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To investigate the prognostic value of occult lymph node metastases (OLNMs) in patients with pathologically lymph node negative (pN0) esophageal squamous cell carcinoma (ESCC). OLNMs were detected in 516 pN0 ESCC patients by immunohistochemical staining. The correlation between the clinicopathological features and OLNM, and the prognostic value of OLNM was explored. Eighty-eight patients (17.1%) had OLNMs, including 37 patients with isolated tumor cells (ITCs), 49 patients with micrometastases, and 2 patients with macrometastases (> 2 mm). The OLNM-positive group had poorer differentiation and a more advanced pT category. The 5-year overall survival and disease-free survival for patients with OLNMs were significantly worse than those of IHC-negative patients (P 0.05). The multivariate analysis showed that OLNM was an independent prognostic factor. In subgroup analyses, the IHC-negative patients had significant survival advantages compared with the ITC group and the micrometastasis group, whereas the survival for the ITC group was similar to that of the micrometastasis group. IHC staining in pN0 ESCC patients might help to identify patients at high risk of death after resection, and ITCs in the lymph nodes appear to have a prognostic value equal to that of micrometastases.

Esophageal squamous cell carcinoma (ESCC) in the young patients is comparatively rare and has not been well studied. We analyzed the clinical and survival data of 127 ESCC patients

More studies are needed to clarify treatments and prognosis of early esophageal squamous cell carcinoma (ESCC). This retrospective study was designed to review the outcome of surgical treatment for early ESCC, evaluate the results of a left thoracotomy for selected patients with early ESCC, and identify factors affecting lymph node metastases and survival. The clinicopathological data of 228 patients with early ESCC who underwent transthoracic esophagectomy with lymphadenectomy without preoperative adjuvant treatment were reviewed. The χ(2) test or Fisher's exact test were used to detect factors related to lymph node metastasis. Univariate and multivariate analyses were performed to identify prognostic factors. There were 152 males and 76 females with a median age of 55 years. Two hundred and eight patients underwent a left thoracotomy, and the remaining 20 patients with lymph nodes in the upper mediastinum more than 5 mm in short-axis diameter by computed tomography scan underwent a right thoracotomy. No lymph node metastasis was found in the 18 patients with carcinoma in situ, while lymph node metastases were detected in 1.6% (1/62) of patients with mucosal tumours and 18.2% (27/148) of patients with submucosal tumours. Only 7 patients showed upper mediastinal lymph node metastases in the follow-up. The 5- and 10-year overall survival rates were 81.4% and 70.1%, respectively. Only histologic grade (P0.001) and pT category (P=0.001) significantly correlated with the presence of lymph node metastases. In multivariate analysis, only histologic grade (P=0.026) and pT category (P=0.008) were independent prognostic factors. A left thoracotomy is acceptable for selected patients with early ESCC. Histologic grade and pT category affected the presence of lymph node metastases and were independent prognostic factors for early ESCC.

Basaloid squamous cell carcinoma (BSCC) of the esophagus is a rare carcinoma with distinct characteristics. No standard treatment has been established. This retrospective study was designed to investigate the clinical and pathological characteristics, diagnosis, treatment, and prognosis of esophageal BSCC.Clinical data were retrospectively analyzed from 26 patients with pathologically confirmed esophageal BSCC who underwent transthoracic esophagectomy with lymphadenectomy between January 1995 and June 2010 at the Cancer Hospital of Shantou University Medical College. Clinicopathologic data between BSCC patients and different histologic grades of esophageal squamous cell carcinoma (ESCC) patients were statistically compared by means of the χ(2) test or Fisher's exact test. The Kaplan-Meier and log-rank methods were used to estimate and compare survival rates.Microscopically, BSCC was characterized by a nesting, lobular, or trabecular arrangement of small crowded cells with scant cytoplasm. None of the histologic specimens taken at preoperative esophagoscopy were diagnosed as BSCC. The median survival time (MST) of the 26 patients was 29.0 months (95% confidence interval, 9.0-49.0), and the 1-, 3-, and 5-year overall survival rates were 73.1, 42.7, and 36.6%, respectively. The MST for BSCC patients was significantly lower than that of well-differentiated SCC patients (P = 0.024), but there were no significant differences between the MST for BSCC patients and that of moderately or poorly differentiated SCC patients (P0.05).BSCC of the esophagus is a rare but distinctive disease and is prone to be misdiagnosed by endoscopic biopsy. The prognosis is poorer than well-differentiated SCC, but similar to moderately or poorly differentiated SCC.

