Abstract
PurposeTo investigate the lymph node metastasis pattern and significance of dissection of the left gastric artery lymph nodes in radical en bloc esophagectomy for esophageal squamous carcinomas based on the lymphatic drainage pathway revealed by carbon nanoparticle labeling.Materials and methodsPatients who underwent en bloc esophagectomy endoscopically were retrospectively enrolled. Carbon nanoparticles were injected in the submucosa of upper thoracic esophagus to label the relevant draining lymph nodes. The clinical data, lymph nodes dissected, surgical technique, and complications were analyzed.ResultsEn bloc esophagectomy was successful in all 179 patients. Metastases to the left gastric artery lymph nodes were positive in 42 patients (23.5%) but negative in 137 (76.5%). The left gastric lymph nodes were labeled, whereas no celiac lymph nodes were labeled by carbon nanoparticles. A total of 4652 lymph nodes were resected, with 26 lymph nodes per patient. Seventy-three patients had lymph node metastasis (73/179). Seventeen patients had metastasis to the recurrent laryngeal nerve lymph nodes (9.5%). The metastasis rate of the lower thoracic esophageal cancer to the left gastric artery lymph nodes was 37.0%, significantly greater than that at the middle (15.4%) or upper (6.7%) thoracic segment. The lymph node metastasis rate was significantly (P < 0.05) increased with the length of the cancerous lesion, infiltration depth, and poor differentiation. Univariate analysis revealed that the metastasis rate to the left gastric artery lymph nodes was significantly (P < 0.05) associated with paraesophageal lymph node metastasis, para-cardial lymph metastasis, and TNM classification. Multivariate analysis indicated that cancer location (odds ratio 8.32, 95% confidence interval 2.12–32.24) was significantly (P < 0.05) associated with metastasis to the left gastric artery lymph nodes, with the cancer at the middle and lower thoracic segments significantly more than in the upper thoracic segment.ConclusionCertain patterns exist in lymph node metastasis of esophageal cancer, and in radical esophagectomy of esophageal cancers, dissection of the left gastric artery lymph nodes is necessary to prevent possible residual or metastasis of esophageal squamous carcinomas based on the lymphatic drainage pathway of esophageal carcinomas demonstrated by carbon nanoparticle labeling.
Highlights
As one of the commonest malignancies, esophageal carcinoma ranks sixth among the commonest causes of cancer-related mortality across the globe, and the incidence is still rapidly on the rise [1, 2] with a poor 5-year survival rate of 10–15% despite multiple approaches of treatment [3]
Metastases to the left gastric artery lymph nodes were positive in 42 patients (23.5%) but negative in 137 (76.5%)
Certain patterns exist in lymph node metastasis of esophageal cancer, and in radical esophagectomy of esophageal cancers, dissection of the left gastric artery lymph nodes is necessary to prevent possible residual or metastasis of esophageal squamous carcinomas based on the lymphatic drainage pathway of esophageal carcinomas demonstrated by carbon nanoparticle labeling
Summary
As one of the commonest malignancies, esophageal carcinoma ranks sixth among the commonest causes of cancer-related mortality across the globe, and the incidence is still rapidly on the rise [1, 2] with a poor 5-year survival rate of 10–15% despite multiple approaches of treatment [3]. Lymph node status is one particular strong prognostic index for survival and recurrence after esophagectomy [4,5,6,7]. Some surgeons adopt limited resection strategies, like limited two-field nodal dissection with transthoracic or transhiatal resection, whereas others favor three-field lymph node dissection which may possibly improve long-term survival after esophagectomy [8,9,10,11]. A systematic review and meta-analysis has suggested that more radical lymphadenectomy to increase the lymph node yield in esophagectomy is significantly associated with improved disease-free and overall survivals in both Eastern and Western populations [7]. Extended lymphadenectomy may increase physical injury to the patient, especially in open esophagectomy; the mortality associated with this approach has not been demonstrated to be increased [7, 12]
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