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Journal of Digestive Diseases 2015; 16; 197–204
doi: 10.1111/1751-2980.12230
Original article
Lymphovascular invasion and nodal metastasis in intramucosal adenocarcinoma of the esophagus and esophagogastric junction Zhi Gang LI,* Hui ZHU,† Hong SHI,† Hao XIE,‡ John R GOLDBLUM,† Prashanthi N THOTA§ & Xiuli LIU† *Department of Surgery, Second Military Medical University, Shanghai, China, †Department of Anatomic Pathology, Cleveland Clinic, ‡Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, § Department of Gastroenterology, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
OBJECTIVE: To evaluate the tumor parameters predictive of lymphovascular invasion (LVI) and nodal metastases in intramucosal adenocarcinoma (IMAC) of the esophagus and esophagogastric junction. METHODS: In all, 171 cases of IMAC from esophagectomy database (1986–2009) were reviewed. LVI was evaluated on HE and by immunohistochemistry stain for D2-40 (in selected cases). Univariate analysis was performed to identify predictors for LVI (in this cohort) and nodal metastasis (for pooled data from literature review). RESULTS: Altogether 150 IMAC were included in the study after histology review; 7 (4.7%) showed LVI and one (0.7%) had nodal metastasis. LVI-positive IMAC were thicker (tumor thickness 3.0 ± 2.8 mm vs 1.3 ± 1.2 mm, P = 0.01), and more likely to invade the outer muscularis mucosae (M3) (P = 0.004), be
poorly differentiated (P < 0.001), and to show a nodular or plaque-like lesion (P = 0.04) compared with LVI-negative IMAC. Patients’ age, gender, the frequency of tumor multifocality, ulceration and tumor size were not significantly different between these two groups. The pooled rates of LVI and nodal metastases in IMAC from five published studies and this cohort were 6.0% (range 2.9–16.7%) and 3.4% (range 0–10.0%), respectively. Pooled analysis of studies with histology review showed that LVI in IMAC was associated with a nodal metastases rate of 27.3%. CONCLUSION: For IMAC of the esophagus and esophagogastric junction, LVI is associated with tumor thickness, M3 invasion, poor differentiation and the presence of nodular or plaque-like lesion; by pooled analysis, it is associated with a risk of nodal metastasis of 27.3%.
KEY WORDS: esophageal neoplasms, esophagogastric lymphovascular invasion, lymphatic metastasis.
junction,
intramucosal
adenocarcinoma,
INTRODUCTION Correspondence to: Xiuli LIU, Department of Anatomic Pathology, Cleveland Clinic, 9500 Euclid Avenue/L25, Cleveland, Ohio 44195, USA. Email: [email protected] Conflict of interest: None. © 2015 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
Treatment for intramucosal adenocarcinoma (IMAC) of the esophagus and esophagogastric junction (EGJ) is evolving. A recent study has suggested that survival after esophagectomy for IMAC is excellent and is determined more by the patient than the characteristics of the cancer.1 Esophagectomy should be reserved for patients with a long segment of IMAC or those in
197
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whom endoscopic therapies fail or are inappropriate, such as the patients with a high risk of nodal metastases. While several studies have demonstrated a low rate of nodal metastasis in patients with early esophageal adenocarcinoma, many of these studies had small sample sizes.2–4 A recent and relatively large study showed a prevalence of nodal metastases of 7.4% in patients with IMAC of the esophagus and EGJ.5 In addition, Lee et al.5 suggested a simple scoring system to predict lymph node metastases in early esophageal adenocarcinoma, including IMAC. This scoring system included variables such as tumor size, depth of invasion, differentiation and lymphovascular invasion (LVI), but was generated using data from a cohort of mixed IMAC and submucosally invasive esophageal adenocarcinomas. The aims of this study were to examine LVI and nodal metastasis rates in the largest cohort, to our knowledge, of IMAC of the esophagus and EGJ and to perform a literature review with pooled analysis on LVI and nodal metastasis rates in IMAC of the esophagus and EGJ. PATIENTS AND METHODS Medical records of 171 cases of IMAC from a clinical esophagectomy database (1986–2009) were reviewed. Of these, 21 cases were excluded due to incomplete clinical information or pathologic materials (n = 9), squamous cell carcinoma (n = 4), submucosal invasion (n = 3) and high-grade dysplasia (n = 5). Pathological reports and original slides of each case were also reviewed. Histological re-review was performed by two gastrointestinal pathologists. The IMAC were classified into four groups based on the depth of invasion: (i) invasion into the lamina propria (LP) without invasion of the muscular mucosae (MM); (ii) invasion into but not through the superficial layer of MM (M1); (iii) invasion through the superficial MM but not into a separate deeper layer of MM (M2); and (iv) invasion into the deeper layer of MM (M3).6,7 Other histological features including the size, focality and location of the tumor and the presence or absence of lymph node metastasis were assessed according to the previously published criteria8,9 and the World Health Organization classification10. IMAC of the EGJ was defined as an adenocarcinoma whose epicenter was at the EGJ, where the tubular esophagus ends and the most proximal limit of the gastric fugal folds
