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Journal meeting

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Esophagus cancer

• Question : How extend lymphadenectomy is enough for esophagus cancer?

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Background Data• Increased number of regional lymph nodes containing

metastases predicts decreased survival following esophagectomy for cancer, and increased extent of lymphadenectomy is associated with improved survival.

• Therefore, extend lymphadenectomy of some extent is required.

• However, what constitutes optimum lymphadenectomy to maximize survival is controversial.

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Lymphatic drainage of esophagus

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• Radical esophagectomy should encompass all lymph node stations having a greater than 10% incidence of metastases

• lymphatic metastasis cannot be diagnosed precisely either by ultrasonography or CT imaging before surgery.

• Therefore, radical surgery for cancer of the thoracic esophagus requires complete

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three-field lymph node dissection.

•  upper mediastinal lymph nodes (including the node group of the recurrent laryngeal nerve chain)

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• paratracheal lymph nodes on both sides , subcarinal, right and left hilar lymph nodes, posterior mediastinal lymph nodes adjacent to the descending aorta and left pleura, and diaphragmatic lymph nodes are dissected.

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• For the abdominal procedure, after an upper midline laparotomy, en-bloc dissection of lymph nodes is carried out along the cardia, lesser curvature, left gastric artery, celiac axis, common hepatic artery, and splenic artery

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Method• Deta base : Worldwide Esophageal Cancer Collaboration

data.• The entire project was approved by the Case Cancer

Institutional Review Board of Case Western Reserve University.

• Method : total of 4627 patients who had esophagectomy alone for esophageal cancer. (no pre- or postoperative adjuvant therapy) for esophageal cancer and had follow-up for all-cause mortality.)

• Risk-adjusted 5-year survival was averaged for each number of lymph nodes resected.

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Method

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ResultpN0M0 CancerspTis cancers

regardless of histopathologic cell type, survival was excellent and not associated with extent of lymphadenectomy.

T1N0M0 cancersG1 : survival was unrelated to extent of lymphadenectomyG2/G3 cancers : survival was increased with more extensive lymphadenectomy

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ResultpN0M0 CancersT2N0M0 and T3/T4N0M0 cancers

G1 : limited data , due to few case numberG2/G3 cancers : survival was increased with more extensive lymphadenectomy

•.

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ResultN+M0 Cancers1 to 6 nodes positive (N1~2)

survival increased with extent of lymphadenectomy for all T classifications

7 or more nodes positiveT2 and T3/T4 cancers : Survival increased, albeit minimally, with extent of lymphadenectomy

T1 : very few case number to assessing the survival value

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Optimum Lymphadenectomy pTis

no optimum extent of lymphadenectomy pT1 N0M0 cancers

10 for adenocarcinomas 12 for squamous cell carcinomas

pT2 N0M0 cancers 15 for adenocarcinomas 22 for squamous cell carcinomas

T3/T4N0M0 cancers 31 for Adenocarcinomas 42 for squamous cell carcinomas

Optimum number of nodes resected was determined by the value at which standardizedVIMP first dropped below 5%.

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Optimum Lymphadenectomy T2 N1~2M0 cancers(1 to 6 nodes)

15 T2 N3M0 cancers(7 or more nodes positive)

insufficient data were available T3/T4N1M0 cancers

29 T3/T4N2M0 cancers

50 T3/T4N3M0 cancers

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DiscussionExtent of lymphadenectomy was either unassociated

with or minimally increased survival for patients with extremes of esophageal cancer (TisN0M0 and T2N3 lesion) and those with well-differentiated(G1) pN0 cancer.

pN+ cancers improved survival!!more accurate determination of number of positive

nodes (stage purification), or therapeutic effect of removing micrometastases.

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Limitationdespite worldwide data, there was a paucity of cases

at the extremes, such as well-differentiated (G1)pT3/T4N0 and pT2 N3.

No morbidity information according to extent of lymphadenectomy

The main problem is that each institution has a different method of counting the number of lymph nodes resected.

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RecommendationsIf there is uncertainty as to T and histopathologic

grade, it is recommended that 30 or more nodes be resected to maximize 5-year survival. It is recommended that to maximize 5-year

survival, a minimum of 10 nodes be resected for T1 cancer, 20 nodes for T2 cancer, and 30 or more nodes for T3/T4 cancers.

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Thanks for your attention!