Subtype of metastatic esophageal cancer not a contraindication to surgery

1. Supraclavicular lymph node (SCLN) positive patients with esophageal cancer, who were subsequently SCLN negative after neo-adjuvant chemotherapy, were not shown have a decreased 3-year survival rate following esophagectomy compared to patients who were originally SCLN negative.

Evidence Rating Level: 2 (Good)           

Study Rundown: Esophageal cancer is a particularly aggressive gastrointestinal cancer with high rates of nodal metastasis. SCLN metastasis has conventionally been defined as a distant metastasis and esophageal cancer with SCLN involvement is considered stage IV disease and, thus, a contraindication to surgery. In light of the increased use of pre-operative neo-adjuvant therapy in the treatment of advanced esophageal cancers, the authors sought to potentially re-evaluate the clinical role SCLN metastases in predicting operative outcomes. The authors found no difference between survival rates in patients who were SCLN positive pre-therapy but negative post-therapy compared to those who were SCLN negative throughout, suggesting a benefit of surgical resection in SCLN positive patients who have exhibited a significant response to chemotherapy. Additionally, the rate of 3-year survival of 20% in pathologically confirmed SCLN positive cases does illustrate some benefit to surgical intervention but a more robust comparative study to other modalities of treatment could validate any such benefit. One major limitation to the study is the lack of sensitivity in the identification of SCLN status before the initiation of any therapy. The authors identified patients with SCLN metastasis using computed tomography (CT) or 18F-FDG positron emission tomography (PET), shown in prior studies to have a sensitivity of just 51-57%. Of the 47 patients with pathologically confirmed SCLN metastasis after therapy, only 28 of these were identified before the start of the therapy, a sensitivity of only around 60%. Thus, the study did not accurately characterize all patients who were SCLN positive.

Click to read the study in Annals of Surgery

Relevant Reading: Preoperative Chemoradiotherapy for Esophageal or Junctional Cancer

In-Depth [systematic review]: A total of 323 patients with squamous cell carcinoma of the thoracic esophagus undergoing esophagectomy following neo-adjuvant chemotherapy at Osaka University in Japan were included in the study. Disease was characterized pre-therapy using CT with (18F-FDG)- PET when possible. Surgery was performed 3-5 weeks after the conclusion of the chemotherapy. 57 (18%) of included patients were shown to be SCLN positive before the initiation of any therapy. Of these patients, 17 (30%) patients were classified to show a “major” (grade 2/3) response to neo-adjuvant chemotherapy. The incidence of post-therapy SCLN positive metastasis was significantly lower in such patients compared to those with a minor response (24% vs 60%, p = .012). Overall survival for SCLN positive patients post-therapy was significantly lower than those with nodal disease who were SCLN negative (20% vs 46%, p = .003). This relationship held when stratifying the analysis by tumor location in the middle and upper esophagus, respectively. Patients who were SCLN positive pre-therapy but negative post-therapy did not demonstrate decreased rates survival compared to those who were SCLN negative throughout (65% vs 58%, p = .21).

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