Journal of Digestive Diseases 2015; 16; 197–204 starts, or within the proximal 5 cm of the stomach (cardia) that extends into the EGJ or esophagus. Great efforts were taken to exclude adenocarcinoma of the proximal stomach by carefully reviewing the macroscopic description in the original pathological reports and histologically reviewing the slides. The tumor grade was assigned according to the definitions of the American Joint Committee on Cancer: G1, well-differentiated; G2, moderately differentiated; G3, poorly differentiated; G4, undifferentiated. More specifically, tumors showing minimal gland formation and instead single cells, small clusters of cells or a solid sheet of cells were considered poorly differentiated. In cases where both moderate and poor differentiation was present, the tumor was classified as poorly differentiated when >10% of the tumor showing poor differentiation. Multifocality of IMAC was defined as the presence of ≥2 discrete IMACs separated by non-carcinomatous mucosa either grossly or microscopically after reviewing and matching the pathological reports and corresponding slides. Tumor thickness was measured microscopically from the surface of the tumor to the area of the deepest invasion. In cases with multifocal IMAC, the thickness of the thickest lesion was measured and used for the entire case. Information on the gross features, that is, mucosal ulceration, nodules and plaque-like lesions were recorded for each case after reviewing the original pathological report. Hematoxylin and eosin (HE)-stained slides of tumors were assessed for LVI. LVI was defined as the presence of tumor emboli in endothelial cell-lined spaces in the invasive front of the tumors. Cases that had clusters of tumor cells immediately adjacent to endothelial cell-lined spaces or tumor cells in empty spaces without endothelial lining were considered possible LVI and were then subjected to immunohistochemistry stain for D2-40, which has been reported to increase the detection rate of LVI in esophageal adenocarcinoma.11 Immunohistochemical staining for D2-40 was performed on whole tissue sections from Hollande’s fixed or formalin-fixed and paraffin-embedded tissues using an automated stainer (Ventana Medical Systems, Inc., Tucson, AZ, USA) by standard avidin-biotinperoxidase methods. Epitope retrieval techniques were used for antigen retrieval as follows: high pH ethylenediaminetetraacetic acid buffer and a steamer at 120°C for 5 min. Deparaffinized tissue sections were then stained with antibodies against D2-40 (clone D2-40, diluted 1:50; Covance, Princeton,
© 2015 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
Journal of Digestive Diseases 2015; 16; 197–204
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NJ, USA). Diaminobenzidine was served as the chromogen. Positive and negative controls for this antibody were included in the study.
RESULTS
Statistical analysis
The characteristics of the 150 patients with IMAC in this cohort are shown in Table 1. Among the 150 IMAC cases, 7 (4.7%) showed LVI, including five on routine stain and two by immunohistochemistry for D2-40 (Fig. 1a,b). Compared to LVI-negative IMAC, LVI-positive IMAC were thicker (tumor thickness 3.0 ± 2.8 mm vs 1.3 ± 1.2 mm, P = 0.01) and more likely to show M3 invasion (100% vs 30.2%, P = 0.004), be poorly differentiated (85.7% vs 11.9%, P < 0.001) (Fig. 1c) and show a nodular or plaque-like lesion (P = 0.04) (Table 1). Patients’ age (65.7 ± 8.8 years vs 62.7 ± 10.5 years, P = 0.40) and gender (male:
Statistical analyses were performed using R software package (R Development Core Team [2014], R Foundation for Statistical Computing, Vienna, Austria). Continuous variables were presented as mean ± standard deviation or medians and ranges, while categorical variables were presented as frequencies or percentages. χ2 or Fisher’s exact tests were used to compare categorical data. Continuous data were analyzed using the Wilcoxon rank–sum test. A two-sided P value < 0.05 was considered statistically significant.
Clinicopathological findings in the esophagectomy specimens
Table 1. Clinical and tumor characteristics in 150 patients with intramucosal adenocarcinoma (IMAC) of the esophagus and esophagogastric junction Patients Characteristics
Total cohort
with LVI (n = 7)
without LVI (n = 143)
P value
Age, year (mean ± SD) Male gender, n (%) Tumor location, n (%) Esophagus Esophagogastric junction Tumor multifocality, n (%) Tumor size, mm (mean ± SD) Total tumor size Largest size of the tumor Average tumor size of each case Tumor thickness, mm (mean ± SD) Depth of invasion,† n (%) LP M1 M2 M3 Differentiation, n (%) Well Moderate Poor Macroscopic finding, n (%) Ulceration Lack of ulceration Macroscopic finding, raised lesion, n (%) Nodule Plaque None Total number of nodes examined (mean ± SD)
62.9 ± 10.4 130 (86.7)
65.7 ± 8.8 7 (100)
62.7 ± 10.5 123 (86.0)
0.40 0.60 1.00
109 (72.7) 41 (27.3) 61 (40.7)
5 (71.4) 2 (28.6) 2 (28.6)
104 (72.7) 39 (27.3) 59 (41.3)
1.2 ± 1.0 0.9 ± 0.9 0.8 ± 0.9 1.4 ± 1.4
1.2 ± 1.1 1.1 ± 1.2 1.1 ± 1.2 3.0 ± 2.8
1.2 ± 1.0 0.9 ± 0.9 0.8 ± 0.9 1.3 ± 1.2
42 (28.2) 42 (28.2) 15 (10.1) 50 (33.5)
0 (0) 0 (0) 0 (0) 7 (100)
42 (29.6) 42 (29.6) 15 (10.6) 43 (30.2)
50 (33.3) 77 (51.3) 23 (15.4)
0 (0) 1 (14.3) 6 (85.7)
50 (35.0) 76 (53.1) 17 (11.9)
42 (28.0) 108 (72.0)
2 (28.6) 5 (71.4)
40 (28.0) 103 (72.0)
39 (26.0) 25 (16.7) 86 (57.3) 13 ± 10
4 (57.1) 2 (28.6) 1 (14.3) 16 ± 11
35 (24.5) 23 (16.1) 85 (59.4) 13 ± 10
0.70 0.80 0.90 1.00 0.01 0.004
0.05). There was no difference in the nodal metastasis rate in IMAC confined to the LP compared with those with invasion of the MM (including M1, M2 and M3) (0% vs 3.3%, P = 0.10) (Table 3).
