T2N0M0 Esophageal Cancer
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Objective:
T2N0M0 esophageal cancer, the most locally advanced cancer still confined to the esophagus, may be at the limit of curative resection. The objectives of this study were to determine 1) ability of endoscopic esophageal ultrasound (EUS) to accurately stage T2N0M0 cancers, 2) how best to use this information for treatment decisions, and 3) whether surgery alone is appropriate.
Methods:
From a prospective database of 978 patients, 742 of whom were clinically staged (cTNM) by EUS, 61 (8.2%) were cT2N0M0 and 53 had surgery as first therapy. Referent values were calculated from the 445 clinically staged patients who had surgery as first therapy. Of patients who had surgery as first therapy (666/978), 31 (4.7%) were pT2N0M0. Survival was estimated by the Kaplan-Meier method.
Results:
Referent values (percents) for accuracy, sensitivity, specificity, positive predicted value, and negative predicted value were 78, 49, 81, 19, 95 for cT2; 71, 68, 78, 83, 60 for cN0; and 86, 29, 89, 13, 96 for cT2N0M0. Of incorrectly staged cT2N0M0, 29 (63%) were overstaged and 17 (37%) understaged. Of incorrectly clinically staged pT2N0M0, 14 (82%) were overstaged and 3 (18%) understaged. For cT2N0M0, 5-year and median survivals were 52% and 7.1 years, and for pT2N0M0, 61% and 14.1 years (Figure).
Conclusions:
1) cT2N0M0 cancers are unlikely to be pT2N0M0; most are overstaged. 2) Patients with cT2N0M0 cancers should have surgery first, and clinically understaged patients should receive postoperative adjuvant therapy because patients with advanced tumors have previously been shown to benefit from this strategy. 3) pT2N0M0 cancers are uncommon; these patients have acceptable survival with surgery alone, and the role of postoperative adjuvant therapy will be difficult to define. 
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