Introduction Primary mucoepidermoid carcinoma (MEC) of the esophagus is an uncommon neoplasm characterized by a diffuse mixture of squamous and mucus-secreting glandular carcinoma cells. Its biological behavior and response to therapies have not been well studied. Surgical resection is still the primary treatment, but the prognosis is poor. This retrospective study was designed to investigate the clinical characteristics, diagnosis, treatment, and prognosis of primary esophageal MEC. Methods Clinical data were retrospectively analyzed from 36 patients with pathologically confirmed primary esophageal MEC who underwent transthoracic esophagectomy with lymphadenectomy between January 1991 and June 2010 at the Cancer Hospital of Shantou University Medical College. There were 27 men and 9 women ranging in age from 40 to 78 years (median, 58 years). Twenty-six of the 36 patients were treated with surgery alone. The other 10 were treated with surgery plus postoperative radiotherapy. The Kaplan-Meier and log-rank methods were used to estimate and compare survival rates. Cox's hazard regression model was used to identify prognostic factors, with entry factors of gender, age (≤60 years versus >60 years), length of the primary lesion (≤5 cm versus >5 cm), location of the primary lesion, macroscopic tumor type, tumor cell differentiation, pT, pN, pTNM stage, operation type (radical/palliative), and radiotherapy (yes/no). Results The clinical symptoms, radiological and endoscopic features of primary esophageal MEC were similar to those of esophageal squamous cell carcinoma (ESCC). Of the 20 cases who underwent preoperative endoscopic biopsy, 18 cases were misdiagnosed as ESCC and 2 were misdiagnosed as esophageal adenosquamous carcinoma. The mean follow-up duration of this series was 38.8 months (range, 3–142 months). Twenty-two patients had died, 12 were still alive, and 2 were lost to follow-up. The median survival time of the 36 patients was 29.0 months (95% confidence interval=20.0–38.0), and the 1-, 2-, 3-, and 5-year overall survival rates were 80.6%, 57.1%, 34.4%, and 25.8%, respectively. The 5-year survival rate of 25.8% was lower than 5-year absolute survival rate of 39.2% for ESCC patients who had undergone surgical resection during the same period at our center. For patients who underwent a radical operation, the 5-year survival rate of 32.0% for MEC patients was also lower than that of 41.7% (908/2175) for ESCC patients. In univariate analysis, pN (pN0/pN1–3) (p = 0.003) and operation type (radical/palliative) (p = 0.006) significantly influenced the median survival time of MEC patients. In multivariate analysis, pN (pN0/pN1–3) (p = 0.002) and operation type (radical/palliative) (p = 0.004) were independent prognostic factors. Conclusions Primary esophageal MEC is a rare disease and prone to be misdiagnosed. Lymph node metastasis and operation are independent prognostic factors. Surgical resection is the primary treatment, but the prognosis is poor.

Primary small cell carcinoma of esophagus (SCCE) is a relatively rare and highly aggressive tumor characterized by early dissemination and poor prognosis. The optimal treatment has not yet been established, and the role of surgery has remained controversial. Most of the limited diseases were treated conventionally by surgery, but the five-year survival rate was still very low. This retrospective study was designed to investigate the clinical characteristics, treatment, and prognostic factors of limited disease SCCE. Clinical data of 40 SCCE patients with clinically limited disease who received transthoracic esophagectomy with lymphadenectomy at the Cancer Hospital of Shantou University Medical College from November 1990 to December 2009 were reviewed to summarize the clinical characteristics and treatment impacted on the survival. Twenty-five cases of the 40 patients were treated with surgery alone, eight cases were treated with surgery + postoperative chemotherapy, four cases were treated with surgery + postoperative radiotherapy, and the other three were treated with surgery + postoperative radiochemotherapy. The Kaplan-Meier and log-rank methods were used to estimate and compare survival rates. Cox's hazard regression model was used to identify the prognostic factors with the entry factors of gender, age (≤ 60 years versus > 60 years), length of the primary lesion (≤ 5 cm versus > 5 cm), location of the primary lesion, macroscopic tumor type, pT, pN, pTNM stage, operation (radical/palliative), and chemotherapy (yes/no). The mean follow-up duration of this series was 24.7 months (1-121 months). Thirty-four patients died of the disease during the follow-up, five were still alive, and one was lost of follow-up. The median survival time of the 40 patients was 13.0 months (95% confidence interval 4.7-21.3), and the 6-, 12-, 24-, 36-, and 60-month overall survival rates (OS) were 77.5%, 56.4%, 28.9%, 23.7%, 10.5%, respectively. In univariate analysis, age (≤ 60 years versus >60 years) (P=0.049), operation (radical/palliative) (P=0.008), and chemotherapy (yes/no) (P= 0.013) significantly influenced the OS of the SCCE patients. In multivariate analysis, operation (P=0.015) and chemotherapy (P=0.031) were independent prognostic factors. The patients who received radical surgery and postoperative chemotherapy had relatively better survival. Surgical resection combined with chemotherapy should be recommended to patients with limited disease SCCE.