Nodal metastasis in IMAC in relation to tumor differentiation Tumor differentiation information was available in three studies, with poor differentiation seen in 21.3%, 3.8% and 15.3% of IMAC, respectively (average 14.7%). The pooled nodal metastasis rate was 2.5% (2/41) in poorly differentiated IMAC compared with 0.8% (2/237) in well or moderately differentiated IMAC (P = 0.10, Table 4).
Nodal metastasis in IMAC in relation to LVI Information on LVI status was available in six studies. The nodal metastasis rate in LVI-positive IMAC ranged from 0% to 66.7% (mean 28.6%), which was higher than that of 1.1% for LVI-negative IMAC (P = 0.000000006). In the five studies with histology review, the nodal metastasis rate in LVI-positive IMAC ranged from 0% to 66.7% (mean 27.3%), which was higher than that of 0.3% in LVI-negative IMAC (P = 0.0000002) (Table 5). DISCUSSION IMAC is defined as neoplastic epithelium that has invaded beyond the basement membrane of the malignant glands into the surrounding LP or MM, but not below the MM. Because of the presence of lymphatic and blood vessels in the esophageal mucosa, IMAC possess a small but definite risk of lymph node metastasis. As such, esophagectomy had been used as a mainstay of treatment in the past decades. However, treatment for IMAC of the esophagus and EGJ is evolving: endoscopic resection has been increasingly used, with esophagectomy being reserved for patients with a long IMAC or those in whom endoscopic therapies fail or are inappropriate; for example, patients at a high risk of nodal metastases. Thus, patient selection has become critical and the prediction of lymph node metastases in IMAC is a key component in dictating therapy. Previous studies on nodal metastasis in this disease had relatively small sizes with rates varying
© 2015 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
†IMAC patients are not further divided into M1, M2 or M3. ‡One case of IMAC in the current study cannot be further divided into M1, M2 or M3. §The nodal metastasis rate is not significantly different between IMAC invading muscularis mucosae and IMAC confined to the lamina propria (P = 0.10). NA, not applicable; LP, IMAC confined to the lamina propria; M1, IMAC invading the inner muscularis mucosae; M2, IMAC invading the space between the inner and outer muscularis mucosae; M3, IMAC invading the outer muscularis mucosae; nodal met., nodal metastasis.
1 (1.8) 2 (11.8) 3 (10.0) 1 (0.9) 7 (3.3)§ 57† 17 30 108 212 NA 1 (12.5) 1 (2.0) 2 (3.4) NA 8 50 58 NA 1 (8.3) 0 (0) 1 (3.7) NA 12 15 27 NA 1 (10.0) 0 (0) 1 (1.9) NA 10 42 52 Leers et al.2 (2011) Liu et al.3 (2005) Abraham et al.6 (2007) Current study‡ Total
18 36 NA 42 96
0 (0) 0 (0) NA 0 (0) 0 (0)
M1 (n) References
LP (n)
Nodal met. in LP IMAC (n, %)
Nodal met. in MI IMAC (n, %)
M2
Nodal met. in M2 IMAC (n, %)
M3
Nodal met. in M1–M3 IMAC (n, %) Muscularis mucosae (M1–M3)
Journal of Digestive Diseases 2015; 16; 197–204
Nodal met. in M3 IMAC (n, %)
ZG Li et al. Table 3. Nodal metastasis rate in esophageal and esophagogastric junction intramucosal adenocarcinoma (IMAC) according to the deepest invasion in the current study and the literature reviewed
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significantly from 0% to 16.7%.1–4,6 One recent study showed a nodal metastasis rate of 7.4% in a cohort of IMAC without histological review.5 In addition, this study suggested a simple scoring system to predict lymph node metastases in early esophageal adenocarcinoma including IMAC. This scoring system included variables such as tumor size, depth, differentiation and LVI.5 The small size of this study and lack of histological reviews make it difficult to identify tumor characteristics associated with nodal metastasis. In the current study, nodal metastasis was seen in only one (0.7%) case of IMAC. This tumor was poorly differentiated and invaded the outer MM (M3) but did not show LVI on routinely stained sections. The nodal metastasis rate in our cohort is similar to that in previous reports,2–4 but lower than the two other reports reviewed in this study. One of these included only IMAC invading MM6 and the other had no histological review of the tumors.5 The pooled nodal metastasis rate from the five studies with histology review is only 2.0%. None of the 96 IMAC confined to the LP had nodal metastasis; in contrast, 3.3% (7/212) of the IMAC invading the MM had nodal metastasis, although this does not reach statistic difference. Poor differentiation has been shown to be a risk factor for nodal metastasis.5 In the literature review, 14.7% of IMAC were reported to be poorly differentiated tumors; but nodal metastasis was noted in only 2.5% of these poorly differentiated IMAC, which was not significantly different from that (0.8%) in well or moderately differentiated IMAC (P = 0.10). A pooled analysis of the literature review and our current study showed that LVI was associated with nodal metastasis. LVI-positive IMAC had a nodal metastasis rate of 28.6%; in contrast, LVI-negative IMAC had only a nodal metastasis rate of 1.1% (P = 0.000000006). Moreover, the pooled nodal metastasis rate from the five studies with histology review was 27.3% in LVI-positive compared with that in LVI-negative IMAC (27.3% vs 0.3%, P = 0.00000002). A limitation of this study is that it is a singlecenter study covering more than 23 years and immunohistochemical stain for D2-40 was not performed on all patients. No survival data and analysis were included in this study. However, the clinical outcome and survival of these and an additional 14 patients with IMAC were reported recently.1 Survival
© 2015 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
Journal of Digestive Diseases 2015; 16; 197–204
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Table 4. Nodal metastasis rate in esophageal and esophagogastric junction intramucosal adenocarcinoma (IMAC) according to the tumor differentiation in the current study and the literature reviewed
References Leers et al.2 (2011) Liu et al.3 (2005) Current study Total P value
IMAC cases (n)
Poorly differentiated IMAC (n, %)
Nodal metastasis in poorly differentiated IMAC (n, %)
Well or moderately differentiated IMAC (n, %)
75 53 150 278
16 (21.3) 2 (3.8) 23 (15.3) 41 (14.7)
1 (6.3) 0 (0) 1 (4.3) 2 (2.5)
59 (78.7) 51 (96.2) 127 (84.7) 237 (85.3)
Nodal metastasis in well to moderately differentiated IMAC (n, %) 0 (0) 2 (3.9) 0 (0) 2 (0.8) 0.10
One case cannot be evaluated due to small size of the cancer.
