Strategies and technical key points of lymph node dissection along the left recurrent laryngeal nerve in robot-assisted esophagectomy / 中华消化外科杂志

Esophagectomy and lymph node dissection are the cornerstones for the treatment of esophageal cancer. Upper mediastinal lymph node dissection is of great value for accurate staging and improving the prognosis of patients. Lymph node dissection along the left recurrent laryngeal nerve is the most challenging procedures in esophageal surgery, and there has been no relevant consensus on the scope and boundary of lymph node dissection. In recent years, with the application of endoscopic technology, especially robotic surgery system in esophagectomy, and the introduction of the concept of superior mediastinal microdissection, the authors have proposed the border of lymph node dissection along the left recurrent laryngeal nerve, so as to achieve precise, radical and standardized dissection. Combined with their own experiences, the authors elaborate on the anatomic boundary, extent and technique of lymph node dissection along the left recurrent laryngeal nerve.

Impact of the number of lymph node examined on the prognosis of esophageal squamous cell carcinoma / 中华消化外科杂志

Objective To investigate the effect of the number of lymph nodes examined (NLNE) on the prognosis of esophageal squamous cell carcinoma (ESCC).Methods The retrospective case-control study was conducted.The clinicopathological date of 628 ESCC patients who underwent radical resection in the Tianjin Medical University Cancer Institute and Hospital from January 2005 to March 2013 was collected.Patients underwent radical resection of ESCC through right thorax.Observation indicators:(1) surgical and postoperative pathological examinations;(2) follow-up and survival situations;(3) effect of NLNE on the prognosis of ESCC;(4) factors analysis affecting prognosis of ESCC patients;(5) subgroup analysis.Follow-up using outpatient examination,telephone interview and mail was performed to detect postoperative survival up to February 2018.Measurement data with skewed distribution were described as M (range).Receiver operating characteristic (ROC) curve analysis was used to determine the appropriate cut-off of the NLNE.The survival curve and survival rate were respectively drawn and calculated by the Kaplan-Meier method,and the survival analysis was done by the log-rank test.Multivariate analysis was done by the Cox proportional hazard model.Results (1) Surgical and postoperative pathological examinations:472 and 156 patients underwent respectively Ivor-Lewis and Mckeown operations.There were 284 patients with tumor diameter ≤ 3.5 cm and 344 patients with tumor diameter ＞ 3.5 cm.The total NLNE was 11 139 for all of the 628 patients,with an average NLNE of 18 per case(range,2-78 per case) and a median NLNE of 16 per case.Of 628 patients,high-,moderate-and low-differentiated tumors were respectively detected in 48,469 and 111 patients;staging T0-1,T2,T3 and T4a of depth of tumor invasion in 30,119,260 and 219 patients;N0,N1,N2 and N3 of degree of lymph node metastasis in 349,173,69 and 37 patients;rN0,rN1,rN2 and rN3 of rate of lymph node metastasis in 349,184,54 and 41 patients.(2) Follow-up and survival situations:all the 628 patients were followed up for 3-144 months,with a median time of 36 months.The 1-,3-and 5-year survival rates were 82.4％,53.7％ and 41.3％,respectively.