International Multicenter Study on the Impact of Extracapsular Lymph Node Involvement in Primary Surgery Adenocarcinoma of the Esophagus on Overall Survival and Staging Systems.

OBJECTIVE: The current pathological lymph node (pN) staging is based on the number of positive lymph nodes but does not take into consideration characteristics of the involved lymph nodes itself. The current study aims to examine the prognostic value of extracapsular lymph node involvement (EC-LNI) and intracapsular lymph node involvement (IC-LNI) for esophageal adenocarcinoma treated by primary surgery. METHODS: From the databases of five European high volume centers, 1639 adenocarcinoma patients with primary R0-resection were withheld after excluding 90-day mortality. Oncologic variables, including number of resected lymph nodes, number of resected positive lymph nodes, and EC-LNI/IC-LNI were examined. The Union Internationale contre le Cancer (UICC) 7th edition prognostic staging was used as baseline staging system. Statistical analysis was performed by Cox proportional hazards modeling and verified using the Random Survival Forest technique. RESULTS: EC-LNI showed significantly worse overall 5-year survival compared with IC-LNI overall (13.4% vs 37.2%, P < 0.0001), including in each pN-category [16.4% vs 45.6% in pN1 (P < 0.0001), 16.1% vs 23.8% (P = 0.047) in pN2 (P = 0.065), and 8.7% vs 26.3% in pN3 categories, respectively]. pN1 IC-LNI patients show a 5-year overall survival comparable (P = 0.92) with stage IIB (ie, pT3N0). Reclassifying the UICC prognostic stages according to these findings into an adapted staging model showed a significant (P < 0.0001) increase in homogeneity, discriminatory ability, and monotonicity compared with the original UICC TNM 7th edition prognostic staging. CONCLUSIONS: These data suggest that lymph node capsular status is an important prognostic factor and should be considered for the future edition of the TNM staging system for esophageal cancer.

Signet ring cells in esophageal and gastroesophageal junction carcinomas have a more aggressive biological behavior.

OBJECTIVE: To clarify the biologic behavior of esophageal signet ring cell (SRC) carcinomas of the esophagus and gastroesophageal junction (GEJ). To evaluate the accuracy of pretreatment biopsies in diagnosing true SRC carcinoma. BACKGROUND: In contrast with gastric cancer, little is known about the biologic behavior and prognosis of SRC. METHODS: All adenocarcinomas (ADC) of the esophagus and GEJ-patients undergoing primary resection between 1990 and 2009 were included (n = 920). Specimens containing SRCs (n = 114) were classified according to World Health Organization criteria (>50% SRC or <50% SRC). RESULTS: Thirty-two patients showed more than 50% SRC and 71 patients showed less than 50% SRC. Overall cancer-specific 5-year survival was worse for SRC (22.4%, P < 0.0001) and for SRC > 50% (13.6%, P = 0.0001) compared with ADC. Complete resection was achieved in 86.5% of patients (n = 697) in ADC, 69.5% (n = 57) in SRC < 50%, and 78.1% (n = 25) in SRC > 50% (vs ADC, respectively, P < 0.0001 and P = 0.1801). In 379 pN + R0 patients, the median number of positive lymph nodes was comparable between ADC and SRC < 50% (4 vs 5, P = 0.207) or SRC > 50% (4 vs 8, P = 0.077). Compared with ADC, SRC > 50% showed more pN3's (30% vs 61%, P = 0.006), higher recurrence (56% vs 42% for ADC, P = 0.003), and local-regional recurrences (29% vs 16%, P = 0.002). Pretreatment biopsies were unreliable to define the presence of SRC > 50% (sensitivity = 56.3%, positive predictive value = 43.9%). CONCLUSIONS: SRCs are aggressive neoplasms associated with poorer prognosis than other ADCs after primary esophagectomy. Because our data suggest that pretreatment biopsies failed to reliably define presence of SRC > 50%, presence of SRCs in pretreatment biopsies seems to be of no use to define treatment strategy or prognosis.

Endobronchial valves for persistent postoperative pulmonary air leak: accurate monitoring and functional implications.

An alveolar-pleural fistula is a communication between the pulmonary parenchyma distal to a segmental bronchus and the pleural space. A postoperative pulmonary expiratory air leak after an anatomic pulmonary resection is usually managed conservatively. The use of endobronchial valves is a minimal invasive method that may be effective for the treatment of a persistent postoperative pulmonary air leak. We present and discuss the advantages of a digital thoracic drainage system for the accurate, objective and reproducible air leak assessment during endobronchial valve placement. Our case also illustrates that, even after lobectomy, lobar exclusion with valves allows air leak resolution without atelectasis and with moderate functional alteration. We discuss the anatomic and physiologic changes induced by valves placed for air leak closure.

Additional value of whole-body fluorodeoxyglucose positron emission tomography in the detection of distant metastases of non-small-cell lung cancer.

The purpose of this work was to evaluate the additional value of whole-body positron emission tomography (WB-PET) in the distant staging of non-small-cell lung cancer (NSCLC). One hundred forty-four patients with NSCLC in whom conventional staging (CS) was negative or equivocal for metastases, and who underwent WB-PET as part of their initial work-up, were retrospectively analyzed. Conventional staging consisted of thoracic computed tomography (CT), upper abdominal ultrasound and/or CT, and bone scintigraphy or brain CT on indication. Final M stage was based on histology, additional imaging, or follow-up of = 18 months. An additional lesion suspect for metastasis was found on WB-PET in 11 patients. This was true positive in 7 (3 bone, 1 retroperitoneal lymph nodes, 1 lung, and 2 asymptomatic coexisting colorectal cancer) and false positive in 4 patients (3 bowel, 1 breast). Twenty-four lesions in 21 patients remained equivocal after CS. Whole- body PET correctly characterized 20 lesions in 18 patients as true positive (n = 1) or true negative (n = 19). Whole-body PET was false positive in one patient (adrenal adenoma) and false negative in 2 patients (2 bone, 1 lung lesion). Despite negative results of modern CS and WB-PET, 16 of 86 patients (19%) who underwent a curative resection, experienced a systemic relapse. After thorough modern CS, WB-PET correctly detected additional distant malignant lesions in only 5% of the patients, while the combined staging strategy probably still misses micrometastatic disease in one fifth of the patients. The most important contribution of WB-PET was its ability to exclude malignancy in the majority of distant lesions with equivocal CS.