Table 5. Nodal metastasis rates in esophageal and esophagogastric junction intramucosal adenocarcinoma (IMAC) according to the lymphovascular invasion (LVI) status in the current study and the literature reviewed
References Leers et al.2 (2011) Liu et al.3 (2005) Barbour et al.4 (2010) Abraham et al.6 (2007) Current study Subtotal from studies with histology review Lee et al.5 (2013) Total
IMAC cases (n)
LVI-negative (n, %)
Nodal metastasis in LVI-negative IMAC (n, %)
LVI-positive IMAC (n, %)
Nodal metastasis in LVI-positive IMAC (n, %)
75 53 35 30 150 343
69 (92.0) 50 (94.3) 34 (97.1) 25 (83.3) 143 (95.3) 321 (93.6)
0 (0) 0 (0) 0 (0) 0 (0) 1 (0.7) 1 (0.3)
6 (8.0) 3 (5.7) 1 (2.9) 5 (16.7) 7 (4.7) 22 (6.4)
1 (16.7) 2 (66.7) 0 (0) 3 (60.0) 0 (0) 6 (27.3)*
122 465
116 (95.1) 437 (94.0)
4 (3.4) 5 (1.1)
6 (4.9) 28 (6.0)
2 (33.3) 8 (28.6)**
*P = 0.00000002 when compared to nodal metastasis rate in LVI-negative IMAC cases pooled from studies with histology review. **P = 0.000000006 when compared to nodal metastasis rate in LVI-negative IMAC cases in studies pooled from studies with and without histology review.
after esophagectomy for IMAC is determined more by the patients’ characteristics than by the characteristics of the cancers. The low rate of LVI and nodal metastasis in the current study precluded a meaningful multivariate analysis. A limitation of literature review in this study was that one study had no histology review and histology reviewers might have used different criteria. The higher rate of nodal metastasis in the study without histology review and significant diagnostic changes in a few patients in our current study strongly suggested that future studies identifying risk factors for nodal metastasis should include detailed histology review. In conclusion, nodal metastasis rate in IMAC is low (2.0% pooled from studies with histology review) and is seen in up to 27.3% of patients with LVI. While the depth of mucosal invasion and poor differentiation are not associated with nodal metastasis, the number of cases was small, even with the literature review. Large studies accurately assessing
mucosal invasion depth, tumor grade, LVI and other features, such as tumor thickness and tumor budding, by histology review are needed to confirm our current findings and identify the risk factors for nodal metastasis and for better IMAC patient selection for esophagectomy. REFERENCES 1 Li Z, Rice TW, Liu X et al. Intramucosal esophageal adenocarcinoma: primum non nocere. J Thorac Cardiovasc Surg 2013; 145: 1519–24, 1524.e1–3. 2 Leers JM, DeMeester SR, Oezcelik A et al. The prevalence of lymph node metastases in patients with T1 esophageal adenocarcinoma: A retrospective review of esophagectomy specimens. Ann Surg 2011; 253: 271–8. 3 Liu L, Hofstetter WL, Rashid A et al. Significance of the depth of tumor invasion and lymph node metastasis in superficially invasive (T1) esophageal adenocarcinoma. Am J Surg Pathol 2005; 29: 1079–85. 4 Barbour AP, Jones M, Brown I et al. Risk stratification for early esophageal adenocarcinoma: analysis of lymphatic spread and prognostic factors. Ann Surg Oncol 2010; 17: 2494–502.
© 2015 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
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5 Lee L, Ronellenfitsch U, Hofstetter WL et al. Predicting lymph node metastases in early esophageal adenocarcinoma using a simple scoring system. J Am Coll Surg 2013; 217: 191–9. 6 Abraham SC, Krasinskas AM, Correa AM et al. Duplication of the muscularis mucosae in Barrett esophagus: an underrecognized feature and its implication for staging of adenocarcinoma. Am J Surg Pathol 2007; 31: 1719–25. 7 Kaneshiro DK, Post JC, Rybicki L, Rice TW, Goldblum JR. Clinical significance of the duplicated muscularis mucosae in Barrett esophagus-related superficial adenocarcinoma. Am J Surg Pathol 2011; 35: 697–700. 8 Haggitt RC. Barrett’s esophagus, dysplasia, and adenocarcinoma. Hum Pathol 1994; 25: 982–93. 9 Hamilton SR, Smith RR. The relationship between columnar epithelial dysplasia and invasive adenocarcinoma arising in Barrett’s esophagus. Am J Clin Pathol 1987; 87: 301–12. 10 Hamilton SR, Aaltonen LA. Pathology and Genetics of Tumours of the Digestive System. Lyons: IARC Press, 2000.