(3)Effect of NLNE on the prognosis of ESCC:ROC curve showed that the appropriate cut-off value of the NLNE was 16.Using NLNE =16 as a cut-off value,5-year survival rate was respectively 36.7％ in patients with NLNE ＜ 16 and 45.1％ in patients with NLNE ≥ 16,with a statistically significant difference in survival (x2 =9.527,P＜0.05).According to a median NLNE of 23,the patients with NLNE ≥ 16 were further divided into patients with 16 ≤ NLNE ≤ 23 and NLNE ＞ 23.Results showed that 5-year survival rate in patients with NLNE ＜ 16,16 ≤ NLNE ≤ 23 and NLNE ＞ 23 was respectively 36.7％,41.2％ and 50.3％,with a statistically significant difference in survival among them (x2 =10.588,P＜0.05),between patients with NLNE ＜ 16 and 16 ≤ NLNE ≤ 23 (x2 =4.419,P＜0.05).There was no statistically significant difference between patients with 16 ≤ NLNE ≤ 23 and NLNE ＞ 23 (x2 =1.413,P＞0.05).Five-year survival rate in patients with NLNE ≤ 23 and NLNE ＞23 was respectively 38.6％ and 50.3％,with a statisctically significant difference (x2 =5.885,P＜0.05).(4)Factors analysis affecting prognosis of ESCC patients:results of univariate analysis showed that age,smoking history,BMI,tumor diameter,NLNE,depth of tumor invasion,degree and rate of lymph node metastasis were related factors affecting the prognosis of ESCC patients (x2 =5.454,4.875,7.669,10.691,10.588,30.612,59.780,76.565,P＜0.05).Results of muhivariate analysis showed that age,tumor diameter,NLNE,depth of tumor invasion and rate of lymph node metastasis were independent factors affecting the prognosis of ESCC patients [HR=1.268,1.300,0.762,1.354,1.357,95％ confidence interval (CI):1.034-1.556,1.038-1.629,0.662-0.878,1.183-1.549,1.089-1.692,P＜0.05].(5) Subgroup analysis:among 279 patients with lymph node metastasis,5-year survival rate in patients with NLNE ＜ 16,16 ≤ NLNE ≤ 23 and NLNE ＞ 23 was respectively 23.7％,19.4％ and 39.5％,with a statistically significant difference among them (x2 =8.397,P＜0.05),between patients with 16≤ NLNE ≤ 23 and NLNE ＞ 23 (x2=5.425,P＜0.05).There was no statistically significant difference between patients with NLNE ＜ 16 and 16 ≤ NLNE ≤ 23 (x2 =0.389,P＞ 0.05).Five-year survival rate in patients with NLNE ≤ 23 and NLNE ＞ 23 was respectively 21.9％ and 39.5％,with a statisctically significant difference (x2=7.942,P＜ 0.05).Among 349 patients without lymph node metastasis,5-year survival rate in patients with NLNE ＜ 16,16 ≤ NLNE ≤ 23 and NLNE ＞ 23 was respectively 45.6％,60.3％ and 59.2％,with a statistically significant difference among them (x2 =9.755,P＜0.05) and between patients with NLNE ＜ 16 and 16 ≤ NLNE ≤ 23 (x2 =8.208,P＜0.05).There was no statistically significant difference between patients with 16 ≤ NLNE ≤ 23 and NLNE ＞ 23 (x2 =0.284,P＞0.05).Five-year survival rate in patients with NLNE ≤ 23 and NLNE ＞ 23 was respectively 51.1％ and 59.2％,with no statisctically significant difference (x2 =1.147,P＞ 0.05).Conclusions The NLNE is an independent factor affecting the prognosis of ESCC patients,and at least 16 to 23 lymph nodes should be dissected.For patients with lymph node metastasis,and more than 23 lymph nodes should be dissected.For patients without lymph node metastasis,more than 23 lymph nodes dissection cannot obviously improve the prognosis of patients.

Comparison of the prognostic value of the seventh and eighth edition of The AJCC Esophageal Cancer Staging System for the patients with stage Ⅱ and Ⅲesophageal squamous cell carcinoma / 中华外科杂志

