title: A Model Based on Pathologic Features of Superficial Esophageal Adenocarcinoma Complements Clinical Node Staging in Determining Risk of Metastasis to Lymph Nodes.
abstract: OBJECTIVE
  It is important to identify superficial (T1) gastroesophageal adenocarcinomas (EAC) that are most or least likely to metastasize to lymph nodes, to select appropriate therapy. We aimed to develop a risk stratification model for metastasis of superficial EAC to lymph nodes using pathologic features of the primary tumor.
  
  
  METHODS
  We collected pathology data from 210 patients with T1 EAC who underwent esophagectomy from 1996 through 2012 on factors associated with metastasis to lymph nodes (tumor size, grade, angiolymphatic invasion, and submucosal invasion). Using these variables, we developed a multivariable logistic model to generate 4 categories for estimated risk of metastasis (<5% risk, 5%-10% risk, 15%-20% risk, or >20% risk). The model was validated in a separate cohort of 39 patients who underwent endoscopic resection of superficial EAC and subsequent esophagectomy, with node stage analysis.
  
  
  RESULTS
  We developed a model based on 4 pathologic factors that determined risk of metastasis to range from 2.9% to 60% for patients in the first cohort. In the endoscopic resection validation cohort, higher risk scores were associated with increased detection of lymph node metastases at esophagectomy (P = .021). Among patients in the first cohort who did not have lymph node metastases detected before surgery (cN0), those with high risk scores (>20% risk) had 11-fold greater odds for having lymph node metastases at esophagectomy compared with patients with low risk scores (95% confidence interval, 2.3-52 fold). Increasing risk scores were associated with reduced patient survival time (P < .001) and shorter time to tumor recurrence (P < .001). Patients without lymph node metastases (pT1N0) but high risk scores had reduced times of survival (P < .001) and time to tumor recurrence (P = .001) after esophagectomy than patients with pT1N0 tumors and lower risk scores.
  
  
  CONCLUSIONS
  Pathologic features of primary superficial EACs can be used, along with the conventional node staging system, to identify patients at low risk for metastasis, who can undergo endoscopic resection, or at high risk, who may benefit from induction or adjuvant therapy.
authors.affiliation: Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Electronic address: davisonjm@upmc.edu.
authors.forename: Jon M
authors.initials: JM
authors.lastname: Davison
authors.affiliation: Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Landau
authors.affiliation: Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
authors.forename: James D
authors.initials: JD
authors.lastname: Luketich
authors.affiliation: Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
authors.forename: Kevin M
authors.initials: KM
authors.lastname: McGrath
authors.affiliation: Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
authors.forename: Tyler J
authors.initials: TJ
authors.lastname: Foxwell
authors.affiliation: Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Biostatistics, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania.
authors.forename: Douglas P
authors.initials: DP
authors.lastname: Landsittel
authors.affiliation: Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio.
authors.forename: Michael K
authors.initials: MK
authors.lastname: Gibson
authors.affiliation: Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Electronic address: nasonks@upmc.edu.
authors.forename: Katie S
authors.initials: KS
authors.lastname: Nason
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology* / Q000556:secondary*; D000368:Aged; D015331:Cohort Studies; D003661:Decision Support Techniques; D004938:Esophageal Neoplasms / Q000473:pathology* / Q000556:secondary*; D005260:Female; D006801:Humans; D008198:Lymph Nodes / Q000473:pathology*; D008297:Male; D015233:Models, Statistical; D009362:Neoplasm Metastasis; D010336:Pathology / Q000379:methods*; D018570:Risk Assessment
keywords: Lymphatic Invasion; Prognostic; Submucosal Invasion; Tumor Budding; Tumor Grade