Journal of Digestive Diseases 2015; 16; 197–204 11 Saad RS, Lindner JL, Liu Y, Silverman JF. Lymphatic vessel density as prognostic marker in esophageal adenocarcinoma. Am J Clin Pathol 2009; 131: 92–8. 12 Hirasawa K, Kokawa A, Oka H et al. Superficial adenocarcinoma of the esophagogastric junction: long-term results of endoscopic submucosal dissection. Gastrointest Endosc 2010; 72: 960–6. 13 Alvarez Herrero L, Pouw RE, van Vilsteren FGI et al. Risk of lymph node metastasis associated with deeper invasion by early adenocarcinoma of the esophagus and cardia: study based on endoscopic resection specimens. Endoscopy 2010; 42: 1030–6. 14 Altorki NK, Lee PC, Liss Y et al. Multifocal neoplasia and nodal metastases in T1 esophageal carcinoma: implications for endoscopic treatment. Ann Surg 2008; 247: 434–9. 15 Shimada H, Nabeya Y, Matsubara H et al. Prediction of lymph node status in patients with superficial esophageal carcinoma: analysis of 160 surgically resected cancers. Am J Surg 2006; 191: 250–4.
© 2015 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
Journal of Digestive Diseases 2015; 16; 197–204
doi: 10.1111/1751-2980.12230
Original article
Lymphovascular invasion and nodal metastasis in intramucosal adenocarcinoma of the esophagus and esophagogastric junction Zhi Gang LI,* Hui ZHU,† Hong SHI,† Hao XIE,‡ John R GOLDBLUM,† Prashanthi N THOTA§ & Xiuli LIU† *Department of Surgery, Second Military Medical University, Shanghai, China, †Department of Anatomic Pathology, Cleveland Clinic, ‡Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, § Department of Gastroenterology, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
OBJECTIVE: To evaluate the tumor parameters predictive of lymphovascular invasion (LVI) and nodal metastases in intramucosal adenocarcinoma (IMAC) of the esophagus and esophagogastric junction. METHODS: In all, 171 cases of IMAC from esophagectomy database (1986–2009) were reviewed. LVI was evaluated on HE and by immunohistochemistry stain for D2-40 (in selected cases). Univariate analysis was performed to identify predictors for LVI (in this cohort) and nodal metastasis (for pooled data from literature review). RESULTS: Altogether 150 IMAC were included in the study after histology review; 7 (4.7%) showed LVI and one (0.7%) had nodal metastasis. LVI-positive IMAC were thicker (tumor thickness 3.0 ± 2.8 mm vs 1.3 ± 1.2 mm, P = 0.01), and more likely to invade the outer muscularis mucosae (M3) (P = 0.004), be
poorly differentiated (P < 0.001), and to show a nodular or plaque-like lesion (P = 0.04) compared with LVI-negative IMAC. Patients’ age, gender, the frequency of tumor multifocality, ulceration and tumor size were not significantly different between these two groups. The pooled rates of LVI and nodal metastases in IMAC from five published studies and this cohort were 6.0% (range 2.9–16.7%) and 3.4% (range 0–10.0%), respectively. Pooled analysis of studies with histology review showed that LVI in IMAC was associated with a nodal metastases rate of 27.3%. CONCLUSION: For IMAC of the esophagus and esophagogastric junction, LVI is associated with tumor thickness, M3 invasion, poor differentiation and the presence of nodular or plaque-like lesion; by pooled analysis, it is associated with a risk of nodal metastasis of 27.3%.
KEY WORDS: esophageal neoplasms, esophagogastric lymphovascular invasion, lymphatic metastasis.
junction,
intramucosal
adenocarcinoma,
INTRODUCTION Correspondence to: Xiuli LIU, Department of Anatomic Pathology, Cleveland Clinic, 9500 Euclid Avenue/L25, Cleveland, Ohio 44195, USA. Email: [email protected] Conflict of interest: None. © 2015 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
Treatment for intramucosal adenocarcinoma (IMAC) of the esophagus and esophagogastric junction (EGJ) is evolving. A recent study has suggested that survival after esophagectomy for IMAC is excellent and is determined more by the patient than the characteristics of the cancer.1 Esophagectomy should be reserved for patients with a long segment of IMAC or those in
197
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whom endoscopic therapies fail or are inappropriate, such as the patients with a high risk of nodal metastases. While several studies have demonstrated a low rate of nodal metastasis in patients with early esophageal adenocarcinoma, many of these studies had small sample sizes.2–4 A recent and relatively large study showed a prevalence of nodal metastases of 7.4% in patients with IMAC of the esophagus and EGJ.5 In addition, Lee et al.5 suggested a simple scoring system to predict lymph node metastases in early esophageal adenocarcinoma, including IMAC. This scoring system included variables such as tumor size, depth of invasion, differentiation and lymphovascular invasion (LVI), but was generated using data from a cohort of mixed IMAC and submucosally invasive esophageal adenocarcinomas. The aims of this study were to examine LVI and nodal metastasis rates in the largest cohort, to our knowledge, of IMAC of the esophagus and EGJ and to perform a literature review with pooled analysis on LVI and nodal metastasis rates in IMAC of the esophagus and EGJ. PATIENTS AND METHODS Medical records of 