title: Clinical T2N0 Esophageal Cancer: Identifying Pretreatment Characteristics Associated With Pathologic Upstaging and the Potential Role for Induction Therapy.
abstract: BACKGROUND
  Although studies have suggested standard therapy for clinical T2N0 esophageal cancer should be primary surgery, we hypothesize there is a subgroup for whom induction therapy may result in improved overall survival.
  
  
  METHODS
  Patients with cT2N0 esophageal cancer receiving induction therapy or upfront esophagectomy (UE) were identified in the National Cancer Data Base. The UE patients were dichotomized as (1) pathologically upstaged, or (2) same-staged or downstaged. Logistic regression models identified variables associated with upstaging, and Kaplan-Meier analysis compared median overall survival.
  
  
  RESULTS
  From 2006 to 2012, 932 cT2N0 patients (52.2%) received UE, and 853 (47.8%) received induction therapy first. In all, 326 of 713 UE patients (45.7%) were upstaged: 87 of 326 (26.7%) had T upstaging; 98 of 326 (30.1%) had N upstaging; and 141 of 326 (43.3%) had both. Patients upstaged after UE had a higher tumor grade (35.1% versus 57.1% grade 3), and a higher rate of lymphovascular invasion (57.1% versus 17.7%; both p < 0.001). Variables associated with upstaging included lymphovascular invasion (odds ratio 6.0, 95% confidence interval: 2.9 to 12.5, p < 0.001) and tumor grade 3 (odds ratio 9.4, 95% confidence interval: 1.8 to 48.4, p = 0.007). Of upstaged UE patients, only 144 (44.2%) received adjuvant therapy. The median overall survival for cT2N0 patients upstaged after UE was 27.5 ± 2.5 months versus 43.9 ± 2.9 months for induction therapy patients (any resultant pathologic stage, p < 0.001).
  
  
  CONCLUSIONS
  Half of all cT2N0 patients were pathologically upstaged after UE, with worse survival compared with patients receiving induction therapy. Refining an upstaging model would help select patients for induction therapy and increase the rate of chemotherapy in patients at risk for systemic disease.
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri.
authors.forename: Pamela
authors.initials: P
authors.lastname: Samson
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri.
authors.forename: Varun
authors.initials: V
authors.lastname: Puri
authors.affiliation: Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri.
authors.forename: Clifford
authors.initials: C
authors.lastname: Robinson
authors.affiliation: Division of Medical Oncology, Washington University in St. Louis, St. Louis, Missouri.
authors.forename: Craig
authors.initials: C
authors.lastname: Lockhart
authors.affiliation: Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, Missouri.
authors.forename: Danielle
authors.initials: D
authors.lastname: Carpenter
authors.affiliation: Division of Cardiothoracic Surgery, St. Luke's Hospital, Chesterfield, Missouri.
authors.forename: Stephen
authors.initials: S
authors.lastname: Broderick
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri.
authors.forename: Daniel
authors.initials: D
authors.lastname: Kreisel
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri.
authors.forename: A Sasha
authors.initials: AS
authors.lastname: Krupnick
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri.
authors.forename: G Alexander
authors.initials: GA
authors.lastname: Patterson
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri.
authors.forename: Bryan
authors.initials: B
authors.lastname: Meyers
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri. Electronic address: crabtreet@wustl.edu.
authors.forename: Traves
authors.initials: T
authors.lastname: Crabtree
mesh_terms: D000230:Adenocarcinoma / Q000188:drug therapy / Q000473:pathology* / Q000556:secondary / Q000601:surgery; D000368:Aged; D000970:Antineoplastic Agents / Q000627:therapeutic use*; D002294:Carcinoma, Squamous Cell / Q000188:drug therapy / Q000473:pathology / Q000556:secondary / Q000601:surgery; D059248:Chemoradiotherapy; D017024:Chemotherapy, Adjuvant; D003131:Combined Modality Therapy; D004938:Esophageal Neoplasms / Q000188:drug therapy / Q000473:pathology* / Q000601:surgery; D016629:Esophagectomy; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging / Q000379:methods*; D012074:Remission Induction; D012189:Retrospective Studies; D012307:Risk Factors; D012959:Socioeconomic Factors; D016896:Treatment Outcome
chemical_list: D000970:Antineoplastic Agents