Therapeutic Lymph Node Dissection
Lymph Node Dissection in Surgical Treatment of Esophageal Neoplasms

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The optimal lymphadenectomy for esophageal cancer remains controversial. The choice of surgical access determines to a great extent the type of lymphadenectomy possible. En bloc resections and three-field lymphadenectomy are concepts pioneered in the West and East, respectively; both should be performed in specialized centers because such extended lymph node dissection has substantial morbidity rates. Recent focus in research is on refining the indications for these procedures. Patient management strategies should be individualized.

Section snippets

Choice of surgical access

The type of surgical access contributes not only to postoperative morbidity and mortality rates but also to a large extent the ability to perform an extensive lymphadenectomy. The relative merits of transthoracic versus transhiatal resection for cancer of the esophagus are addressed in many studies. Transhiatal resection has the potential benefits of being less invasive and faster. The lack of a thoracotomy may reduce postoperative pain and enhance postoperative recovery, especially regarding

Lymphadenectomy: the rationale

The esophageal wall has a rich network of submucosal lymphatics and, thus, is prone to longitudinal spread of tumor. Intramural metastases may present microscopically as subepithelial spread, skip lesions, or satellite nodules, all of which may be found some distance away from the main tumor. The incidence of intramural metastasis and multiple tumors is up to 30% [31], and obtaining an adequate axial margin in esophagectomy is important to prevent anastomotic recurrence [32].

Early cancers have

En bloc esophagectomy

The concept of en bloc esophagectomy stems from the theory that malignant tumors should be resected with a complete covering of the surrounding normal tissues. The lower esophageal longitudinal muscle fibers arise and insert in part from the subpleural and pericardial fibrous layers, so these structures must be regarded as the serosa of the esophagus as opposed to the usual serosal layer that can be identified easily for the rest of the gastrointestinal tract. En bloc resection entails the

Three-field lymphadenectomy

Unfortunately the nomenclature of the nodal stations involved in esophageal lymphadenectomy is not uniform (Fig. 1). The American Joint Committee on Cancer [51] and the Guidelines for Clinical and Pathologic Studies on Carcinoma of the Esophagus advocated by the Japanese Society for Esophageal Diseases [52] denote different numbers to the nodal stations. Nodal groups according to the description by Akiyama and colleagues [2] also differ. Another confusing issue is the classification of the

Summary

The optimal lymphadenectomy for esophageal cancer remains controversial. En bloc resection and three-field lymphadenectomy have definite merits, but they are not suitable for all patients. Given their relatively high morbidity rates, appropriate patient selection is important and they should be performed in experienced centers. En bloc resection has been a concept developed in the West and applied mainly to tumors of the lower esophagus. The indication for three-field lymphadenectomy is being

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      However, there is no unified standard for esophagectomy for esophageal carcinoma internationally, and the most controversial point is the extent of lymph node dissection. Too extensive lymph node dissection could increase the surgical trauma and the incidence of complications.10–13 In recent years, some investigators proposed that lymph node dissection for some regions in specific patients can be omitted, such as subcarinal nodes and common hepatic nodes.14–17

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      There were “upward and downward metastasis” and “skip metastasis” in the node metastatic patterns of thoracic esophageal carcinoma,6,10,11 which drove surgeons to pursue a wide range of lymph node dissection. As proved by years of clinical practice, too extensive lymph node dissection increased surgical trauma and the incidence of complications, and 3-field lymph node dissection did not offer meaningful improvement in survival for all patients with thoracic esophageal carcinoma.2–5 Rational extent of lymph node dissection can ensure surgical effect and postoperative quality of life and reduce the incidence of postoperative complications.

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      Several studies also suggested that extended lymphadenectomy containing a cervical lymph node dissection may prevent recurrent disease and improve the long-term outcomes.17,18 However, other authors have reported that extended nodal dissection did not contribute to reduced recurrence rates or to increased long-term survival outcomes.4,5,10,11,19-21 We found that the 2-, 5-, and 10-year rates of isolated cervical lymph node recurrence were 4.1%, 5.6%, and 7.3%, respectively, by using the Kaplan-Meier estimate in this study.

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