171 cases of IMAC from a clinical esophagectomy database (1986–2009) were reviewed. Of these, 21 cases were excluded due to incomplete clinical information or pathologic materials (n = 9), squamous cell carcinoma (n = 4), submucosal invasion (n = 3) and high-grade dysplasia (n = 5). Pathological reports and original slides of each case were also reviewed. Histological re-review was performed by two gastrointestinal pathologists. The IMAC were classified into four groups based on the depth of invasion: (i) invasion into the lamina propria (LP) without invasion of the muscular mucosae (MM); (ii) invasion into but not through the superficial layer of MM (M1); (iii) invasion through the superficial MM but not into a separate deeper layer of MM (M2); and (iv) invasion into the deeper layer of MM (M3).6,7 Other histological features including the size, focality and location of the tumor and the presence or absence of lymph node metastasis were assessed according to the previously published criteria8,9 and the World Health Organization classification10. IMAC of the EGJ was defined as an adenocarcinoma whose epicenter was at the EGJ, where the tubular esophagus ends and the most proximal limit of the gastric fugal folds
Journal of Digestive Diseases 2015; 16; 197–204 starts, or within the proximal 5 cm of the stomach (cardia) that extends into the EGJ or esophagus. Great efforts were taken to exclude adenocarcinoma of the proximal stomach by carefully reviewing the macroscopic description in the original pathological reports and histologically reviewing the slides. The tumor grade was assigned according to the definitions of the American Joint Committee on Cancer: G1, well-differentiated; G2, moderately differentiated; G3, poorly differentiated; G4, undifferentiated. More specifically, tumors showing minimal gland formation and instead single cells, small clusters of cells or a solid sheet of cells were considered poorly differentiated. In cases where both moderate and poor differentiation was present, the tumor was classified as poorly differentiated when >10% of the tumor showing poor differentiation. Multifocality of IMAC was defined as the presence of ≥2 discrete IMACs separated by non-carcinomatous mucosa either grossly or microscopically after reviewing and matching the pathological reports and corresponding slides. Tumor thickness was measured microscopically from the surface of the tumor to the area of the deepest invasion. In cases with multifocal IMAC, the thickness of the thickest lesion was measured and used for the entire case. Information on the gross features, that is, mucosal ulceration, nodules and plaque-like lesions were recorded for each case after reviewing the original pathological report. Hematoxylin and eosin (HE)-stained slides of tumors were assessed for LVI. LVI was defined as the presence of tumor emboli in endothelial cell-lined spaces in the invasive front of the tumors. Cases that had clusters of tumor cells immediately adjacent to endothelial cell-lined spaces or tumor cells in empty spaces without endothelial lining were considered possible LVI and were then subjected to immunohistochemistry stain for D2-40, which has been reported to increase the detection rate of LVI in esophageal adenocarcinoma.11 Immunohistochemical staining for D2-40 was performed on whole tissue sections from Hollande’s fixed or formalin-fixed and paraffin-embedded tissues using an automated stainer (Ventana Medical Systems, Inc., Tucson, AZ, USA) by standard avidin-biotinperoxidase methods. Epitope retrieval techniques were used for antigen retrieval as follows: high pH ethylenediaminetetraacetic acid buffer and a steamer at 120°C for 5 min. Deparaffinized tissue sections were then stained with antibodies against D2-40 (clone D2-40, diluted 1:50; Covance, Princeton,
© 2015 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
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NJ, USA). Diaminobenzidine was served as the chromogen. Positive and negative controls for this antibody were included in the study.
RESULTS
Statistical analysis
The characteristics of the 150 patients with IMAC in this cohort are shown in Table 1. Among the 150 IMAC cases, 7 (4.7%) showed LVI, including five on routine stain and two by immunohistochemistry for D2-40 (Fig. 1a,b). Compared to LVI-negative IMAC, LVI-positive IMAC were thicker (tumor thickness 3.0 ± 2.8 mm vs 1.3 ± 1.2 mm, P = 0.01) and more likely to show M3 invasion (100% vs 30.2%, P = 0.004), be poorly differentiated (85.7% vs 11.9%, P < 0.001) (Fig. 1c) and show a nodular or plaque-like lesion (P = 0.04) (Table 1). Patients’ age (65.7 ± 8.8 years vs 62.7 ± 10.5 years, P = 0.40) and gender (male:
Statistical analyses were performed using R software package (R Development Core Team [2014], R Foundation for Statistical Computing, Vienna, Austria). Continuous variables were presented as mean ± standard deviation or medians and ranges, while categorical variables were presented as frequencies or percentages. χ2 or Fisher’s exact tests were used to compare categorical data. Continuous data were analyzed using the Wilcoxon rank–sum test. A two-sided P value < 0.05 was considered statistically significant.