AIM: To analyze a modified staging system utilizing lymph node ratio (LNR) in patients with esophageal squamous cell carcinoma (ESCC). METHODS: Clinical data of 2011 patients with ESCC who underwent surgical resection alone between January 1995 and June 2010 at the Cancer Hospital of Shantou University Medical College were reviewed. The LNR, or node ratio (Nr) was defined as the ratio of metastatic LNs ompared to the total number of resected LNs. Overall survival between groups was compared with the log-rank test. The cutoff point of LNR was established by grouping patients with 10% increment in Nr, and then combining the neighborhood survival curves using the log-rank test. A new TNrM staging system, was constructed by replacing the American Joint Committee on Cancer (AJCC) N categories with the Nr categories in the new TNM staging system. The time-dependent receiver operating characteristic curves were used to evaluate the predictive performance of the seventh edition AJCC staging system and the TNrM staging system. RESULTS: The median number of resected LNs was 12 (range: 4-44), and 25% and 75% interquartile rangeswere8 and 16. Patients were classified into four Nr categories with distinctive survival differences (Nr0: LNR = 0; Nr1: 0% 20%). From N categories to Nr categories, 557 patients changed their LN stage. The median survival time (MST) for the four Nr categories (Nr0-Nr3) was 155.0 mo, 39.0 mo, 28.0 mo, and 19.0 mo, respectively, and the 5-year overall survival was 61.1%, 41.1%, 33.0%, and 22.9%, respectively (P < 0.001). Overall survival was significantly different for the AJCC N categories when patients were subgrouped into 15 or more vs fewer than 15 examined nodes, except for the N3 category (P = 0.292). However, overall survival was similar when the patients in all four Nr categories were subgrouped into 15 or more vs fewer than 15 nodes. Using the time-dependent receiver operating characteristic, we found that the Nr category and TNrM stage had higher accuracy in predicting survival than the AJCC N category and TNM stage. CONCLUSION: A staging system based on LNR may have better prognostic stratification of patients with ESCC than the current TNM system, especially for those undergoing limited lymphadenectomy.

The role of adjuvant radiotherapy in patients with esophageal squamous cell carcinoma (ESCC) remains controversial. This retrospective study was designed to analyze the impact of adjuvant radiotherapy in patients with T3 stage ESCC after radical resection.Data of a single-center cohort of 692 patients with T3 stage ESCC who underwent radical resection, with or without adjuvant radiotherapy, were reviewed. Univariate and multivariate analyses were performed to compare overall survival (OS) and locoregional recurrence-free survival (LRFS).Two hundred and forty-six patients received adjuvant radiotherapy (S + R group), and 446 patients underwent surgery alone (S group). The median survival time and 5-year OS rate were 40.0 months and 40.9 % for the entire population, 50.0 months and 45.6 % for the S + R group and 38.0 months and 38.3 % for the S group (P = 0.114 for S + R group vs. S group). The 5-year LRFS rate for the S + R group was significantly higher than that for S group (50.8 vs. 35.9 %, P0.001). In subgroup analyses, adjuvant radiotherapy was found to improve the 5-year OS in the subgroups of tumor length5 cm, pN0 and pN1 categories, pTNM stage IIa, IIb and IIIa (P0.005).Adjuvant radiotherapy is effective in local control of radically resected T3 stage ESCC and may improve the overall survival in certain subgroups, such as the patients with tumor length5 cm, pN0 and pN1 categories, pTNM stage IIa, IIb and IIIa. Further studies are required to confirm our results.