Objective@#To compare and evaluate the prognostic value of the 7th and 8th edition of The AJCC Esophageal Cancer Staging System for patients with stage Ⅱ and Ⅲ esophageal squamous cell carcinoma.@*Methods@#The clinical data of 328 esophageal cancer patients who received operation at Department of Esophageal Cancer, Tianjin Tumour Hospital from January 2006 to December 2010 were restrospectively analyzed. There were 63 female and 265 male patients. The mean age was 65 (range: 33 to 87) years. Univariate and multivariate analysis were performed to identify the prognosis factors.@*Results@#The five years overall survival rates among patients with stage Ⅱ and Ⅲ were both significantly different (χ2=87.035, 84.730, all P=0.000) according to the 7th and 8th editions of the TNM staging systems. The five years overall survival rate among patients with stage ⅡB and ⅢA were significantly different (39.6% vs 23.4%, P=0.001) according to the 7th edition of the esophageal cancer staging systems.According to the 8th edition of the esophageal cancer staging system, the 5 years survival rate of patients with stage ⅡA and ⅡB, ⅢB and Ⅳ was statistically significant (58.5% vs. 35.5%, P=0.040; 18.9% vs. 0, P=0.000). In multivariate analysis, tumor size, T staging, N staging and tumor differentiation (HR=1.592, 95%CI: 1.185 to 2.139, P=0.002; HR=1.519, 95% CI: 1.236 to 1.867, P=0.000; HR=1.647, 95% CI: 1.448 to 1.874, P=0.000; HR=1.404, 95% CI: 1.059 to 1.861, P=0.018) were the main independent prognosis factors affecting the prognosis of esophageal squamous cell carcinoma patients.@*Conclusions@#Both the 7th and the 8th editions of TNM staging systems are able to reflect the clinical prognosis of patients receiving radical resection of esophageal cancer, and the factors of tumor size, differentiaton, invasion depth and lymph node metastases are the independent predictors of prognosis. The 8th edition provides a more detailed and more reasonable for the staging of stage Ⅱ and Ⅲ for esophageal cancer patients than the 7th edition, and it is more accurate for the prognosis of patients with esophageal cancer after surgery.

Predictive value of log odds of positive lymph nodes for the prognosis of patients with node-negative squamous cell carcinoma of the thoracic esophagus after radical esophagectomy / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the log odds of positive lymph nodes(LODDS) on the prognosis of patients with node-negative squamous cell carcinoma of the thoracic esophagus after radical esophagectomy.</p><p><b>METHODS</b>Clinical data of 136 patients with node-negative squamous cell carcinoma of the thoracic esophagus after radical esophagectomy from January 2005 to January 2009 were retrospectively analyzed. LODDS was estimated using the calculation: log(pnod+0.5)/(tnod-pnod+0.5), in which pnod indicates the number of positive lymph nodes and tnod indicates the total number of lymph nodes retrieved. The best cut-off value for LODDS was identified by using the receiver operating characteristic (ROC) curve. Drawing of survival curves was employed with the Kaplan-Meier estimator, and survival rate was analyzed using Log-rank test. The Cox proportional hazard model was used to identify independent factors associated with prognosis.</p><p><b>RESULTS</b>A total of 136 patients, including 112 males and 24 females, seventy-nine patients were 65 years or older(range 27-92 years), and were included in the present study. Among them, the most cancer site was the middle third of the thoracic esophagus(115 cases), followed by the lower third(13 cases), and the upper third(8 cases). There were 70 patients with tumor diameter ≤3.5 cm and 66 patients with tumor diameter >3.5 cm. There were 32 patients with stage pT1-2, and 104 with stage pT3-4. The number of patients in TNM classification I, II and III was 14, 85 and 37, respectively. All the patients received radical esophagectomy with primary tumor resection and lymph node dissection. The median follow-up time was 44.2 months(range, 4.4-98.4 months). Five-year overall survival rate was 43.2%, and the median total survival time was 48 months. ROC analysis showed that the appropriate cut-off value of LODDS was -1.2. There were 99 patients with LODDS≤-1.2(LODDS1 stage), 37 patients with LODDS >-1.2(LODDS2 stage), the median survival time and 5-year survival rate were 56.5 months and 48.3% in patients with LODDS1 stage and 30.0 months and 29.7% in patients with LODDS 2 stage, respectively, with significant difference(χ(2)=4.980, P=0.026). Multivariate analyses showed that recurrence(HR=0.627, 95% CI:0.395 to 0.996; P=0.048) and LODDS >-1.2(HR=1.853; 95% CI:1.155 to 2.974; P=0.011) were the independent factors affecting the prognosis of patients.</p><p><b>CONCLUSIONS</b>For patients with node-negative squamous cell carcinoma of the thoracic esophagus after radical esophagectomy, LODDS stage has a unique prediction for prognosis, and patients with LODDS less than -1.2 (cut-off value) have a better prognosis.</p>

