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J Thorac Cardiovasc Surg 2007;133:317-324
© 2007 The American Association for Thoracic Surgery

General Thoracic Surgery

T2N0M0 esophageal cancer

^a Center for Swallowing and Esophageal Disorders, Cleveland Clinic, Cleveland, Ohio.
^b Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
^c Department of Gastroenterology, Cleveland Clinic, Cleveland, Ohio.
^d Department of Solid Tumor Oncology, Cleveland Clinic, Cleveland, Ohio.
^e Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.

Presented at the Eighty-sixth Annual Meeting of The American Association for Thoracic Surgery, Philadelphia, Penn, April 29-May 3, 2006.

Received for publication May 10, 2006; revisions received August 10, 2006; accepted for publication September 5, 2006.

^_* Reprint requests: Thomas W. Rice, MD, Cleveland Clinic, 9500 Euclid Avenue/Desk F24, Cleveland, OH 44195. (Email: ricet{at}ccf.org).

OBJECTIVE: The study objective was to develop a treatment algorithm for cT2N0M0 esophageal cancer by determining (1) errors in clinical staging and (2) consequences of overtreatment and undertreatment of incorrectly clinically staged patients.

METHODS: Of 742 clinically staged patients, 61 (8.2%) had cT2N0M0 cancer; 45 underwent surgery alone; 8 underwent surgery and postoperative adjuvant therapy; and 8 underwent induction therapy, then surgery. As reference, 31 of 666 patients (4.7%) who underwent surgery first had pT2N0M0 cancer and a 5-year survival of 61% ± 9.3%. Referent values were calculated from 445 clinically staged patients who underwent surgery first. Unmatched and matched survival comparisons were made using the log-rank test.

RESULTS: Only 7 of 53 cT2N0M0 cancers treated with surgery first were pT2N0M0 (13% positive predictive value). Of incorrectly staged cT2N0M0 cancers (46/53), 29 (63%) were overstaged and 17 (37%) were understaged. Most overstaged cancers were pT1 (11 [38%] T1a and 15 [52%] T1b), and most understaged cancers were pN1 (13 [76%]). Matched overstaged patients treated by surgery alone (25/28) had a 5-year survival similar to that of patients with pTNM (69% ± 9.8% vs 63% ± 13%, P =.8). Understaged patients did better at 5 years than patients with pTNM if they had postoperative adjuvant therapy, not surgery alone (43% ± 22% vs 10% ± 9.5%, P = .17). Induction therapy decreased 5-year survival compared with all other treatment strategies (13% ± 12% vs 52% ± 7.4%, P =.05).

CONCLUSIONS: Patients with cT2N0M0 cancers should undergo surgery first with lymphadenectomy. Clinically understaged patients should receive postoperative adjuvant therapy. In the unlikely event that patients with cT2N0M0 cancers are found to have an uncommon pT2N0M0 cancer, they will have acceptable survival with surgery alone.

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Discussion
J. Thorac. Cardiovasc. Surg. 2007 133: 323-324. [Extract] [Full Text] [PDF]