Clinicopathological findings in the esophagectomy specimens
Table 1. Clinical and tumor characteristics in 150 patients with intramucosal adenocarcinoma (IMAC) of the esophagus and esophagogastric junction Patients Characteristics
Total cohort
with LVI (n = 7)
without LVI (n = 143)
P value
Age, year (mean ± SD) Male gender, n (%) Tumor location, n (%) Esophagus Esophagogastric junction Tumor multifocality, n (%) Tumor size, mm (mean ± SD) Total tumor size Largest size of the tumor Average tumor size of each case Tumor thickness, mm (mean ± SD) Depth of invasion,† n (%) LP M1 M2 M3 Differentiation, n (%) Well Moderate Poor Macroscopic finding, n (%) Ulceration Lack of ulceration Macroscopic finding, raised lesion, n (%) Nodule Plaque None Total number of nodes examined (mean ± SD)
62.9 ± 10.4 130 (86.7)
65.7 ± 8.8 7 (100)
62.7 ± 10.5 123 (86.0)
0.40 0.60 1.00
109 (72.7) 41 (27.3) 61 (40.7)
5 (71.4) 2 (28.6) 2 (28.6)
104 (72.7) 39 (27.3) 59 (41.3)
1.2 ± 1.0 0.9 ± 0.9 0.8 ± 0.9 1.4 ± 1.4
1.2 ± 1.1 1.1 ± 1.2 1.1 ± 1.2 3.0 ± 2.8
1.2 ± 1.0 0.9 ± 0.9 0.8 ± 0.9 1.3 ± 1.2
42 (28.2) 42 (28.2) 15 (10.1) 50 (33.5)
0 (0) 0 (0) 0 (0) 7 (100)
42 (29.6) 42 (29.6) 15 (10.6) 43 (30.2)
50 (33.3) 77 (51.3) 23 (15.4)
0 (0) 1 (14.3) 6 (85.7)
50 (35.0) 76 (53.1) 17 (11.9)
42 (28.0) 108 (72.0)
2 (28.6) 5 (71.4)
40 (28.0) 103 (72.0)
39 (26.0) 25 (16.7) 86 (57.3) 13 ± 10
4 (57.1) 2 (28.6) 1 (14.3) 16 ± 11
35 (24.5) 23 (16.1) 85 (59.4) 13 ± 10
0.70 0.80 0.90 1.00 0.01 0.004
0.05). There was no difference in the nodal metastasis rate in IMAC confined to the LP compared with those with invasion of the MM (including M1, M2 and M3) (0% vs 3.3%, P = 0.10) (Table 3).
Nodal metastasis in IMAC in relation to tumor differentiation Tumor differentiation information was available in three studies, with poor differentiation seen in 21.3%, 3.8% and 15.3% of IMAC, respectively (average 14.7%). The pooled nodal metastasis rate was 2.5% (2/41) in poorly differentiated IMAC compared with 0.8% (2/237) in well or moderately differentiated IMAC (P = 0.10, Table 4).
Nodal metastasis in IMAC in relation to LVI Information on LVI status was available in six studies. The nodal metastasis rate in LVI-positive IMAC ranged from 0% to 66.7% (mean 28.6%), which was higher than that of 1.1% for LVI-negative IMAC (P = 0.000000006). In the five studies with histology review, the nodal metastasis rate in LVI-positive IMAC ranged from 0% to 66.7% (mean 27.3%), which was higher than that of 0.3% in LVI-negative IMAC (P = 0.0000002) (Table 5). DISCUSSION IMAC is defined as neoplastic epithelium that has invaded beyond the basement membrane of the malignant glands into the surrounding LP or MM, but not below the MM. Because of the presence of lymphatic and blood vessels in the esophageal mucosa, IMAC possess a small but definite risk of lymph node metastasis. As such, esophagectomy had been used as a mainstay of treatment in the past decades. However, treatment for IMAC of the esophagus and EGJ is evolving: endoscopic resection has been increasingly used, with esophagectomy being reserved for patients with a long IMAC or those in whom endoscopic therapies fail or are inappropriate; for example, patients at a high risk of nodal metastases. Thus, patient selection has become critical and the prediction of lymph node metastases in IMAC is a key component in dictating therapy. Previous studies on nodal metastasis in this disease had relatively small sizes with rates varying
© 2015 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
†IMAC patients are not further divided into M1, M2 or M3. ‡One case of IMAC in the current study cannot be further divided into M1, M2 or M3. §The nodal metastasis rate is not significantly different between IMAC invading muscularis mucosae and IMAC confined to the lamina propria (P = 0.10). NA, not applicable; LP, IMAC confined to the lamina propria; M1, IMAC invading the inner muscularis mucosae; M2, IMAC invading the space between the inner and outer muscularis mucosae; M3, IMAC invading the outer muscularis mucosae; nodal met., nodal metastasis.
1 (1.8) 2 (11.8) 3 (10.0) 1 (0.9) 7 (3.3)§ 57† 17 30 108 212 NA 1 (12.5) 1 (2.0) 2 (3.4) NA 8 50 58 NA 1 (8.3) 0 (0) 1 (3.7) NA 12 15 27 NA 1 (10.0) 0 (0) 1 (1.9) NA 10 42 52 Leers et al.2 (2011) Liu et al.3 (2005) Abraham et al.6 (2007) Current study‡ Total
18 36 NA 42 96
0 (0) 0 (0) NA 0 (0) 0 (0)
M1 (n) References
LP (n)
Nodal met. in LP IMAC (n, %)
Nodal met. in MI IMAC (n, %)
M2
Nodal met. in M2 IMAC (n, %)
M3
Nodal met. in M1–M3 IMAC (n, %) Muscularis mucosae (M1–M3)
Journal of Digestive Diseases 2015; 16; 197–204
Nodal met. in M3 IMAC (n, %)
ZG Li et al. Table 3. Nodal metastasis rate in esophageal and esophagogastric junction intramucosal adenocarcinoma (IMAC) according to the deepest invasion in the current study and the literature reviewed
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significantly from 0% to 16.7%.1–4,6 One recent study showed a nodal metastasis rate of 7.4% in a cohort of IMAC without histological review.5 In addition, this study suggested a simple scoring system to predict lymph node metastases in early esophageal adenocarcinoma including IMAC. This scoring system included variables such as tumor size, depth, differentiation and LVI.5 The small size of this study and lack of histological reviews make it difficult to identify tumor characteristics associated with nodal metastasis. In the current study, nodal metastasis was seen in only one (0.7%) case of IMAC. This tumor was poorly differentiated and invaded the outer MM (M3) but did not show LVI on routinely stained sections. The nodal metastasis rate in our cohort is similar to that in previous reports,2–4 but