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Original Articles: General Thoracic

Clinical T2-T3N0M0 Esophageal Cancer: The Risk of Node Positive Disease

Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York

Accepted for publication April 1, 2011.

^_* Address correspondence to Dr Stiles, Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Ste M404, Weill Medical College of Cornell University, 525 E 68th St, New York, NY 10021 (Email: brs9035{at}med.cornell.edu).

Presented at the Forty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2011.

Background: No consensus exists on the optimal treatment strategy for clinical T2-T3N0M0 esophageal cancer. This study was conducted to determine rates of nodal positivity (N+) and to evaluate results of treatment strategies in this cohort.

Methods: Surgically treated patients with cT2-T3N0M0 esophageal cancer were reviewed. Adequacy of lymph node dissection was assessed by guidelines applied to clinical stage. Survival was determined by Kaplan-Meier analysis. Univariate and multivariate analyses were done for predictors of N+ and survival.

Results: We identified 102 patients, 51 cT2N0 and 51 cT3N0, 39 (38%) of whom had induction therapy. Despite being clinically node negative, 61 patients (60%) had nodal metastases. Applied to cT classification, adequate nodal dissection was achieved in 64 patients (63%). Transthoracic esophagectomy was more likely than transhiatal esophagectomy to achieve adequate nodal dissection (69% versus 31%, p = 0.005). Adequate nodal dissection was more likely to document pN+ disease in both the surgery alone group (70% versus 50%, p = 0.13) and induction therapy group (71% versus 33%, p = 0.02). Five-year overall survival was 44% with surgery alone and 55% with induction therapy. On multivariate analysis, pN+ was the strongest predictor of overall survival (relative risk 2.73, confidence interval: 1.29 to 5.78).

Conclusions: Most cT2-T3N0M0 patients have pN+ disease. Despite induction therapy, more than 50% have persistent nodal disease. Transthoracic esophagectomy is more likely to detect pN+ disease and more likely to meet criteria of adequate nodal dissection than is transhiatal esophagectomy. Therefore, the majority of patients with cT2-T3N0M0 should be considered for neoadjuvant protocols and should be treated by transthoracic resection whenever possible.

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