Characteristics and risk factors of lymph node metastasis in pN1 stage esophageal squamous cell carcinoma / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze the pattern and the clinicopathologic risk factors of lymph node metastasis (LNM) in pN1 stage esophageal squamous cell carcinoma.</p><p><b>METHODS</b>Clinical data of 181 patients (154 male and 27 female patients, aging from 38 to 84 years) who underwent esophagectomy during January 2005 and December 2008 were reviewed, including 69 cases through left thoracotomy and 112 cases through right thoracotomy. All patients underwent systematic lymphadenectomy. The risk factors related to lymph node metastasis were analyzed by χ² test and Logistic regression analysis.</p><p><b>RESULTS</b>The relatively highest LNM site were middle and lower thoracic paraesophageal (38.4%), right and left cardiac (35.3%) and the left gastric artery (38.8%). The LNM of middle and lower thoracic paraesophageal was correlated with T stage (χ² =11.754, P=0.009). A correlation was also found among the LNM of upper mediastinum and the location of tumor (P=0.039). The T stage (χ² =8.694, P=0.034) and TNM stage (χ² =6.906, P=0.032) were the risk factors of the LNM of middle and lower mediastinum. The risk factors of the LNM of abdomen were the location of tumor, the length of tumor, T stage and TNM stage (χ² =5.713 to 16.749, P>0.05). Multivariate analysis showed that the location of tumor is the independent risk factors for the abdominal lymph node metastasis.</p><p><b>CONCLUSIONS</b>The relatively highest LNM sites are correlated with the location of tumor, T stage, the length of tumor and TNM stage. According to the risk factors of LNM, the relatively highest LNM sites should be mainly swept.</p>

Clinical features and risk factors of anastomotic leakage after radical esophagectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze the clinical features and risk factors of anastomotic leakage after radical esophagectomy of esophageal carcinoma.</p><p><b>METHODS</b>The clinical data of 547 esophageal cancer patients underwent radical esophagectomy in Tianjin Medical University Cancer Hospital from January 2012 to December 2013 was analyzed retrospectively. There were 421 male and 126 female patients, with a median age of 65 years (ranging from 29 to 82 years). There were 155 cases of upper esophageal carcinoma, 340 cases of middle esophageal carcinoma and 52 cases of lower esophageal carcinoma. The surgical procedures included 41 cases completed through Sweet, 145 cases completed through McKeown, 279 cases completed through Ivor Lewis, 82 cases completed through minimally invasive esophagectomy. Moreover, 24 of 547 cases underwent preoperative neoadjuvant radiochemotherapy. χ² test and Cox's proportional hazards regression model were used for univariate analysis and multivariate analysis of the risk factors of postoperative anastomotic leakage.</p><p><b>RESULTS</b>Twenty-seven of 547 cases with esophagectomy occurred anastomotic leakage and the incidence rate was 4.94% (27/547). One of 27 cases died and the mortality rate was 3.70% (1/27). The time of anastomotic leakage found was 4 to 45 days, with a median time of 10 days. There were 0 case of early leakage, 20 cases of mid-term leakage, 7 cases of late leakage. Three of 27 cases with anastomotic leakage had tracheoesophageal fistula, while 3 cases had contralateral pleural fistula. As to the incidence rate of anastomotic leakage, there was statistically significant difference between cervical anastomotic leakage (8.14%, 18/221) and intrathoracic anastomotic leakage (2.76%, 9/326) (χ² =7.41, P=0.000), among Sweet (4.88%, 2/41), McKeown (9.66%, 14/145), Ivor Lewis (2.51%, 7/279) and MIE (4.88%, 4/82) (χ² =21.48, P=0.000), and between with (16.67%, 4/24) and without (4.40%, 23/523) neoadjuvant radiochemotherapy (χ² =9.20, P=0.000). The multivariate analysis showed that anastomotic site (HR=2.594, P=0.048), surgical approach (HR=5.689, P=0.003) and preoperative neoadjuvant radiochemotherapy (HR=3.604, P=0.027) are independent risk factors for anastomotic leakage after esophagectomy.</p><p><b>CONCLUSIONS</b>The mid-term anastomotic leakage after esophagectomy occurs higher. McKeown is a main surgical procedure and neoadjuvant radiochemotherapy is an important factor for the anastomotic leakage.</p>

