (3 years = 14%, n = 222); pN3-nonregional node (3 years = 0%, n = 17 [p < 0.0001]). This modified nodal staging system better predicts survival than the current AJCC nodal staging system in which survival for pN1 (3 years = 24%) and pM1a (3 years = 23%) do not differ (p = 0.67). The use of induction before surgical resection did not alter the predictive effect of the new nodal staging system.

Conclusions

Modification of the AJCC nodal classification system to incorporate the number of involved lymph nodes with regional and nonregional node location simplifies and better predicts long-term survival than does the current AJCC nodal system.

Section snippets

Patients

This study included 1,027 patients with histologically confirmed invasive squamous cell carcinoma or adenocarcinoma of the esophagus and gastroesophageal junction who had a minimum of four resected lymph nodes. There were 595 patients who received neoadjuvant therapy, and 432 were treated with surgery alone. All patients were resected with curative intent at the University of Texas M. D. Anderson Cancer Center (MDACC) between 1970 and 2005. Patients who did not survive longer than 30 days were

Patient and Survival Characteristics

The study population included all patients who had squamous cell carcinoma or adenocarcinoma treated from 1970 to 2005 who underwent esophageal resection at MDACC. Mean potential follow-up for the group was 145 months (range, 7.2 to 442). Demographics of the sample group are depicted in (Table 1). As expected for this group of North American patients, the vast majority were male with adenocarcinoma of the distal esophagus or gastroesophageal junction. Pathologic downstaging after neoadjuvant

Comment

The current AJCC esophageal cancer staging system is based on a T (tumor depth), N (regional nodal statues), and M (nonregional nodes or systemic metastases) staging classification [2]. Although the staging system currently in place is good at predicting long-term survival, as indicated by our data, modifications to the system results in more ordered differentiation of stages and eliminates some of the complicated features of the N and M portions of the TNM system. Revision of the esophageal

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