Impact of Subtype and Location on Pathological Upstaging of Clinical T1b/T2N0 Esophageal Cancer
Mallika Gopal BS1, Praveen Sridhar MD2, Sowmya R Rao PhD2, Kei Suzuki3, Virginia Litle3, Hiran Fernando MD4
1Boston University School of Medicine, Boston, MA, USA; 2Department of Surgery, Boston University, Boston, MA, USA; 3Division of Thoracic Surgery, Boston University, Boston, MA, USA, 4Thoracic Surgery, Inova Fairfax Medical Campus, Virginia Commonwealth University, Falls Church, VA, USA
Background: Patients with clinical stage T1bN0 usually undergo primary resection while treatment of cT2N0 remains controversial. Some advocate initial surgery and others neoadjuvant therapy. Patients ultimately upstaged may have benefited from neoadjuvant therapy, and patients remaining N0/downstaged may suffer additional morbidity from neoadjuvant therapy. This study was undertaken to identify factors associated with pathological upstaging.
Methods: A retrospective study of 25 patients with clinically staged T1b/T2N0 esophageal cancer. Patients were treated with neoadjuvant therapy (n=4) or primary surgical resection (n=21). Clinical staging included CT/PET scan, endoscopic ultrasound and endoscopic mucosal resection for small tumors. Tumor characteristics predicting pathological upstaging were analyzed using fisher's exact test.
Results: There were 7 cT1bN0M0 and 18 cT2N0M0 tumors. Neoadjuvant therapy was used in 4, and 21 patients had primary surgery. Following resection, only one T1b tumor underwent nodal upstaging. Among patients with T2 tumors, seven were downstaged (two received neoadjuvant therapy) and six were upstaged. Squamous cell carcinomas [SCC] (n=4 (67%); p = 0.0065) and middle-third tumors (p = 0.0115) were more likely to be upstaged than downstaged or accurately staged. Among upstaged patients, 67% had SCC and 50% had middle-third cancers. Additionally, 60% of patients with SCC [n=5] experienced recurrence and subsequent mortality during follow-up. There was no in-hospital mortality.
Conclusion: This preliminary study supports the current strategy of initial surgery for cT1bN0 esophageal cancer. For cT2N0, neoadjuvant therapy should be considered for squamous cell/middle-third tumors, and initial surgery for distal adenocarcinomas is a reasonable approach.
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