lower than the two other reports reviewed in this study. One of these included only IMAC invading MM6 and the other had no histological review of the tumors.5 The pooled nodal metastasis rate from the five studies with histology review is only 2.0%. None of the 96 IMAC confined to the LP had nodal metastasis; in contrast, 3.3% (7/212) of the IMAC invading the MM had nodal metastasis, although this does not reach statistic difference. Poor differentiation has been shown to be a risk factor for nodal metastasis.5 In the literature review, 14.7% of IMAC were reported to be poorly differentiated tumors; but nodal metastasis was noted in only 2.5% of these poorly differentiated IMAC, which was not significantly different from that (0.8%) in well or moderately differentiated IMAC (P = 0.10). A pooled analysis of the literature review and our current study showed that LVI was associated with nodal metastasis. LVI-positive IMAC had a nodal metastasis rate of 28.6%; in contrast, LVI-negative IMAC had only a nodal metastasis rate of 1.1% (P = 0.000000006). Moreover, the pooled nodal metastasis rate from the five studies with histology review was 27.3% in LVI-positive compared with that in LVI-negative IMAC (27.3% vs 0.3%, P = 0.00000002). A limitation of this study is that it is a singlecenter study covering more than 23 years and immunohistochemical stain for D2-40 was not performed on all patients. No survival data and analysis were included in this study. However, the clinical outcome and survival of these and an additional 14 patients with IMAC were reported recently.1 Survival
© 2015 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
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T1a esophageal adenocarcinoma
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Table 4. Nodal metastasis rate in esophageal and esophagogastric junction intramucosal adenocarcinoma (IMAC) according to the tumor differentiation in the current study and the literature reviewed
References Leers et al.2 (2011) Liu et al.3 (2005) Current study Total P value
IMAC cases (n)
Poorly differentiated IMAC (n, %)
Nodal metastasis in poorly differentiated IMAC (n, %)
Well or moderately differentiated IMAC (n, %)
75 53 150 278
16 (21.3) 2 (3.8) 23 (15.3) 41 (14.7)
1 (6.3) 0 (0) 1 (4.3) 2 (2.5)
59 (78.7) 51 (96.2) 127 (84.7) 237 (85.3)
Nodal metastasis in well to moderately differentiated IMAC (n, %) 0 (0) 2 (3.9) 0 (0) 2 (0.8) 0.10
One case cannot be evaluated due to small size of the cancer.
Table 5. Nodal metastasis rates in esophageal and esophagogastric junction intramucosal adenocarcinoma (IMAC) according to the lymphovascular invasion (LVI) status in the current study and the literature reviewed
References Leers et al.2 (2011) Liu et al.3 (2005) Barbour et al.4 (2010) Abraham et al.6 (2007) Current study Subtotal from studies with histology review Lee et al.5 (2013) Total
IMAC cases (n)
LVI-negative (n, %)
Nodal metastasis in LVI-negative IMAC (n, %)
LVI-positive IMAC (n, %)
Nodal metastasis in LVI-positive IMAC (n, %)
75 53 35 30 150 343
69 (92.0) 50 (94.3) 34 (97.1) 25 (83.3) 143 (95.3) 321 (93.6)
0 (0) 0 (0) 0 (0) 0 (0) 1 (0.7) 1 (0.3)
6 (8.0) 3 (5.7) 1 (2.9) 5 (16.7) 7 (4.7) 22 (6.4)
1 (16.7) 2 (66.7) 0 (0) 3 (60.0) 0 (0) 6 (27.3)*
122 465
116 (95.1) 437 (94.0)
4 (3.4) 5 (1.1)
6 (4.9) 28 (6.0)
2 (33.3) 8 (28.6)**
*P = 0.00000002 when compared to nodal metastasis rate in LVI-negative IMAC cases pooled from studies with histology review. **P = 0.000000006 when compared to nodal metastasis rate in LVI-negative IMAC cases in studies pooled from studies with and without histology review.
after esophagectomy for IMAC is determined more by the patients’ characteristics than by the characteristics of the cancers. The low rate of LVI and nodal metastasis in the current study precluded a meaningful multivariate analysis. A limitation of literature review in this study was that one study had no histology review and histology reviewers might have used different criteria. The higher rate of nodal metastasis in the study without histology review and significant diagnostic changes in a few patients in our current study strongly suggested that future studies identifying risk factors for nodal metastasis should include detailed histology review. In conclusion, nodal metastasis rate in IMAC is low (2.0% pooled from studies with histology review) and is seen in up to 27.3% of patients with LVI. While the depth of mucosal invasion and poor differentiation are not associated with nodal metastasis, the number of cases was small, even with the literature review. Large studies accurately assessing
mucosal invasion depth, tumor grade, LVI and other features, such as tumor thickness and tumor budding, by histology review are needed to confirm our current findings and identify the risk factors for nodal metastasis and for better IMAC patient selection for esophagectomy. REFERENCES 1 Li Z, Rice TW, Liu X et al. Intramucosal esophageal adenocarcinoma: primum non nocere. J Thorac Cardiovasc Surg 2013; 145: 1519–24, 1524.e1–3. 2 Leers JM, DeMeester SR, Oezcelik A et al. The prevalence of lymph node metastases in patients with T1 esophageal adenocarcinoma: A retrospective review of esophagectomy specimens. Ann Surg 2011; 253: 271–8. 3 Liu L, Hofstetter WL, Rashid A et al. Significance of the depth of tumor invasion and lymph node metastasis in superficially invasive (T1) esophageal adenocarcinoma. Am J Surg Pathol 2005; 29: 1079–85. 4 Barbour AP, Jones M, Brown I et al. Risk stratification for early esophageal adenocarcinoma: analysis of lymphatic spread and prognostic factors. Ann Surg Oncol 2010; 17: 2494–502.
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