Clinical outcomes and benefits for staging of surgical lymph node mapping after esophagectomy.

Dissection of lymph nodes (LN) immediately after esophagectomy is utilized by some surgeons to aid determination of LN stations involved in esophageal cancer. Some suggest that this increases LN yield and gives information regarding the pattern of lymphatic spread, others feel that this may compromise a circumferential resection margin (CRM) assessment. The aim of this study is to evaluate the effect of ex vivo dissection on the assessment of the CRM and the pattern of lymph node dissemination in patients with adenocarcinoma of the esophagus and gastroesophageal junction (GEJ) undergoing radical surgery after neoadjuvant chemotherapy and their prognostic impact. Data from consecutive patients with potentially curable adenocarcinoma of the distal esophagus and GEJ who received neoadjuvant treatment followed by surgery were analyzed. Clinical and pathological findings were reviewed and LN burden and location correlated with clinical outcome. Pathology specimens were dissected into individual LN groups 'ex-vivo' by the surgeon. A total of 301 patients were included: 295 had a radical proximal and distal resection margin however in 62(20.6%) CRM could not be assessed. A median of 33(10-77) nodes were recovered. A 117(38.9%) patients were ypN0 while 184(61.1%) were LN positive (ypN1-N3). LN stations close to the tumor were most frequently involved. Twenty-seven (14.7%) patients had only thoracic stations involved, 48(26.1%) only abdominal stations and 109 (59.2%) had both. Median survival for yN0 patients was 171 months compared to 24 months for those LN positive (P< 0.001). Multivariate analyses identified ypT-category, ypN-category, male gender, and nonradical resection (proximal or distal) margin as significant prognostic factors. Surgical dissection of nodes after esophagectomy enables accurate LN assessment, but may compromise CRM assessment in up to 20% of cases. It also provides valuable information regarding the pattern of nodal spread.

Prognostic impact of extracapsular lymph node involvement after neoadjuvant therapy and oesophagectomy.

BACKGROUND: The significance of extracapsular lymph node involvement (LNI) is unclear in patients with oesophageal cancer who have undergone neoadjuvant treatment followed by oesophagectomy. The aim of this study was to assess the incidence and prognostic significance of extracapsular LNI in a large multicentre series of consecutive patients with oesophageal cancer treated by neoadjuvant chemotherapy or chemoradiotherapy and surgery. METHODS: Data from a consecutive series of patients treated at two European centres were analysed. All patients with squamous cell carcinoma or adenocarcinoma of the oesophagus or gastro-oesophageal junction, who received neoadjuvant chemotherapy or chemoradiation followed by transthoracic oesophagectomy and two-field lymphadenectomy with curative intent, were included. RESULTS: Between January 2000 and September 2013, 704 patients underwent oesophagectomy after neoadjuvant therapy. A median of 28 (range 5-77) nodes per patient was recovered. Some 347 patients (49·3 per cent) had no LNI (ypN0). Of the remaining 357 patients (50·7 per cent) with LNI (ypN1-3), extracapsular LNI was found in 190 (53·2 per cent). Five-year overall survival rates were 62·7 per cent for patients with N0 disease, 44·9 per cent for patients without extracapsular spread and 14·0 per cent where extracapsular LNI was identified (P < 0·001). Multivariable analyses demonstrated the presence of extracapsular LNI as an independent prognostic factor. CONCLUSION: The presence of extracapsular LNI after neoadjuvant therapy carries a poor prognosis.

The presence of lymphovascular and perineural infiltration after neoadjuvant therapy and oesophagectomy identifies patients at high risk for recurrence.

BACKGROUND: In patients treated for oesophageal cancer the importance of lymphovascular and perineural invasion (PNI) after neoadjuvant therapy has yet to be established. The aim of this study was to assess the incidence and prognostic significance of these factors in a consecutive series of patients with cancer of the oesophagus or gastro-oesophageal junction (GOJ) who underwent neoadjuvant therapy followed by oesophagectomy. METHODS: Clinical and pathology results from patients with potentially curable adenocarcinoma, or squamous cell carcinoma of the oesophagus or GOJ were reviewed. Patients were treated with neoadjuvant chemotherapy or chemoradiation followed by transthoracic oesophagectomy and two-field lymphadenectomy. The presence of venous invasion (VI), lymph vessel invasion (LI) and perineural invasion (PNI) were correlated with clinical outcomes. RESULTS: A total of 396 patients underwent oesophagectomy after neoadjuvant therapy for oesophageal cancer. Venous invasion was identified in 150 (38%) of patients, LI in 203 (51%) patients and PNI in 204 (52%) patients. In all, 123 (31%) patients had no evidence of either VI, LI or PNI. A total of 96 (24%) had a combination of two factors and 94 (24%) had all three factors. The presence of VI, LI and PNI was significantly related to tumour stage (P=0.001). Median overall survival was 170.8 months when all three factors were absent, 44.0 months when one factor was present, 27.1 months when two factors were present and 16.0 months when all were present. Multivariate analyses revealed VI, LI and PNI or a combination of these factors were independent predictors of prognosis. CONCLUSIONS: In oesophageal cancer patients treated with neoadjuvant therapy followed by oesophagectomy the presence of VI, LI and PNI has an important prognostic impact and may identify patients at high risk of recurrence who would benefit from adjuvant therapies.

Immunohistochemical characterization of endometrial leucocytes in endometritis.

AIMS: Leucocytes are a normal and variable component of the endometrial stromal cell population. The aim of this study was to characterize endometrial leucocytes in established cases of endometritis in order to determine whether there are objective characteristics of the leucocyte infiltrate which would allow its identification as part of an inflammatory process rather then the normal physiological leucocyte infiltrate. METHODS AND RESULTS: We examined endometrial tissue from 79 cases of endometritis and 22 histologically normal controls. Leucocytes were characterized immunohistochemically for CD45, CD20, CD68, CD3 and CD56 and numbers were analysed semiquantitatively on a scale of 0-4. In many endometritis cases the overall number of leucocytes was increased. Furthermore, leucocytes were unusually distributed with a tendency to accumulate superficially beneath the endometrial surface. Whilst numbers of macrophages, T lymphocytes and endometrial granulated lymphocytes (uterine natural killer cells) did not differ between endometritis samples and controls, most endometritis cases contained a substantially increased number of B cells, which normally represent 1% or less of the endometrial leucocyte population. B lymphocytes were also observed in unusual locations such as intraepithelially and within glandular lumina. CONCLUSIONS: These results suggest that immunohistochemical characterization of endometrial leucocytes may be helpful in establishing a diagnosis of endometritis in equivocal cases.