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Increasing Tumor Length Is Associated With Increased Regional Lymph Node Metastases and Decreased Survival in Esophageal Cancer
Nicholas R. Kunio*1, Brian S. Diggs1, Gennadiy Bakis1, Brandon H. Tieu2, Paul H. Schipper2, Brett C. Sheppard1, John G. Hunter1, James P. Dolan1
1General Surgery, Oregon Health & Science University, Portland, OR; 2Cardiothoracic Surgery, Oregon Health & Science University, Portland, OR
Background: Depth of tumor invasion is a key factor in determining clinical and pathologic stage in esophageal cancer. The effect of increased tumor length on overall survival and staging has received less attention, but may be an equally important prognostic feature of a primary esophageal cancer.
Methods: We reviewed final pathology reports of all patients in our esophageal cancer research database where tumor length was well documented. In order to eliminate treatment effect on tumor size only patients that did not receive neoadjuvant chemoradiation were included in the analysis. Association between tumor length and survival was assessed with a Cox proportional hazards model. Association with nodal involvement and resection used a linear regression model.
Results: 86 patients undergoing esophagectomy from March 1995 to April 2013 were included in the analysis. 72 (85%) were men and the median age was 64. 74 (86%) of patients had adenocarcinoma (AC) and 12 (14%) had squamous cell carcinoma (SCC). Median tumor length was 2.8 cm, interquartile range (1.7, 5.0) and median number of nodes removed was 10 (5, 17). 16 (19%) patients received adjuvant chemotherapy or radiation, 63 (73%) did not, and the remaining 7 (8%) were unknown. For all patients a significant decrease in survival was seen with increasing tumor length (hazard ratio 1.18 for every 1 cm increase in tumor length, 95% CI 1.06-1.31, p=0.003). On multivariate analysis, controlling for age, gender, number of positive lymph nodes, and adjuvant chemoradiation, there was decreased survival with increasing tumor length in all patients (HR 1.23, 95% CI 1.07-1.39, p=0.003). A significant increase in positive lymph nodes was seen with increasing tumor length (p<0.001) in all patients, while no difference was seen in total lymph nodes harvested.
Conclusion: The findings of this study suggest an important association between esophageal cancer tumor length and regional lymph node metastasis as well as overall survival. Future clinical staging of esophageal cancer may benefit from adding tumor length to current methods relying on depth of invasion (T status) and an estimation of positive lymph nodes from CT or EUS (N status).
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