Analysis of early lymph node metastasis pattern and prognosis in thoracic esophageal squamous cell carcinoma / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the pattern of early lymph node metastasis of thoracic esophageal squamous cell carcinoma and its prognostic value.</p><p><b>METHODS</b>Clinical and follow-up data of 126 patients with pathological stage pN1 of esophageal squamous cell carcinoma undergoing radical esophagectomy in our department from January 2005 to December 2008 were analyzed retrospectively. Impact of lymph node metastasis pattern on prognosis was investigated.</p><p><b>RESULTS</b>The relatively common sites of lymph node metastasis were upper mediastinum(53.8%), middle and lower thoracic paraesophageal(38.3%), right and left cardiac(34.4%) and the left gastric artery(36.8%). Univariate analysis showed that the lymph node metastasis of subcarinal, middle and lower thoracic paraesophageal and the left gastric artery was associated with 5-year survival rate. Multivariate analysis revealed that the presence of subcarinal and middle and lower thoracic paraesophagea lymph node metastasis was an independent risk factor of survival.</p><p><b>CONCLUSIONS</b>Upper mediastinal, middle and lower thoracic paraesophageal, right and left cardiac and the left gastric artery are the earliest lymph node metastasis sites of esophageal squamous cell carcinoma. The presence of subcarinal and middle and lower thoracic paraesophagea lymph node metastasis is an independent risk factor of survival. Patient prognosis should be analyzed with lymph node metastasis pattern based on the 7th edition UICC-AJCC TNM classification system.</p>

Effect of number of metastatic lymph nodes and metastatic lymph node ratio on the prognosis in patients with adenocarcinoma of the esophagogastric junction after curative resection / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To analyze the effects of number of positive lymph nodes and metastatic lymph node ratio (LNR) in evaluation of recurrence risk and overall survival in patients with adenocarcinoma of the esophagogastric junction (AEG) after curative resection.</p><p><b>METHODS</b>Clinical data of 337 AEG patients who underwent curative resection in our hospital were retrospectively reviewed. The pN stage was categorized based on the number of metastatic lymph nodes and LNR stage, and was determined by the best cutoff approach at log-rank test. Univariate Kaplan-Meier survival analysis and multivariate Cox proportional hazard model were used to analyze the effects of pN and LNR on recurrence-free survival and overall survival of these patients. Receiver operating characteristic (ROC) curves were plotted to compare the accuracy of prognosis prediction with pN and LNR.</p><p><b>RESULTS</b>The 5-year recurrence-free survival rate and overall survival rate for all patients were 25.5% and 29.9%, respectively. The 5-year recurrence-free survival rates were 47.6%, 23.2%, 17.1% and 5.7% for pN0, pN1, pN2, and pN3, respectively, (P < 0.001) and the 5-year overall survival rates were 53.3%, 28.9%, 18.9% and 7.3%, respectively (P < 0.001). The 5-year recurrence-free survival rates were 47.6%, 24.3%, 11.4% and 2.0% for LNR0, LNR1, LNR2, and LNR3, respectively (P < 0.001), and the 5-year overall survival rates were 53.3%, 28.5%, 15.0%, 2.6%, respectively (P < 0.001). Univariate analysis showed that tumor size, macroscopic type, degree of differentiation, pT, pN, LNR and TNM stage were significantly associated with RFS and OS (P < 0.05). Cox multivariate analysis showed that either pN or LNR was independent risk factor for RFS and OS (P < 0.001). When pN and LNR were entered into the Cox hazard ratio model as covariates at the same time, LNR remained as an independent prognosis factor for RFS and OS (P < 0.001), but pN was not (P > 0.05). ROC curves showed that the area under the curve of LNR stage was larger than that of pN stage in prediction of both RFS and OS, however the differences were not statistically significant (P > 0.05).</p><p><b>CONCLUSIONS</b>LNR is an independent risk factor associated with the prognosis of AEG patients. The value of LNR in prediction of recurrence hazard and overall survival was better than that of pN stage. It offers some helpful suggestions for AEG patients risk classification, allowing clinicians to develop a reasonable treatment.</p>

