title: Risk of lymph node metastasis in submucosal esophageal cancer: a review of surgically resected patients.
abstract: OBJECTIVE
  Endoscopic local procedures are increasingly applied in patients with superficial esophageal cancer as an alternative to radical oncologic resection. The objective of this article is to determine the risk of nodal metastases in submucosal (sm) esophageal cancer, comparing the two predominating histologic tumor types, squamous cell cancer (SCC) and adenocarcinoma (ADC).
  
  
  METHODS
  A query of PubMed, MEDLINE, Embase and Cochrane Library (1980-2009) using predetermined search terms revealed 675 abstracts, of which 485 full-text articles were reviewed. A total of 105 articles met the selection criteria. A review of article references and consultation with experts revealed additional articles for inclusion. Studies that enrolled patients with submucosal esophageal cancer and provided adequate extractable data were included.
  
  
  RESULTS
  The pooled outcomes of 7645 patients with esophageal cancer involving the sm level of infiltration were included in the analysis. Overall, the percentage of lymph node metastasis in submucosal cancer was 37%. Lymph node (N), lymphatic (L) and vascular (V) invasion in sm1 esophageal cancers was 27, 46 and 22%, respectively. Within sm2 lesions, N, L and V invasion were involved in 38, 63 and 38% of patients, respectively. Finally, N, L and V involvement in patients with sm3 lesions was 54, 69 and 47%, respectively. The rates of lymph node metastasis for sm1 and sm2 were higher in SCC compared with ADC, whereas the lymph node metastasis for sm3 was comparable, with >50% involvement in both histologic subtypes. SCC revealed an overall more aggressive behavior compared with ADC (N+: 45 vs 26%; L+: 57 vs 37%; V+: 40 vs 18%).
  
  
  CONCLUSIONS
  While endoscopic therapy may be adequate in selected patients with 'low-risk' sm1 ADC, submucosal SCC necessitates esophageal resection and systematic lymphadenectomy because of its aggressive nature and tendency for early metastasis.
authors.affiliation: Johannes Gutenberg-University of Mainz, Mainz, Germany. gockel@ach.klinik.uni-mainz.de
authors.forename: Ines
authors.initials: I
authors.lastname: Gockel
authors.forename: George
authors.initials: G
authors.lastname: Sgourakis
authors.forename: Orestis
authors.initials: O
authors.lastname: Lyros
authors.forename: Ursula
authors.initials: U
authors.lastname: Polotzek
authors.forename: Carl Christoph
authors.initials: CC
authors.lastname: Schimanski
authors.forename: Hauke
authors.initials: H
authors.lastname: Lang
authors.forename: Toshitaka
authors.initials: T
authors.lastname: Hoppo
authors.forename: Blair A
authors.initials: BA
authors.lastname: Jobe
mesh_terms: D000230:Adenocarcinoma / Q000556:secondary* / Q000601:surgery; D002294:Carcinoma, Squamous Cell / Q000556:secondary* / Q000601:surgery; D004938:Esophageal Neoplasms / Q000473:pathology* / Q000601:surgery; D016629:Esophagectomy; D004945:Esophagoscopy; D004947:Esophagus / Q000473:pathology* / Q000601:surgery; D006801:Humans; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D009092:Mucous Membrane / Q000473:pathology; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D018579:Patient Selection; D018570:Risk Assessment; D012307:Risk Factors