AIM: To investigate the clinical characteristics, diagnosis, treatment, and prognosis of primary adenosquamous carcinoma (ASC) of the esophagus. METHODS: A total of 4015 patients with esophageal carcinoma underwent surgical resection between January 1995 and June 2012 at the Cancer Hospital of Shantou University Medical College. In 37 cases, the histological diagnosis was primary ASC. Clinical data were retrospectively analyzed from these 37 patients, who underwent transthoracic esophagectomy with lymphadenectomy. The χ2 or Fisher’s exact test was used to compare the clinicopathological features between patients with ASC and those with squamous cell carcinoma (SCC). The Kaplan-Meier and Log-Rank methods were used to estimate and compare survival rates. A Cox proportional hazard regression model was used to identify independent prognostic factors. RESULTS: Primary esophageal ASC accounted for 0.92% of all primary esophageal carcinoma cases (37/4015). The clinical manifestations were identical to those of other types of esophageal cancer. All of the 24 patients who underwent preoperative endoscopic biopsy were misdiagnosed with SCC. The median survival time (MST) was 21.0 mo (95%CI: 12.6-29.4), and the 1-, 3-, and 5-year overall survival rates were 67.5%, 29.4%, and 22.9%, respectively. In multivariate analysis, only adjuvant radiotherapy (HR = 0.317, 95%CI: 0.114-0.885, P = 0.028) was found to be an independent prognostic factor. The MST for ASC patients was significantly lower than that for SCC patients [21.0 mo (95%CI: 12.6-29.4) vs 46.0 mo (95%CI: 40.8-51.2), P = 0.001]. In subgroup analyses, the MST for ASC patients was similar to that for poorly differentiated SCC patients. CONCLUSION: Primary esophageal ASC is a rare disease that is prone to be misdiagnosed by endoscopic biopsy. The prognosis is poorer than esophageal SCC but similar to that for poorly differentiated SCC patients.

IntroductionMore data are essential to test the efficacy of the seventh edition of the American Joint Committee on Cancer (AJCC) staging system for esophageal squamous cell carcinoma (ESCC). This retrospective study was designed to identify the prognostic factors for survival of patients with ESCC who underwent surgical resection alone and to evaluate the new AJCC staging system for ESCC.MethodsData of a single-center cohort of 2011 patients with ESCC who underwent surgical resection alone according to the new staging system were reviewed. Univariate and multivariate analyses were performed to identify prognostic factors.ResultsThe 1-, 3-, and 5-year overall survival rates were 83.5, 57.4, and 47.4%, respectively, with a median survival time of 51.0 months. Age, histologic grade, R-category, pT category, pN category, pM category, pTNM stage, and the extent of lymph node metastasis were independent prognostic factors (p < 0.05). In separate subgroup analyses, the survival differences were not significant for pN2 versus pN3 category (p = 0.159) and stages IA versus IB (p = 0.922). Subdivisions by depth of infiltration rather than tumor grade for pT1N0M0 cancers and modified nodal categories (0, 1, 2–3, and ≥4 positive lymph nodes) better represented a survival advantage.ConclusionsThe seventh edition of the AJCC staging system for ESCC is acceptable in predicting survival. However, tumor location does not influence survival in our study. Subdivisions of pT1N0M0 cancers and the N-classification may need to be modified.

To review the clinical characteristics, diagnosis, treatment and prognosis of esophageal mucoepidermoid carcinoma (MEC).Clinical data of 36 patients with pathologically confirmed esophageal MEC who received surgical treatment in Cancer Hospital of Shantou University Medical College from Jan 1991 to Jun 2010 were retrospectively analyzed. The survival analysis was performed using Kaplan-Meier method.Of the 4253 patients diagnosed as esophageal cancer during the same time in our center, only 36 had esophageal MEC, accounted for 0.8%. This group included 27 men and 9 women ranging in age from 40 to 78 years (median 58 years). Esophageal MEC showed similar clinical symptoms, radiological and endoscopic features to esophageal squamous cell carcinoma (ESCC). Of the 20 cases who received preoperatively endoscopic biopsy, 18 were misdiagnosed as ESCC and 2 were misdiagnosed as esophageal adenosquamous carcinoma. The mean follow-up duration of this series was 38.8 months (3-142 months). 22 patients died of the disease during the follow-up period, 12 were still alive and 2 were lost of follow-up. The median survival time (MST) of the 36 patients was 29.0 months, and the 1-, 2-, 3-, and 5-year overall survival rates (OS) were 80.6%, 57.1%, 34.4%, 25.8%, respectively.Esophageal MEC is a rare disease and prone to be misdiagnosed by endoscopic biopsy. Surgical resection is the primary treatment but the prognosis is poor.