esophagus staging

[BraggPeak]

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Esophageal cancer staging continues to confuse me.

If you have a GE junction tumor, and have supraclav nodes or mediastinal....are these considered regional or are they non-regional and thus metastatic disease?

 

[deleted4401]

Isn't it based on where the tumor is? I.e. if it is GE junction than celiac is regional, but SCV is metastatic and if it's upper esophagus, then celiac is metastatic?
It's sort of an academic point, though ... Either case they aren't really curable.
S

 

[Brim]

I've been confused by the change in the recent edition of the AJCC Staging Manual as well.

wagy27 is correct that the regional nodes are now defined to be "from periesophageal cervical nodes to celiac nodes."

So, celiac LNs are now considered regional, regardless of the location of the primary tumor. Also, it seems that supraclav nodes are now to be considered distant nodes (non-regional), even for upper and cervical esophageal cancers? That's my guess. I don't know... If so, the manual is inconsistent, because on the staging diagram showing the nodal locations (Figure 10.3) the supraclav nodes are included. I wonder if they meant to imply that supraclav nodes are regional or if this was a mistake.

For now, I would go by the AJCC's statement: "from periesophageal cervical nodes to celiac nodes." So celiac LN+ would be M0 but supraclav LN+ would be M1.

 

[Palex80]

"GE junction tumor" has become an entity of its own in clinical practice and clinical studies, but it's still not clearly defined, in my opinion, in the AJCC system. One can classify a GE junction tumor both as esophagus or a gastric tumor.

The Siewert classification (I-III) was used by some authors in the past to better define these tumors. Siewert I would be esophagus, Siewert III would be gastric, Siewert II is a matter of debate.

 

[Brim]

"GE junction tumor" has become an entity of its own in clinical practice and clinical studies, but it's still not clearly defined, in my opinion, in the AJCC system. One can classify a GE junction tumor both as esophagus or a gastric tumor.

The Siewert classification (I-III) was used by some authors in the past to better define these tumors. Siewert I would be esophagus, Siewert III would be gastric, Siewert II is a matter of debate.

Actually, I disagree. The recent AJCC staging manual (7th ed.) clearly defines GE junction tumors, esophageal tumors, and gastric tumors.

"In this edition, cancers whose epicenter is in the lower thoracic esophagus, EGJ, or within the proximal 5 cm of the stomach (cardia) that extend into the EGJ or esophagus (Siewert III) are stage grouped similar to adenoca. of the esophagus . . . . All other cancers with an epicenter in the stomach > 5 cm distal to the EGJ, or those within 5 cm of the EGJ but not extending into the EGJ or esophagus, are stage grouped using the gastric cancer staging system."

 

[RadOncDoc21]

I'm too lazy to look but doesn't histology also factor into the staging system as well as location?

 

[BraggPeak]

It does...they have made it as complicated as possible.

I still don't see how someone with a
Cervical esophagus lesion and a celiac lymph node is not considered metastatic.

 

[Palex80]

Actually, I disagree. The recent AJCC staging manual (7th ed.) clearly defines GE junction tumors, esophageal tumors, and gastric tumors.

"In this edition, cancers whose epicenter is in the lower thoracic esophagus, EGJ, or within the proximal 5 cm of the stomach (cardia) that extend into the EGJ or esophagus (Siewert III) are stage grouped similar to adenoca. of the esophagus . . . . All other cancers with an epicenter in the stomach > 5 cm distal to the EGJ, or those within 5 cm of the EGJ but not extending into the EGJ or esophagus, are stage grouped using the gastric cancer staging system."

Dear Brim

You are correct, the current AJCC-system is clearly better, that the ones we had before, but:

I am not convinced that the current AJCC-system clearly defines the distinction between esophagus, esophageal junction and gastric tumors. I think the problem is created by adding words like "epicenter" in the definition and perhaps by using rather wide margins (5 cm are probably too much).

Instead of trying to group some EGJ-tumors to esophagus and others to gastric, they should have better (in my opinion) created an own group called EGJ, covering all tumors which extend within 3(?) cm of the Z-line.

Everything which lies over and below this zone is either an esophagus or a gastric tumor.


We have randomized trials looking into the treatment of only EGJ-tumors, but we still don't have an EGJ-tumor entity in AJCC. This is madness...

Sparta!

It does...they have made it as complicated as possible.
I still don't see how someone with a
Cervical esophagus lesion and a celiac lymph node is not considered metastatic.

This is also a disaster. Instead of defining regional nodes for each of the 3 esophagus levels and make this clear, they decided to pool all of them in one big group. A recipe for disaster...