Invited Commentary

Abstract

In the United States, the histology of esophageal carcinoma has shifted dramatically toward adenocarcinoma of the distal esophagus, but in Asia, mid-thoracic squamous cell carcinomas continue to predominate. Esophagectomy is the preferred treatment for localized esophageal carcinoma; however, long-term survival and local control are poor after complete resection. The lymphatic drainage of the esophagus is complex with a rich submucosal lymphatic network and longitudinal drainage pattern. This likely contributes to the high rate of local and regional lymph node recurrence after resection. Strategies used to decrease local recurrence and in turn improve survival after resection include three-field lymphadenectomy and preoperative or postoperative radiotherapy.Three-field lymphadenectomy for thoracic esophageal carcinomas has been highly debated. Even though 20% to 30% of thoracic esophageal carcinomas have cervical metastasis discovered at resection, and this is a marker for increased local recurrence, no randomized trial comparing two-field versus three-field lymphadenectomy has ever demonstrated an improvement in short or long-term survival with the more extensive resection. Many question whether the true advantages of the three-field lymphadenectomy are limited to improved local control and more accurate staging without a significant impact on overall survival.In this retrospective review, Chen and colleagues [1Chen G. Wang Z. Liu X.-y. Liu F.-y. Adjuvant radiotherapy after modified Ivor-Lewis esophagectomy: can it prevent lymph node recurrence of the mid-thoracic esophageal carcinoma?.Ann Thorac Surg. 2009; 87: 1697-1702Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar] evaluate the impact of postoperative radiation therapy on regional lymph node recurrence. They are able to demonstrate a significant decrease in the rate of mediastinal and cervical lymph node recurrence in patients who receive 45 to 60 Gy of radiation to the neck and mediastinum after Ivor Lewis esophagectomy compared with resection alone or resection with adjuvant chemotherapy, but they are unable to demonstrate a significant improvement in overall survival. A recent meta-analysis of preoperative and postoperative therapy for resectable esophageal cancer identified five randomized trials addressing the question of postoperative radiotherapy versus surgery alone for esophageal cancer. No trial demonstrated a significant improvement in 1-year, 3-year, or 5-year survival with the addition of postoperative radiation therapy. [2Malthaner R.A. Wong R.K. Rumble R.B. Zuraw L. Neoadjuvant or adjuvant therapy for resectable esophageal cancer: a systematic review and meta-analysis.BMC Med. 2004; 2: 35Crossref PubMed Scopus (176) Google Scholar] Some trials reported decreased local recurrence, but at the cost of increased morbidity.Surgical and radiation techniques have improved dramatically in the past decade and these modalities can be combined more safely and efficiently. However, these techniques only address local control, and as the control has improved, hematogenous spread becomes a bigger problem. Local therapies likely represent only a portion of the multimodality effort required to treat this aggressive disease, which is already systemic at the time of diagnosis in a majority patients. In the United States, the histology of esophageal carcinoma has shifted dramatically toward adenocarcinoma of the distal esophagus, but in Asia, mid-thoracic squamous cell carcinomas continue to predominate. Esophagectomy is the preferred treatment for localized esophageal carcinoma; however, long-term survival and local control are poor after complete resection. The lymphatic drainage of the esophagus is complex with a rich submucosal lymphatic network and longitudinal drainage pattern. This likely contributes to the high rate of local and regional lymph node recurrence after resection. Strategies used to decrease local recurrence and in turn improve survival after resection include three-field lymphadenectomy and preoperative or postoperative radiotherapy. Three-field lymphadenectomy for thoracic esophageal carcinomas has been highly debated. Even though 20% to 30% of thoracic esophageal carcinomas have cervical metastasis discovered at resection, and this is a marker for increased local recurrence, no randomized trial comparing two-field versus three-field lymphadenectomy has ever demonstrated an improvement in short or long-term survival with the more extensive resection. Many question whether the true advantages of the three-field lymphadenectomy are limited to improved local control and more accurate staging without a significant impact on overall survival. In this retrospective review, Chen and colleagues [1Chen G. Wang Z. Liu X.-y. Liu F.-y. Adjuvant radiotherapy after modified Ivor-Lewis esophagectomy: can it prevent lymph node recurrence of the mid-thoracic esophageal carcinoma?.Ann Thorac Surg. 2009; 87: 1697-1702Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar] evaluate the impact of postoperative radiation therapy on regional lymph node recurrence. They are able to demonstrate a significant decrease in the rate of mediastinal and cervical lymph node recurrence in patients who receive 45 to 60 Gy of radiation to the neck and mediastinum after Ivor Lewis esophagectomy compared with resection alone or resection with adjuvant chemotherapy, but they are unable to demonstrate a significant improvement in overall survival. A recent meta-analysis of preoperative and postoperative therapy for resectable esophageal cancer identified five randomized trials addressing the question of postoperative radiotherapy versus surgery alone for esophageal cancer. No trial demonstrated a significant improvement in 1-year, 3-year, or 5-year survival with the addition of postoperative radiation therapy. [2Malthaner R.A. Wong R.K. Rumble R.B. Zuraw L. Neoadjuvant or adjuvant therapy for resectable esophageal cancer: a systematic review and meta-analysis.BMC Med. 2004; 2: 35Crossref PubMed Scopus (176) Google Scholar] Some trials reported decreased local recurrence, but at the cost of increased morbidity. Surgical and radiation techniques have improved dramatically in the past decade and these modalities can be combined more safely and efficiently. However, these techniques only address local control, and as the control has improved, hematogenous spread becomes a bigger problem. Local therapies likely represent only a portion of the multimodality effort required to treat this aggressive disease, which is already systemic at the time of diagnosis in a majority patients. Adjuvant Radiotherapy After Modified Ivor-Lewis Esophagectomy: Can It Prevent Lymph Node Recurrence of the Mid-Thoracic Esophageal Carcinoma?The Annals of Thoracic SurgeryVol. 87Issue 6PreviewEven if complete resection was performed, some patients with esophageal carcinoma still develop tumor recurrence. This study was undertaken to evaluate the effectiveness of adjuvant radiotherapy after modified Ivor-Lewis esophagectomy on preventing lymph node recurrence of the mid-thoracic esophageal carcinoma. Full-Text PDF