Relative factors of recurrence and metastasis of advanced adenocarcinoma of the esophagogastric junction after curative resection / 中华消化外科杂志

Objective To investigate the correlation between different clinicopathological factors and the recurrence and metastasis of advanced adenocarcinoma of the esophagogastric junction after curative resection,and to analyze the effects of the factors on the prognosis of these patients.Methods The clinical data of 385 patients with advanced adenocarcinoma of the esophagogastric junction who received curative resection at the Affiliated Hospital of Tianjin Medical University from January 2000 to January 2007 were retrospectively analyzed.There were 228 patients did not have tumor recurrence and metastasis (non-recurrence and metastasis group) and 157 patients had tumor recurrence and metastasis (recurrence and metastasis group).Risk factors which might influence postoperative recurrence and metastasis were analyzed using univariate analysis (chi-square test) and multivariate analysis (Logistic regression model).All patients were followed up via out-patient examination or phone call.The survival curve was drawn by Kaplan-Meier method,and the survival analysis was done by Log-rank test.Results The median time for follow-up was 36 months (range,3-108 months).A total of 157 patients had postoperative tumor recurrence and metastasis,and the mean time of tumor recurrence was 17.9 mouths.The results of univariate analysis showed that tumor type,differentiation degree,invasion depth,number of positive and negative lymph nodes,TNM staging were risk factors for the postoperative recurrence and metastasis of adenocarcinoma of the esophagogastric junction after curative resection (x2=5.248,13.493,12.319,18.315,9.704,10.281,P ＜ 0.05).The results of multivariate analysis showed that differentiation degree,invasion depth,number of positive and negative lymph nodes were the independent risk factors influencing the recurrence and metastasis of adenocarcinoma of the esophagogastric junction after curative resection (OR =1.805,1.809,1.520,0.763,P ＜0.05).The numbers of positive lymph nodes in the non-recurrence and metastasis group and the recurrence and metastasis group were 3.86 ± 0.28 and 6.89 ± 0.58,with a significant difference (t =5.118,P ＜ 0.05).The number of negative lymph nodes in the non-recurrence and metastasis group and the recurrence and metastasis group were 14.04 ±0.54 and 10.53 ±0.56,with a significant difference between the 2 groups (t =4.386,P ＜0.05).The 5-year survival rates of patients with the numbers of positive lymph nodes of 0,1-2,3-6 and more than 7 were 46.4％,43.8％,27.1％ and 7.2％,respectively,and the corresponding median survival time were 53,47,35 and 26 months.There was a significant difference in the 5-year survival rate among patients with different numbers of positive lymph nodes (x2 =54.783,P ＜ 0.05).The 5-year survival rates of patients with the number of negative lymph nodes under 9,between 10 and 15 and more than 16 were 22.1％,21.5％ and 45.5％,respectively,and the corresponding median survival time were 28,34,47 months.There was a significant difference in the 5-year survival rate among patients with different numbers of negative lymph nodes (x2=22.814,P ＜ 0.05).Conclusions Tumor type,invasion depth,number of positive and negative lymph nodes are independent risk factors of postoperative recurrence and metastasis of adenocarcinoma of the esophagogastric junction,and the number of positive and negative lymph nodes are important for the prognosis of patients with adenocarcinoma of the esophagogastric junction.

