Proposed Modification of Nodal Status in AJCC Esophageal Cancer Staging System

doi:10.1016/j.athoracsur.2007.01.067

HOME

HELP

FEEDBACK

SUBSCRIPTIONS

Original Articles: General Thoracic

Proposed Modification of Nodal Status in AJCC Esophageal Cancer Staging System

Wayne Hofstetter, MD^a^,_*, Arlene M. Correa, PhD^a, Neby Bekele, PhD^e, Jaffer A. Ajani, MD^b, Alexandria Phan, MD^b, Ritsuko R. Komaki, MD^c, Zhongxing Liao, MD^c, Dipen Maru, MD^d, Tsung T. Wu, MD^d, Reza J. Mehran, MD^a, David C. Rice, MD^a, Jack A. Roth, MD^a, Ara A. Vaporciyan, MD^a, Garrett L. Walsh, MD^a, Ashleigh Francis, BS^a, Shanda Blackmon, MD^a, Stephen G. Swisher, MD^a

^a Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
^b Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
^c Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
^d Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
^e Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas

Accepted for publication January 29, 2007.

^_* Address correspondence to Dr Hofstetter, University of Texas MD Anderson Cancer Center, Department of Thoracic and Cardiovascular Surgery, Esophageal Cancer Program, 1515 Holcombe Blvd, Box 445, Houston, TX 77030 (Email: whofstetter{at}mdanderson.org).

Presented at the Fifty-third Annual Meeting of the Southern Thoracic Surgical Association, Tucson, AZ, Nov 8–11, 2006.

Background: The current American Joint Committee on Cancer (AJCC) esophagealcancer staging for nodal status is difficult to interpret andis based solely on lymph node location relative to the primarytumor’s esophageal location. Recent reports suggest thatthe number of lymph nodes involved is also an important factor.We reviewed our esophageal experience to propose an improvednodal staging system.

Methods: In all, 1,027 patients with resected esophageal cancer from1970 to 2005 were reviewed. Lymph nodes stations were assignedaccording to AJCC criteria. Overall survival was assessed byKaplan-Meier analysis. The impact of location, number of involvedlymph nodes, and use of preoperative chemotherapy or radiationtherapy, or both, was assessed.

Results: Nonregional nodal involvement (n = 17) was associated with decreasedsurvival 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 withsurvival (3-year: 0 nodes = 63%, 1 to 3 nodes = 31%, more than3 nodes = 13%; p < 0.001), and multivariable Cox proportional-hazardsanalysis suggested that the location and number of involvedlymph nodes were independent predictors of survival (p <0.001). We propose a modified nodal staging system that designatesceliac nodes as regional and includes number of involved nodes:pN0, no nodes (3 years = 63%, n = 496); pN1-regional, 1 to 3nodes (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 systembetter predicts survival than the current AJCC nodal stagingsystem in which survival for pN1 (3 years = 24%) and pM1a (3years = 23%) do not differ (p = 0.67). The use of inductionbefore surgical resection did not alter the predictive effectof the new nodal staging system.

Conclusions: Modification of the AJCC nodal classification system to incorporatethe number of involved lymph nodes with regional and nonregionalnode location simplifies and better predicts long-term survivalthan does the current AJCC nodal system.