Research advancement on BNIP3 in gastrointestinal cancer / 中国肿瘤临床

Apoptosis disorders have an important function in the development of gastrointestinal cancer. BNIP3 is a member of the BH3-only subfamily of the bcl-2 family, which contains a BH3 domain and a transmembrane domain, and belongs to the mitochon-drial pro-apoptotic proteins. BNIP3 induces cell death via the caspase-independent mitochondrial apoptotic pathway and mediates au-tophagic cell death. BNIP3 expression is regulated by hypoxia and other factors. BNIP3 expression in tumors exhibits tissue specificity;BNIP3 is highly expressed in some tumors, including breast, lung, and cervical tumors. In pancreatic, gastric, and colorectal cancers, BNIP3 is epigenetically silenced. The absence of BNIP3 in the tumors can cause tumor cells to tolerate hypoxia and may be associated with chemotherapy and radiotherapy resistance. A comprehensive understanding of the spectrum of BNIP3 expression in a various tu-mors is necessary to use BNIP3 as a marker in clinical applications to treat tumors and as a new target in tumor prognosis.

Expression of Krüppel-like factor 4 protein in esophageal squamous cell carcinoma and its clinical significance / 中华消化杂志

Objective To investigate the expression of Krüppel-like factor 4 (KLF4) protein in esophageal squamous cell carcinoma (ESCC) tissues and to explore its correlation with clinical pathological features as well as prognosis.Methods The expression of KLF4 protein in cancer tissues and normal esophageal tissues from surgical paraffin specimens of 98 thoracic ESCC cases with complete clinical,pathological and follow-up date were detected by immunohistochemistry.The expression of KLF4 at protein level in 20 freshly surgical esophageal cancer tissues and normal esophageal mucous tissues were examined by Western blot.The relation between the expression of KLF4 protein,clinicopathological characteristics and prognosis was analyzed,t-test was used for measurement data analysis.Chi-square test was performed to analyze the correlation between KLF4 protein expression and clinicopathological features.Survival analysis was analyzed by the Kaplan-Meier method.The comparisons of survival rates were analyzed by Log-rank test.Results The positive rate of KLF4 protein expression in normal esophageal tissues and ESCC tissues was 82.7％ (81/98) and 43.9％ (43/98),respectively,the difference was statistically significant (x2=31.701,P＜0.01).The expression of KLF4 at protein level in 20 cases of fresh esophageal cancer tissues and normal esophageal mucosa tissues was 0.576±0.050 and 0.684 ± 0.095,respectively,the difference was statistically significant (t =4.932,P＜0.01).The expression of KLF4 at protein level was correlated with lymph node metastasis and TNM stage (x2 =10.871 and 6.482,P=0.001 and 0.039),however not correlated with gender,age,location,tumor size,degree of differentiation and the depth of invasion (x2=0.214,3.442,5.748,0.891,0.013 and 1.479,P=0.644,0.064,0.056,0.345,0.911 and 0.477).In 98 patients,the 5-year survival rate of cases with KLF4 protein positive expression and negative expression was 48.8％ and 25.5％ and the median survival period was 55 months and 26 months,the differences were statistically significant (x2 =5.747 and 4.493,P=0.017 and 0.034).Conclusion KLF4 as a tumor suppressor gene may play an important role in the genesis,development and metastasis of ESCC,and may become a biological indicator of the severity and prognosis in ESCC.